Heart

He is half a dozen years older than me, sitting in a hospital bed, awake and alert, perhaps a little worried, but not acutely unwell. 

Beside him, partially hidden under a sheet of patient labels and some IV supplies, is a single sheet of paper with some squiggly black lines that, to the learned and practiced eye, tell a different story. A distinctive pattern of elevation and depression. Certain waves are far higher and sharper than they should be.

His heart is choking, dying. 

* * *

Fortunately, he did most everything right. He took aspirin. He came to a major hospital, with a cardiac catheterization laboratory capable of emergently imaging his heart, identifying blocked vessels, and reopening them to reperfuse his hypoxic myocardium. 

Unfortunately, the cath lab is busy. A complex case on the table that cannot be interrupted. So the hospital makes phone calls, looking for an available lab, an open table. And a call to 911 as well, and four miles away I flip a righteous U-turn in ten thousand pounds of ambulance and fumble for the siren. 

* * * 

That brings us to now, standing in the room, reassuring this patient, making small talk, as the hospital works to transfer him.  

The cardiologist comes back in. Good news. Mercy Medical Center will take him. They are calling in the team. Load and go. 

We get him on our stretcher, all our wires and tubes in order, paperwork signed, report called, and then his father and son appear in the doorway. 

The boy is maybe ten, and he looks worried, holding his grandfather's hand. 

"It's okay," the man tells his son. "I'll be alright. Listen to grandpa. Remember it's bath night. I'll see you soon."

"I will," says the son, and my partner thumbs the button and the gurney rises with a hydraulic whine, high above the reach of a small boy, who is trying to hide the fact that his eyes are full of tears. 

The gurney starts to move, and I take one step, two --

"Wait, wait," I say suddenly, surprising myself. I look down at the boy, full of thoughts of my daughters at home. 

"You want to give your dad a hug and kiss?" I ask, and even before he's nodding, I've scooped him up, lifted him level with the gurney, so he can wrap his arms around his father's neck and peck him on the cheek. 

Then I set him down, he scurries to grandpa, and we take dad off into the gathering dusk. 

* * *

Five miles away and forty minutes later, I lean against the wall of the cath lab control room, watching the team work through the glass. They are fast, sure, professional, all precise movements and chopped, incomprehensible terminology.

A monitor plays black and white loops, a few seconds of flouroscope imagery at a time, as they probe his heart with wires and radiopaque dye. 

There. An absence, a hole where a dark artery should be. They swap equipment, thread another wire, push the plunger on a syringe, and someone says, "There's your door to balloon." 

On the flouroscope, a little elongated sausage shape appears briefly, then is gone. 

The next flush of dye shows the missing artery, open again. Already the EKG is returning to normal. 

"Did you need something?" the tech asks me.

"Nope. Not a thing at all. Thanks."

The Circle

This story seems unbelievable. I assure you, it's quite true. 

* * *

Early 2006 

I was in the clinical phase of paramedic school, doing rotations through the hospitals. Mid-afternoon on my second shift with the pediatric transport team, they – we – were paged to respond to a small community hospital about seventy miles away, to bring a patient back to the children's hospital.

When we arrived she was awake and happy, sitting up, a little blonde girl, maybe seven or eight years old. She was going to Portland for further tests. As stable as she was, we just put a DVD on – it was a pediatric ambulance, after all, with a TV and all – and had a nice quiet ride back. The transport nurse talked to her a bit, I talked with her some, and she happily chattered back. She was curious and happy and totally unfazed by the situation.

She said a dog in the movie was silly; and I told her about how my dog would go to sleep on the foot of my bed and end up next to me on the pillow when I wake up sometimes. On our way into the pediatric ICU we stopped for a second by a window, so she could see the city. She thought that it was pretty neat.

After we dropped her off in the ICU, I went to have lunch and catch up on my paperwork. An hour or so later I walked past the room the little girl was in, and she waved at me. Her dad – who I hadn't even met – said, "Hey, there's your friend!" Apparently she had been talking about me to her parents. Of course I went out and hung out in her room.

She was curious about everything that was going on, so I stayed in her room and explained as the nurses put in a second IV and got her hooked up to a portable monitor. Then I walked with her and her family over to Imaging so they could do a CT scan, to repeat and confirm what they'd seen on her scan at the community hospital.

She wanted to know about the pulse ox – "the light on my finger" – and I told her it was watching how well she was breathing. I was glad that she was old enough to understand an explanation.

She told me about her family, and I showed her a picture of my dog. "That's the dog that sleeps on your pillow, right?" she asked. Exactly, I told her. Smart, cute as a button, and very brave.

Oh, so terribly brave.

* * *

Her parents had taken her into the small community hospital this morning for an outpatient MRI scan. She'd had some headaches over the past few weeks, some episodes of loss of sensation on one side of her body, and over the past day some nausea and vomiting.

The mass in her head was at least 5 centimeters across. 

Her mom started crying as the image slices came up in real-time, because you could see it. Easily. No radiologist needed. It was surreal, because from the outside, she was perfectly neurologically intact, while the scan clearly showed a huge mass putting pressure on her brain. "Midline shift" is the term. It's a dry term for an ugly thing. 

I got mom a box of tissues while the nurse hugged her. Dad was in the scan room with a lead apron on, holding her hand. He never saw the pictures on the screen.

They scheduled neurosurgery for the next morning.

* * *

A couple days later, I wrote about her in an email to a friend:  I don't know if I'll follow up next week. I don't know if I want to. She seemed happy to have a friend, and her parents both thanked me, which makes me feel a bit better, for making a kid in a scary situation feel a bit better. 

A PICU nurse told me I shouldn't get attached, that you can't do the job if you get attached, which is maybe true for him working twenty-plus years, but not so much for me with this one rotation. We'll see. I was ready to walk away and leave that distance, until I saw that smile and wave and heard "Oh, there's your new friend..." 

Godammit.

* * *

I did try and follow up, two weeks later.

Tried. She had been discharged, a week after surgery. I quickly found out that being a student meant a brick wall as far as any other information was concerned.

In any case, my pediatrics rotation was over, I had new things on my plate, and, in my heart, I felt like I probably didn't want to know.

I wanted that sweet, bright kid to grow up, to do all the normal things that kids do, