Drug-Induced Hallucinations

Pictures

2011-11-13T16:43:00.001-08:00

A picture is worth a thousand words. Nowhere is this more true than in modern medicine. A picture can change a life; sometimes for better, sometimes for worse.

* * * *

Last week I went on a call for "sick person, vomiting." We found a woman, maybe sixty-five, sitting cross-legged on the floor. History was hard. I don't speak Farsi. We managed to get from her husband that he'd woken up to find her vomiting and confused.

I tried to ask her what was going on. She replied and even I could tell that it was word salad, gibberish. Nothing made sense.

She raised her right hand to wipe her mouth, but her left remained obstinately in her lap, unmoving. The fireman called out a blood pressure; "two-ten over one-forty."

"What?!" said her husband, trying to read the Lifepak. "What was her blood pressure?"

"Sir," I asked, "When was the last time you saw her normal?"

"Her blood pressure was what?!"

"Sir ... sir ..." I finally grabbed his shoulder. "Sir. When. Was. She. Last. Normal."

"Uh, uh ... midnight, I talked to her at midnight."

"Okay," I said, changing my grip on his shoulder to a comforting pat, trying not to show the disappointment on my face. "Okay. We'll take her to the hospital."

We carried her downstairs, put her in the ambulance, ran with lights and sirens to the hospital.

I stayed long enough to see the scan.

No one needed a radiologist.

* * * *

A man woke up to find his wife vomiting, and a picture changed their lives.

* * * *

A few months ago my wife woke up vomiting.

A picture changed our lives.

* * * *

So today, my readers, I would ask you to do one thing: Think about what you get frustrated about, what you long for, what you are unhappy with. Then think about what kind of black-and-white picture a doctor could hand you, how it could change your whole world in the space of a heartbeat, and how grateful - how terribly, earnestly, jaw-clenchingly, tearfully grateful - you should be for your life, and what you have, and the opportunities that will open up before you.

For the truth is that life is fragile, and short, and even the best surprises in life means that everything will change. Embrace the change, appreciate every day, and go hug your family. That's what I'm doing.

Nausea

2011-07-21T06:43:00.001-07:00

This is the third time we've transported her in three days. She can't stop throwing up. She goes to the hospital, comes home, feels awful for a while, and calls us again. I'm trying not to be grumpy, and failing. I was sleeping, comfortable finally, curled up just so that the pager and keys and trauma shears don't dig into my side and leg, waiting out the last few hours of a slow night.

* * * *

The fireman -- a friend of mine -- starts to give me report, but it's an hour before the end of my shift and the hospital is a thirty minute drive away. I brush him off and speak more harshly than I intend to her.

"Still puking? Yeah? Taking your meds? Okay, let's go. Come on, the stretcher is outside."

She's a former drug addict and has the scars -- all up and down her arms, and just as much in her demeanor. There's something in the attitude of many addicts that is a bit whiny and pathetic; it's like the drugs have robbed them of all their dignity and self-worth, and they can never really get it back.

Or, it could be that she's been hurling for a week.

* * * *

Paramedics don't love these calls. Even though we know we aren't actually there to save lives, we want to make a difference. We want to take care of breathing problems and heart attacks and gunshot wounds and car wrecks; not nausea and foot pain and difficulty urinating and all the minor, non-emergent complaints that we end up handling as the healthcare safety net.

We run the calls anyway, and we either get bitter or make our peace.

* * * *

I climb into the back of the ambulance, trying not to sigh audibly.

"Anything different?" I ask, and she shakes her head. Just not getting any better. Couldn't get an appointment to see my primary doc.

I hook her up to the monitor, get a blood pressure, glance at the EKG, all the usual business. When I go to attach the electrodes, I find one that I attached yesterday on her shoulder. Huh. I put the fresh electrode in my hand down and clip the wire on the old one. It works just fine.

The old scars on her arms are now mixed with a fresh crop of track marks from the past week. I know, I've put four or five of them there myself. She's not an easy stick, but the past couple nights I managed to get something, maybe get a bit of fluids in, give her some meds.

Last night I went all the way to the end of the nausea protocol and gave her the quarter-cc of inapsine, as she filled up three biohoop bags.

I rub my face with the back of my arm. I know there's no line to be found on her arms. Whatever. I put one in her leg, mid-calf, in a big vein that I spot without even a tourniquet, hoping the hospital won't raise their eyebrows too far. I dump half a liter of fluid and some zofran in it, and she doesn't puke for a bit.

Great. I pull up my chart from last night and copy her meds, allergies, history. I contemplate copying and pasting my narrative.

* * * *

"I don't want to go to the hospital, you know," she tells me as we unload her. "This is the last thing I want to be doing. I wish I was sleeping, not in the ambulance. I just feel so awful."

"I know," I say, patting her shoulder briefly as my partner punches in the code to open the door to the ER. "I know."

Gifts

2011-07-01T00:33:00.001-07:00

I have never met him -- will never meet him, not really -- and yet he still gives me a gift, in an odd way. Maybe not intentionally, certainly not knowingly, but a gift nonetheless. It's not even really a gift for me; just one for me to hold for a while -- I don't know how long -- until I find the ultimate recipient.

* * * *

It's a long drive, and the fire department EMTs have been there for a while when we arrive.

They're still doing CPR.

My partner heads for the monitor and asks the firefighter what she's got for access and what drugs they've given.

I sling the heavy green canvas airway bag at the foot of the staircase, and lean over the firefighter squeezing the BVM. He's got the mask clamped over the patient's face. A crumpled King airway lies on the floor.

"Hm," I say, almost to myself. The red-and-black intubation roll is already coming out of the airway kit. "King didn't work?" I ask the fireman - a good EMT who is in paramedic school - and he shakes his head.

"Nah, man, it just wouldn't advance."

Hm, indeed.

It takes me maybe ninety seconds to get everything together, and then I edge in. Slip the largyngoscope in his mouth, no, no, keep doing CPR, that's fine, aaaand --

Ah.

I see why they had trouble with the King, and why I will have trouble with the tube. I can barely reach his epiglottis with the tip of the Mac 4, and I certainly can't see the cords.

In a second, I know what I have to do. I just wish I'd practiced it more.

I pull the blade out and turn back to my kit. "Bag him," I tell the confused fireman.

"You're not even going to try?" he asks, wondering why I never asked for the tube.

"Nope," I say, unscrewing the cap on a short length of PVC pipe in the bottom of the kit. "Not with that."

The bougie is a long, flexible plastic rod, a couple millimeters across. I slide an ET tube onto it, making sure I have a good eight inches of bougie below the end of the tube. A quick swap for the long Miller blade, and I'm back in the mouth.

Wait - yeah - there. I can just see the bottom of the cords. I hold up my hand, and the fireman carefully passes me the loaded tube. I fish the bougie down until I see it go between the goalposts, and as the fireman holds the top I can slide the tube in ...

* * * *

Of course it doesn't really matter, other than confirming a dismal end-tidal CO2, for the man is dead, and has been dead for some time now. All we are doing is confirming that he is really, exceptionally dead. I never met the man.

So why does it matter?

If we are not challenged, we don't grow. To be challenged by another, to be placed in a position where we have no choice but to stretch our capabilities or risk failure -- that is a gift.

I rarely use a bougie, because it's rarely necessary, and so I am thankful for the unknowing gift of a dead man, who pushed me to use this tool -- because someday there will be someone who isn't dead, who desperately needs an airway, and the bougie is going to let me put it there.

Acting

2011-04-17T01:13:00.000-07:00

(Originally written a number of years ago, when I was a new medic. I was reading a little too much William Barton.)

4am. The inside of our quarters are dark and we leave them that way, ducking out of the rain, locking the door. My partner flops on the couch, benefit of being a lead. I curl up awkwardly on a recliner, trying to get the damn thing to stay back while I lie on my side. I push a few buttons on the pager; it asks, SET AUDIBLE ALERT? and when I confirm it chirps happily.

Radio just a quiescent brick of plastic, sometimes murmuring softing with the voices of dispatchers and other crews, engine nine medic three twenty a trauma at three nine st and southern ave stage for police map page six nine two four dee delta. I clip the pager to my shirtfront so it won't be muffled by my jacket, and think about snuggling up with the radio held close. Maybe if I keep it happy it will stay quiet.

No. I'm more likely to roll over and key it up, treat the entire county to my snores. Instead, I set it on the table next to the chair. Sooner or later one or the other will go off, the startling, not-quite-synchronized tenor BEEP BEEP BEEP BEEP of the radios alerting for a call, or the high soprano DWEEEE DWEEEE DWEEEE of the pager, telling us to move posts.

On days, when the radios went off, I'd always be listening for the one tuned to the fire dispatch channel. What are we going on, I have to know. Punching the button on mine hastily to make it stop alerting, happy little radio with CALL RECIEVED flashing on the tiny screen, the beeping covering up the voice of the dispatcher, FD1 Dispatch up at the comm center, sitting in front of her five screens, maybe occasionally talking to FD2 FireTac sitting next to her. They sound so serious and professional on the air. Go up to the dispatch floor, through three or four remote-locked doors, and they're all laughing and fun, middle-aged women mostly, in jeans and sweatshirts.

But still the radios beep, and FD1 reads out the call that CT1 or CT7 or CT13 just entered, and FD2 waits patiently for us to switch channels and tell her we're going.

At first all we hear is the type of call. There are the meat and potatoes calls, abdominal pain, sick person, minor trauma, was unconscious but awake now. Assaults, ass kicked in a bar fight. Stage for police. Chest pain and breathing problem, could be something, could be nothing. Random calls we hear less frequently. General OB problem. Tyke on the way. Allergic reaction. Animal bite. Too hot or too cold. The ubiquitous traffic accident, could be minor, could be hellacious. And then there are three types of calls that do get our attention, at least a bit. Major trauma. Shooting or stabbing. And unconscious and not breathing. On days I always listened for the type, tried to figure out what was gonna happen.

And then, when we get in the car, I can look at the computer, nuggets of data hidden among vast strings of computer abbreviations. A call might come up looking something like this:

04/17/2006 1RUN#1100320041 CHPN
FMAP: 6284D TMAP: 656D2 FBLK: 0065

1298 MAIN ST <3000>
( HIGH XST: 12TH PL )

BROWN, JOE, SON
SA/C 503 555 1234

0041 ENTRY: M, 41, CH PAINS
0041 FIRSTSUG E23
0041 NEXTENG 'E9 'E4
0041 DISP E23
0041 $ASNCAS E23 #PF0041672384
0041 EMSSUG M321 M315 ?M329 M334
0041 ASST M321
0041 $ASNCAS M321 #MD0128495672
0041 TALKGP OPS1
0041 R1 --> O1
0042 SUPP (CT13 ): SOB, SWEATY, HEART HX
0042 ENRT M321

... and out of that all that's useful is that it's a diaphoretic guy with chest pain and trouble breathing who's had heart trouble before.

At 4am I could care less. I just have to get up, glasses on, make the radio stop beeping, tell someone we're enroute, get to the car. If I'm driving I may not know what we're walking into until we arrive. It's a call.

Doesn't matter what.

Someone told me nights are all bullshit or ohshit. Much more of the former than the latter. I marvel at the way my partner goes from cussing out the patient, dispatchers, fire department, anyone on the road while we drive to a call, to kind, attentive, and caring when we're in someone's house.

And then, well, all of a sudden you're at someone's bedside and they're guppy-breathing, or have crushing substernal chest pain radiating into the left arm, or are seizing, or have stroked out, and it's all you, baby.

Delegation always buys me a few seconds for thought. Get vital signs, fireman. Get some o's, oxygen, on. Start looking for an IV site, partner. Get the monitor. Get a sugar. Get the gurney. When it's bad -- start bagging. Get suction. Get versed. Draw up the sux and amidate. Get the intubation roll. Get the patches on. Continue CPR. Very demanding, when you're the almighty PIC, Person In Charge.

But you have to be, because while they're doing all that crap, all the skills that we could train a moderately clever rhesus monkey to do -- no offence to firemen OR monkeys -- you've got the tough job, the detective work.

When did it start. What does it feel like. Has it happened before. What happened then. Does it radiate. What makes it worse. Better. How bad is it.

And you're standing there, behind the shield of your professionalism and your questions and your neat blue uniform shirt and colorful PARAMEDIC patch, with the firemen in their turnouts and the big red engine and big white ambulance, strobes stuttering lightning in the predawn dark, low rumbling diesels, heart monitor and oxygen bottle and medkit all arrayed. And they look up at you with scared eyes, breathing fast, clutching their chest, pale, diaphoretic, shaking, puking, swaying, bleeding. And they tend to ask the same two questions -- what's happening? Am I going to be okay?

Well.

Maybe you know what's happening. Maybe you have no clue. Tell them a carefully edited version of the truth. It looks like you may be having a heart attack. We're not sure, everything looks good so far. I think you're having an allergic reaction. I think your asthma, your heart failure, your diabetes, your chronical medical condition with a long latin name, that thing, is acting up. We'll have to see. The hospital can run more tests.

But some things we don't say. It looks bad. Your EKG is all wrong. We're behind the eight-ball. You should have called hours ago. You need to be tubed. Your car is destroyed. Your passenger is dead. Ohshitohshit I've never done this -- a surgical airway, decompressing a chest, whatever -- before. I'm as scared as you are.

Which hospital, we say instead. We'll take good care of you. That's a good hospital. Can we lock up your house. Here's your keys.

Do I look worried, sir? No? Then you shouldn't be. A reassuring pat. You can be scared when I looked scared, ok?

I don't explain that I'm a very good actor.

Pop-pop-pop

2011-01-04T14:41:00.000-08:00

This was written a few years ago. Names have been changed, of course.

* * * *

One slow winter night, Emily and I were doing the long, boring loop between downtown and southwest. We'd get sent out southwest. A call would drop downtown, and we'd come back. Someone would clear the hospital, and we'd turn back around. We were chatting about nothing, listening to the radio, and generally being terrifically bored. It had been a while since we'd run a good call.

Another call dropped, and we turned back towards downtown. Barely a minute after she flipped us around, the dispatch radio came to life again.

"Truck 1, Medic 325, stage on a shooting, Southwest Second and Ankeny streets, ..."

I thumped the dash. "Dammit! We're second-out for that! Why do we always miss the good stuff?"

Emily shook her head, a bit exasperated - though I couldn't tell if it was with missing the call or her high-speed, over-eager lead. "I dunno..."

Our tones went off, sudden and jarring as always. We paused, waiting for the computer to come up with the call or the dispatcher to start talking. But the computer remained blank - we were in a dead spot for the wireless data, coming out of the hills. And, strangely, there was no voice dispatch.

This was seriously weird.

The seconds stretched; thirty, forty, and nothing. My pager buzzed, and I looked at it to see the address of the shooting we'd heard dispatched a few minutes before.

Okay, I thought. Second patient?

And finally the dispatcher started talking, and we understood the lapse.

"Medic 327, Medic 324, Medic 326, Medic 322, respond with Truck 1 and Medic 325 already enroute at Two and Ankeny for a multiple shooting, at least five patients ... " Another pause. " ... And Fire Dispatch now calling box 0140, Truck 1 requesting a full first alarm. Assignment is Engine 1, Engine 3, Engine 4, Truck 3, Squad 1, C-2, C-4. Ops channel six."

There was a long moment of silence in the ambulance.

"Holy shit," Emily said.

"Yeah," I told her. "Put your foot down."

We flew down the long boulevard into downtown, and jerkily stopped-and-started our way through traffic lights on mostly deserted streets. Occasionally we'd see cops up ahead, blasting through intersections. I put on a pair of gloves, draped my stethoscope around my neck, and tried not to hassle Emily to go faster. I tried to ignore the icy clench in my gut. The radio traffic wasn't helping.

"... all units responding, police onscene say the scene is secure and you are clear to enter. Correction. Police are asking for medical to expedite ..."

"... Truck 1 assuming command ... and dispatch, we may have as many as seven patients per police. Add two more ambulances ..."

Christ. This might be bad. Might be. Then again, two people could be bad, and five could be shot in the foot or ass or something. I somehow fixated on that idea, and decided we had to get there early, to get a "real" patient. I told Emily to hustle it up, and she shook her head.

As we slammed down 2nd Avenue, I saw the lights of another ambulance approaching across one of the bridges. The offramp would drop them onto 2nd, right in front of us – or behind us. As we closed, it became apparent that we'd get to the stoplight just barely ahead of the other unit.

Suddenly Emily hammered the brakes. The light was red, and the other ambulance was only a hundred yards up the ramp.

"Go, go go!" I yelled.

"But they have the green," she protested.

"Fucking go," I told her, and she buried the gas pedal in the floorboards. I could see the faces of the other crew – good friends of mine both – glaring as we burned past them. I gave them the finger.

Thirty seconds later we were sliding to a stop, among a mess of police cars, fire trucks, and a couple other ambulances. I looked out the window and saw a man laying against the side of a building, shoulders on the ground, chin touching his chest, blood and grey matter painting a cone out from one side of his head.

Whoa.

I was out of the car before it even stopped moving, and walked over to where I saw the first-in ambulance medic, a huge man named Sam, standing on the sidewalk. At least four people were laid out within ten feet, and as I looked over them I realized they were all teenagers.

Oh, Christ, this is that underage juice bar nightclub. Perfect.

I just looked at Sam. Dispassionately, as if we were chatting about a football game in the crew room, he started talking and pointing.

"This one is dead. This one is critical; we're taking her. This one is also critical. That one isn't as bad –"

"Great," I interrupted, tossing my head at the second critical patient. "We've got that one." One patient I can handle. If they're critical I can justify taking them right now. I knew, in theory, how to triage. I knew what criteria I'd need to use to classify patients – critical (red), delayed (yellow), walking wounded (green), or dead (black) – but on the street, in the cold January air, with a bunch of kids bleeding onto the concrete, I desperately didn't want to practice.

Sam nodded and turned away. I glanced behind me. Emily was standing there, holding a backboard, and a single firefighter was with her. No one else, yet. I took a step closer to the patient, and three things jumped out at me:

She had at least four holes in her torso.

She looked at least as confused and scared as I felt.

She was very, very young.

"Okay," I said, taking a deep breath. "Get her boarded and we'll put her in the car and go. We can do everything enroute. I'll grab the gurney, and then -" I'm going to throw up for a few minutes? "- I'll spike some bags and get things ready in the back. You got this?"

"Uh, yeah," she said. "Sure, boss. We'll meet you at the car."

I skittered back to the ambulance, hauled the gurney out, then jumped in the back and proceeded to make a mess. I pulled out everything I thought I could possibly need. Oxygen mask. Two bags of IV fluid. Everything I'd need to put a couple lines in. Monitor leads out and ready. I grabbed the chest decompression kit off the wall, and clenched a little tighter, wondering if she'd dropped a lung.

Okay. Okay. Slow down. I tried to take a few calm breaths, tried to pretend my hands weren't shaking a bit, and then the back doors were open and they were loading the gurney in.

We cut clothes, and I confirmed my earlier estimate of at least four holes in her torso. She was awake, and breathing, but neither of us could feel a pulse at her wrist or hear a blood pressure over all the noise. She couldn't talk much, and when she did it was with a foreign accent I couldn't place. I asked what her name was, but couldn't understand the answer. She told me she was eighteen. Alright, I told her, breathe easy. We've got you.

I listened to her lungs and decided they sounded about equal. No need, yet, for the whaling harpoon of a needle sitting on the bench behind me. Emily helped me get oxygen and the monitor on, and then asked if I wanted help with an IV.

"No," I said, "she's young and healthy. I can drop one on the way. Let's go."

"Alright," she said. "I'm still waiting for a destination from the sup."

Our medic supervisor had showed up a few minutes after us, and was now coordinating ambulances, making sure patients were split evenly between the two trauma centers.

"Well," I snapped, "tell him to hurry the fuck up, we need to leave."

"Copy that," she said, and hopped out. I took the minute's pause to look for a spot for a line. Whoops. Nothing. Great.

The back doors popped open again. "Okay, we're going to Charity."

"Right, let's roll."

She glanced at the patient, then me, and a ghost of a grin appeared on her face. "Code one or code three?" she asked, rhetorically.

"Fuck," I told her, emphatically, already looking at the girl's other arm for some kind of vein, anything.

The car dropped into gear, and the chaos and lights and sound disappeared behind us. The siren yelped occasionally, but otherwise it was abruptly quieter in back. I finally found a spot and slipped an IV in the girl's hand, a twenty-gauge, tiny for this sort of trauma but all I could do. She was trying to ask me something.

I grabbed the monkey bar and leaned over her face. "What did you say?"

"... 'm I gonna die?"

I wanted to tell her no, but my face had to have given away how scared I was for her. Don't lie to your patients. They will know. Thanks, nameless instructors. I put one of my hands over hers.

"I don't think so. We're going to take really good care of you, okay?"

She nodded. I felt awful. Hell of a pep talk, but she seemed a little calmer.

I glanced out the back window, and realized we were only about five minutes out. Still couldn't get a blood pressure. I listened to her lungs again, and now one of them sounded fainter. Way fainter. Shit. I glanced at the chest decompression needle, but decided we were so close, and she needed a chest tube. Hell, she needed to go right into an operating room. Luckily Charity could do direct to OR - but they'd need to know.

I spun the radio to the TRAUMA channel. No dice; I could have sat for half an hour and not gotten through. Screw it, I'll go against procedure and call the hospital direct.

"Charity Hospital, Medic 327, code 3 traffic."

"Charity, go ahead."

"Medic 327, we're, uh, three minutes out, eighteen year old, from the shooting, at least four GSWs to the torso, heart rate of 120, no radial pulse, can't get a BP, all we've got is a small line, and she's maybe got a pneumo."

"... ah ... we're not aware of this patient, 327. I think you were supposed to go to University Med."

Thump-thump. Well. That's the driveway.

"That's nice, Charity. We're on your doorstep. See you in about thirty seconds."

We unloaded quickly, and rushed her through the double doors. I got the fleeting impression of barely controlled chaos before a senior attending trauma surgeon blocked our way. He held out his hands in a placating gesture.

"Whoa, okay, what have you got? We don't know where you're going yet."

Emily told me later that my voice was high and stressed. "Doc, she's eighteen, at least four holes in her chest, I stopped looking after that. Airway is good, she's awake and talking, but I can't feel a blood pressure, we've only got one tiny line, and I think she's dropped a lung."

I raised my finger, pointing at her, and then behind him, to the next set of double doors. "We. Need. An. OR."

He blinked, clearly taken aback. "Uh, okay. Uh. OR 14."

"Thanks," I replied, already in high gear, rolling past him. We slid into the sterile whiteness of the OR, and lifted her from our gurney to the operating table. I stepped back as Emily pulled the gurney away and the nurses and docs crowded around. I'd later learn that it had only been twenty-five minutes since we got to the scene.

"Goddamn," I said to no one in particular, standing in the scrub hallway outside the trauma ORs. "God-damn."

"Well?" Emily asked when I came outside.

"She's gonna die," I sighed. "I mean ... yeah. Yeah. Shit."

* * * *

About six months later, my girlfriend had to ask me why I was sitting at the table, teared up over a picture of a very normal-looking girl at a high school graduation, healthy and happy and very much alive.

Clinical Pearls: Syncope

2010-11-30T19:37:00.001-08:00

I'm doing a new thing here. I'm listening to medical podcasts on the way to work, so I'm going to try and share some of the pearls of clinical wisdom I pick up. The sources are a variety of free podcasts available through iTunes.

If you're an experienced provider, you've probably (like me) forgotten a lot of the nifty bits of clinical information that you were taught in school but didn't NEED to know. The stuff that got lost when you were cramming NREMT and ACLS skill sheets in your head. The stuff that might actually be more useful now that you're out in the field.

So that's what I'll try and bring you: Short, sweet tidbits that can help the experienced (or new) provider up their game.

We see syncope a lot. A lot of it is (or seems) harmless, and many of us like to wastebasket it into the vasovagal category, and don't mind getting a refusal.

Try to be more suspicious. Don't get suckered by how good they look now. Think about the patho. If it's not a seizure or low blood sugar, it's probably not enough blood or oxygen getting to the brain. Arrythmias? Stroke? Aortic stenosis or dissection? Occult (you know, hidden) bleed? Pulmonary embolism? There are some big, scary bears that cause syncope, and you should suspect them before you call it a vagal or psychogenic.

But how do you make that judgement? What should worry you?

First, most of these folks warrant a good assessment. Get a real detailed history. Find out if they had symptoms before they syncopized. Get a good set of vitals, and a 12 lead ECG is an excellent idea. Check neuros. Ask friends and family if they are acting normal. Go LOOKING for trouble.

But who are the folks to be worried about?

• Patients with chest or back pain, new onset, before or after the syncope, should be concerning for aortic aneurysm or dissection, or PE, or cardiac causes.

• Patients who don't return to their baseline after a syncope should be concerning for intracranial pathology (CVA/TIA/bleed).

• And patients who have no prodrome, no symptoms before passing out, no dizziness or tunnel vision, those folks should have you worried about weird rhythms.

Vasovagal syncope is not uncommon -- but just like anxiety attack, it should be a (presumptive, field) diagnosis of exclusion, the one you reach after everything else has been exhausted.

Hope this is helpful to some of y'all. More coming soon!

Drugs

2010-11-05T01:34:00.001-07:00

They say we shouldn't do it. They say that Rapid Sequence Intubation - the practice of sedating and chemically paralyzingly a patient to place a breathing tube in their trachea - is too dangerous for paramedics to perform. They say the studies show it's too risky. They say we're not good enough at intubating. They say you can support a person with basic techniques.

They say, they say. And in many cases - trauma in particular - I tend to agree.

And yet.

* * * *

Drugs got him here, and drugs will be his salvation. He wasn't breathing when the fire department EMTs arrived. Narcan helped his respirations, but nothing else. They're not sure what he took.

They've barely stopped bagging when we walk in. Not down too long, they say. History of drug abuse and suicide attempts. So we start the workup.

I start a line in his ankle, the only site I can find. My partner hooks him up to the monitor. He's breathing forty times a minute, but his oxygen saturations hover around 85%. He won't wake up and his lungs sound like a tire chain in a tumble dryer. Even with suctioning, an NPA, and more bagging, he doesn't really improve. His jaw is locked tight, and all I can do is run the Yankauer over his teeth.

The nearest hospital is 35 miles away, on windy, rain-slick country roads.

They say...

We load him in the ambulance, make a few more desultory attempts at BLS airway managment, and then make the decision.

My partner draws up the drugs. I get out my tools -- Options A, B, and C.

My eye briefly lingers on the small cardboard box of Option D. I can picture what's inside, the plastic package and scalpel and Sharpie-scrawled message some wise-ass coworker has left: "GOOD LUCK. STAY CALM."

I leave the cric kit on the shelf. Everything else, though - tube, bougie, King - I lock and load. Line them up neatly. Lights up. Suction running. All the positioning tricks I know. He predicts like a difficult airway, no matter which mnemonic or scheme I use. Nothing good about this. We can't get his sats over 90%.

My partner, holding two syringes, asks if I'm ready. The firefighter assisting us looks at me expectantly.

Well. I suppose. I'd better be, hadn't I?

He pushes the drugs, and I wait until he stops breathing. His jaw loosens, and I slide the blade into his mouth. Everyone is gathered around - the firefighter holding cric pressure, my partner pulling the patient's head into a better sniffing position - and all of a sudden I can see the cords.

"Whoa! Okay, tube, tube. Good. Okay. Through the cords. Stylette out. Balloon up. Get that capnography on. Ears? Okay, bag. Yeah? Sweet."

And then it's all over but secure the tube, clean up, sedation, NG tube, and so on -- all during the long drive in.

He's hard to sedate and fights us some on the way in -- maybe a speedball? -- but his sats slowly come up.

By the time we leave the hospital he's at 100%, sleeping peacefully with the aid of a versed drip. The doc shrugs her shoulders.

"Don't exactly know what's up. We'll have to wait for labs and imaging. Could be a few different things. Sounds like it was a tough one out there. Good job, guys."

* * * *

They say, they say, and sometimes I think they are right, and sometimes I think they are wrong.

Faker

2010-10-25T16:47:00.001-07:00

We've run on him fifty times. I've written a dozen charts personally in the last year, and I'm one of twelve ambulance medics in our district. Everyone knows him. Everyone knows the address. We groan when the dispatchers name the apartment complex, and snarkily ask our partner if they need help getting mapped in.

Chest pain, always chest pain. He has the history -- a zipper scar, a boxful of pills, a 12 lead with Q waves. He looks scary -- pale, clutching his chest, always telling you it's real bad this time, it's never been this bad. The first time, and the second, and the third, you get worried, you work him up hardcore, pushing the nitro and fentanyl and repeating 12 leads and bypassing the community hospital to go to a cath lab facility, just in case. Just in case.

But the fourth, and the fifth time, your concern start to wane. Despite everything, he's stable. He doesn't decompensate or throw PVCs. He doesn't get cathed. And then the doc at the recieving facility starts to tell you about all his visits. How he requests narcotics by name. The mysterious morphine allergy. And the picture starts to come together in your head.

* * *

We were out of district when the call came down for a domestic at his address. We sent the cover unit an MDC message. Just so you know, if the guy claims chest pain, he's usually not as bad as he looks. Work him up, but he's got a history of seeking. Just so you know.

A while later they write us back. Wasn't him. He beat up his brother. He went to jail.

Huh. Isn't that something.

* * *

But an hour after that, we're toned to the police station. Law enforcement request for medical. I bet my partner a dollar it's him, that he's developed chest pain in the cell.

We walk in. I turn to my partner. "You owe me." He laughs. The firemen are standing around, getting vitals. No one seems rushed. I ask the cops about what happened. Is he still in custody. Yes? Okay. Which hospital? The one by the county lockup? Sure, we can do that. No problem.

I walk back to the cell. Vitals okay? Right. And when did he say the chest pain started? How does the 12 lead look?

"Well," says the fire medic, "actually tonight it's this weakness. And he's acting like he can't talk."

I blink rapidly, and look at the patient. He's not moving anything on his right side. The corner of his mouth droops. A fireman asks him about allergies, and his answer sounds like Animal from the Muppets.

Are you kidding me?

I do the neuro exams. He's definitely a "good" stroke, by the numbers. He's got the risk factors. The fire paramedic rolls her eyes. "He's pulled this before, too. Haven't you seen it?"

No. No, I have not. We can't treat it like he's faking. We have to work it up like it's real. It looks real to me.

"Absolutely," she agrees, and she is in fact a decent paramedic, one of the better ones to ride an engine. "All I'm saying is, don't get too excited."

We load and go. Code 3 to the closest hospital, call the stroke alert, large bore lines in both ACs for CT scans, 12 lead just in case, the whole Happy Meal deal, with toy included.

At the hospital, the ED doc thinks it's genuine. He passes the Hand Drop Test, smacking himself in the face. His reflexes are absent on the affected side. He doesn't have a bleed, on the scans. We tell the doc about the history of seeking and faking, and he nods, but says it's no reason this couldn't be the big, bad, ischemic stroke it appears to be. I agree readily. Absolutely, doc. Just want to make sure you have all the facts in hand.

"Appreciate it," he says. "We'll see. Neurology is coming in -- and pharmacy is sending the tPA up."

Six hours later, dropping off another patient, they tell us he got the 'lytics, and went to the ICU with some improvement showing.

Huh, we say. He finally had the real thing happen. Poor guy.

* * *

A month later, I run into the doc again.

Hey, you remember that stroke? The one who had the history of faking, but turned out to be having the real one? How'd he do?

The doc just shakes his head. "They did CTs and MRIs and all the tests you could imagine. Never found any evidence that he'd actually stroked."

What? Seriously?

The doc sighs and rubs his head. "Oh yeah. Yeah."

"Wow," I say. "What happened? I mean -- he got the tPA. How'd that work out?"

A shrug. "Who knows."

Another doc pipes up. "Bled out, probably. Poor bastard."

Throat

2010-07-02T07:15:00.000-07:00

It's a huge apartment complex. We find the building we want, and park nearby. We shoulder the airway kit and Lifepak and medbox. We walk up the path around to to the front of the building, and then up two flights of stairs.

A young woman, visibly upset, opens the apartment door when we are halfway up the last flight of stairs. Here, she says, in here, leading us to the living room.

He sits on the perfectly normal couch in the perfectly normal apartment, and there is no blood or gore, no gunshot wounds or impaled objects. And yet his eyes are full of fear. His right hand is white-knuckled around his own throat, and he doesn't say a word.

He is barely two months younger than me, and if he lets go of his throat, he cannot breathe.

* * * *

His girlfriend, or wife, tells us the story as she knows it. How he crawled into their room and woke her up. How between a few words he gasped out and his pantomimed gestures she gathered that he tripped over the cat, and struck his throat on the edge of the table. How she called 911 while he sat, trying to stay calm, stenting his own airway open.

He's able to answer questions by nodding. He's healthy. He didn't pass out. Nothing else hurts. We try to look at his throat, but as soon as he lets go his sats drop and he moves no air. We quickly abandon our exam and let him resume his careful hold on his trachea.

Can you walk? we ask. Nod, nod. Good. Let's get some shoes. And we pop a nonrebreather on and walk him down to the ambulance, simple as that, supporting him and taking a break when we need to.

At the car, my partner throws a quick line in while I call the trauma center on the radio. The fire engine has showed up, and I load a couple of friends for the quick trip up to the Level I center. The fire guys sit on the bench seat, doing vitals and reassuring him.

I sit in the airway seat, behind him, out of sight, the cric kit out and open, prepping an ET tube, RSI drugs handy, hoping fervently I won't have to use any of it.

I don't.

* * * *

At the trauma center, at least twenty people have gathered. Trauma surgeons, emergency docs, anesthesia, respiratory ... they crowd the room. Trach trays are opened, sterile gloves donned. Game faces on.

He finally gets really, really worried when he sees everyone gathered for him, and I can see tears well up in his eyes. I'm standing at the foot of the bed -- I have no intention of leaving before I see how this ends. The social worker makes sure she has his girlfriend's information, and steps out of the room to call her.

They prep to attempt a tube with a Glidescope, ready to go into his neck if that doesn't work; anesthesiologists at his head, surgeons at his side. An anesthesiologist has taken over holding his throat. The room is full of quiet, professional chatter; let's go with a six-oh tube and etomidate and sux is fine and are you all ready? A nurse steps up with the syringes full of medicine.

I meet his gaze, and realize that in all the bustle and confusion, there's very little attention being paid to him as a person. And it strikes me how much more frightening that would be.

And so I reach out my hand, and he grabs it, tightly, and I hold his hand until the drugs take hold.

Laundry

2010-06-22T23:12:00.001-07:00

This is what happens when you do laundry in a dual-medic household.

Yes, it's true, She Who Must Be Obeyed works in The Business too.

Accessories

2010-06-07T14:12:00.001-07:00

The scene: A house, at night. A fire engine and ambulance idle softly in the cool air. A patient has been loaded up, and now Yours Truly and a fire lieutenant wait for his wife to lock up the house. Yours Truly notes the fireman is holding some of the lady's belongings.

Me: "... That's a very nice purse you have."

Lt: "Do you like it? It's from my spring collection."

Me: "It matches the color of your eyes."

Lt: *blush*

Overtime

2010-05-25T19:44:00.000-07:00

Eleven hours in to a shift in the city, my phone rings. I glance at the face. "SUPERVISOR JIM." Hmmm. They've been paging for a night shift, more and more frantically. I thumb the green key.

"No."

"Hear me out!"

"No. I'm not working a twenty-four."

"Dammit, just ... listen, okay? It's a sweet deal."

"... okay."

"There are two medics on the car already. The problem is, neither of them is a lead medic. But they're both checked off. And one is in the lead training program. You just need to be THERE, to keep an eye on things. They'll do all the work."

"... no charts?"

"You can sleep in back all night, and just wake up for calls! Come on, man."

I take a deep breath.

"Let me check to make sure the wife doesn't mind."

"You da MAN!"

"And I want movie tickets."

"Done."

* * * *

Three in the morning. I'm horizontal on the bench seat, strapped down against the bumps and turns of post moves. The radio is clipped to the stretcher next to me. I've just, finally dozed off when the tones blare. Damn Motorola. I swear, every time they go off, a year drops off my life.

I try and sit up. Too bad I'm still strapped in. Coughing, I pop the belts and make my way to the jumpseat. We're already moving.

I rub my eyes and address the cab of the ambulance as a whole. "What tomfoolery are we off to now?"

"A stabbing."

"... what?"

"See?" The MDC is turned to face me.

ENTRY: STARTING MED, SAYS SUBJ HERE IS STABBED IN BACK, REFUSING TO ANSWER OTHER QUESTIONS. POLICE ENRT. MED TO STG.

"Huh."

My partner scrolls down.

UPDATE: SOMEONE IN BACKGROUND YELLING, "THE COPS ARE COMING, HIDE THE WEED, HIDE THE WEED!" H/U ON ME. NO ANS ON CALLBACK.

I lean back against the airway seat. "Okay. This is probably BS. Don't stage too close."

We find a spot about ten blocks away and nose up to a curb, shutting the lights off. I close my eyes, and instantly start to drift aw--

*shwzooom!*

The whole ambulance rocks.

"What th' f-"

*shwmm!*
*fwmmm!*
*zmmmm!*

This time I can see the lights, as three more cops rocket past us, in full afterburner, doing somewhere upwards of Mach 2. I look out the back windows as five or six more police cruisers blow past, stacked up in a line, lit up like Christmas trees, and apparently headed for hyperspace.

"Hmmm. Guess they think it's real."

A few minutes later the tac channel crackles. "Per police onscene, medical is cleared to come in."

We zip around the corner, down the street, thread our way through shoals of white police cars, and pull up in front of a house surrounded by uniforms. A man is laying on the porch. I blink and rub my eyes again.

"Okay," I tell the front of the ambulance. "I'm just gonna walk up. If he's truly stabbed, we'll just put him on the gurney and bounce."

As I approach the porch, four cops enter the house with guns drawn. "Police!" they shout. Definitely a secure scene. The man is sprawled on the porch, moaning and holding his side.

"Well?" I ask one of the cops. "Stabbed?"

He nods. "In the back."

I fish my flashlight out, and roll the man slightly to his side. Sho' nuff, there's a neat 4cm puncture wound in his mid-back, thankfully well away from his spine.

I'm already stepping off the porch as my partners and the fire crew approach. "Put him on the gurney," I tell my crew. "No c-spine. I'll be in the bus."

As I climb back in the rig, I spin the dial on my radio all the way to the end, from FIRE DISPATCH, past TAC A and B and C, through EMS OPS, to TRAUMA.

I try to suppress a yawn and key the mike. "Trauma, Medic Six with a system entry..."

* * * *

At the hospital, as the trauma team pokes and prods and ultrasounds and ponders, I chat with a cop and a surgical resident.

"So," the doc asks, "any idea who did this?"

The cop shrugs. "Maybe a domestic. It's not really clear."

Chuckling, the resident suggests, "Was he Standing On A Corner, Minding His Own Business? Was it Sumdood? Or Those Three Guys?" Clearly he's not new to taking care of the Knife & Gun Club.

The cop snickers. "Yeah, probably Sumdood. That guy is always causing trouble."

I wave at the cop. "Well, what are you doing here? Get the f*ck out of here! Go catch him!"

* * * *

Later, in the ambulance, I compose a text message to my supervisor.

Stabbing interrupted my nap. Actually had to work. Damn you!

Parking

2010-05-13T06:40:00.000-07:00

"Well," said the fire captain, "how are you going to get out? Do you want me to back you, or ... ?"

I looked up and down the four-lane highway. Between an engine, a rescue, our ambulance, and two cop cars, we'd completely blocked two lanes. I'd nosed the ambulance up close to a State Police car when we arrived. The trooper was still taking statements from witnesses.

I shrugged at the captain.

"I think I'll just push the state trooper's car into traffic, and then once it's been smashed out of the way by oncoming traffic I should have plenty of room."

"Hey!"

I turned. Oh yeah. The trooper was still taking statements -- five feet away.

"Oh, crap!" I grinned at the fireman. "They have ears!"

The trooper just looked at me and fired up his standard-issue Fifty Megawatt State Trooper Glare. I tried not to wilt.

"Well ... gotta go! You guys take care!"

"Soooo..." The captain was smirking. "I'll back you, then?"

Crosses

2010-03-19T16:42:00.001-07:00

In this part of the country -- maybe everywhere -- when someone is killed in a car wreck, more often than not family or friends will put a cross up by the roadside where it happened. Sometimes there's a name, sometimes flowers, occasionally a photo. If you keep your eyes open, you'll see these little memorials here and there, scattered around, slowly fading and weathering.

I always, my whole life, drove by crosses on the roadside and wondered what happened. Was someone drunk? Just tired, or unlucky? Were they young or old? Just idle thoughts as I drive down highways and back roads.

The other day, as I was driving to work, I passed a roadside memorial I hasn't seem before. For some reason I pulled over to glance at it. The name sounded familiar, though I didn't recognize the photo tacked to the scarred tree.

But then I realized -- if I replaced the lazy afternoon sunlight with 3am mist and strobing LED lights, if I swapped the soft sounds of the breeze and quiet birds for the grumbling mutter of diesels and Hurst tools, if I put fifteen people on the roadway and one wrapped between the car and the tree -- then I knew the place well, because it was my call, and my patient, and we knew even as we struggled to tube her and cut her free that she would never live.

Rules

2010-01-25T13:32:00.001-08:00

I recently got my yearly performance review. While it was generally positive, there was a small attached list of behaviors which are now forbidden to your truly. I thought I would share a few.

* * * *

Per dispatch center request, please do not respond to dispatch directions with "delightful," "by your command," or "pip, pip, righto, guv!" Additionally, please refrain from speaking on the radio in any foreign language.

* * * *

Per fire agency request, please do not provide an exterior building size-up on medical calls, request "the first-in engine company bring up my gurney on arrival," add your ambulance to box alarms, or assume Command on a chest pain.

* * * *

Per chart review committee request, please do not use the phrases "poor life choices," "pharmacologically assisted gravity attack," or "terminal deceleration syndrome" in your documentation. Additionally, we wish to remind you that "Funny Lookin' Beats" is not an acceptable description of ECG ectopy.

* * * *

Per fleet maintenance request, please refrain from turning in a vehicle failure report with reason listed as "PONTOONS DO NOT INFLATE FULLY WHEN ENTERING WATER." Additionally, please refrain from submitting requests for nitrous systems, afterburners, in-seat DVD players, or "bitchen' rims."

* * * *

Finally, per management request, please refrain from operating a lemonade stand, massage parlour, off-track betting establishment, or payday check loan business out of your station.

Moments (IV)

2010-01-13T01:41:00.001-08:00

We drive east, in the darkness and rain, bluegrass and crackling radio traffic in our ears.

Thirty minutes ago, we were giving report to nurses and a doctor, swapping the O2 over, 1-2-3 lift, there we go, no allergies, had three neb treatments, what else can we tell you?

Forty minutes ago, I watch my partner rip out a BVM, in the rear view mirror, and my fingers are resting lightly on the EMERG MASTER switch before he even gives me the nod. Yeah. Blinkies and woo-woos now.

An hour ago, we load a little old lady in the back of the car. She doesn't look great, but her sats perked up nicely on the neb, and she doesn't look awful or anything.

Eighty minutes ago, a firefighter is telling my partner what he knows, as I try to tease information out of an anxious son, carefully as any detective handling a skittish murder witness, firm but kind.

One hundred minutes ago, I was on the phone with my wife. Wait a sec, I said, as tones started whistling on county dispatch. Whoops. That's us. Gotta go. See you in the morning.

Love you.

Twenty minutes ago, through the hospital curtain, I heard a son, talking to a mother who might not have even been able to hear him. I'm here. We're here. Be strong.

Love you.

Spine

2010-01-10T01:56:00.000-08:00

In a quiet, unassuming way, the call is terrifying. In two ways, actually.

She's laying at the bottom of a half-staircase, surrounded by a fire crew. Nothing appears unremarkable. She's awake and talking. She's pink, warm, and dry. She isn't covered in blood. No bones project from her skin.

She isn't moving anything below her waist.

The fire paramedic looks up at me, and gives me a short report. It's all fine until he closes with, "We called medical control to ask about solumedrol -- they said no."

It's all I can do not to gape and shake my head. We move on with the call. Backboard, trauma entry, code 3 to the big hospital. She has true neuro and motor deficits below the level of her bellybutton.

I try to comfort her, reassure her, but she knows exactly what's going on and how ominous it is. I try so hard not to lie to my patients. It's a struggle not to tell her everything will be alright. I don't know that it will be. She's an avid cyclist. She talks about riding hundred-mile races.

After we leave her in the capable care of the trauma team, I ponder the fire medic's seemingly-innocuous words. Did he know anything about the solumedrol he'd asked for, or had he just heard somewhere that it could be used for spinal injury? Did he know about the plethora of studies that question it's effectiveness, or even the dose? I'm sure he didn't realize it would have taken 11 or 12 of the 125mg vials we carry to reach the 30mg/kg dose in this comparatively small patient.

I am forced by these circumstances to come back to my previous point, which is that we should all stick to our areas of expertise. I don't know step one about fighting a house fire. I know just enough about vehicle extrication to be dangerous. I know enough about HazMat to run the hell away. I leave those things to the fire department -- it's their expertise.

But I do know about prehospital medicine. I know the protocols, and the science and medicine behind the protocols, and when medication X or procedure Y is really necessary. I have an idea of when you can step outside the protocols, call medical control for permission to do something unusual.

I know enough to know that asking a doctor if you can give a patient steroids for a spinal injury, in the city, without knowing the dose, only makes you look a fool. That's my area of expertise.

Airway

2009-12-24T14:38:00.000-08:00

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

2009-11-01T01:08:00.000-07:00

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

2009-10-23T08:42:00.000-07:00

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

2009-10-10T20:10:00.001-07:00

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

2009-08-18T15:45:00.001-07:00

(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)

2009-08-12T09:40:00.000-07:00

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)

2009-08-09T22:22:00.000-07:00

"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

2009-07-27T03:17:00.000-07:00

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

2009-07-03T00:58:00.000-07:00

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)

2009-03-16T19:30:00.000-07:00

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

2009-03-03T10:42:00.001-08:00

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

2009-02-10T05:23:00.000-08:00

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

2009-01-11T23:01:00.000-08:00

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

2009-01-04T15:52:00.000-08:00

"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."

Manifesto

2008-11-25T17:33:00.000-08:00

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

2008-11-24T20:55:00.000-08:00

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

2008-09-25T02:47:00.001-07:00

"... 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

2008-09-24T02:02:00.001-07:00

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

Memories

2008-09-02T19:34:00.000-07:00

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

2008-08-26T14:15:00.000-07:00

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

2008-07-02T00:39:00.000-07:00

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

2008-05-11T17:43:00.000-07:00

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

2008-04-30T02:34:00.000-07:00

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

2008-04-23T01:25:00.000-07:00

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

2008-03-21T15:19:00.000-07:00

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

2008-03-07T04:31:00.000-08:00

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

2008-01-23T20:31:00.001-08:00

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

2008-01-08T01:14:00.001-08:00

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."

Overdose

2007-11-29T14:16:00.000-08:00

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

2007-11-13T20:49:00.000-08:00

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

2007-10-28T15:18:00.000-07:00

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

2007-09-04T04:42:00.000-07:00

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

2007-08-14T15:29:00.000-07:00

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

2007-07-31T19:16:00.000-07:00

"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

2007-07-23T22:35:00.000-07:00

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

2007-07-02T13:04:00.000-07:00

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.)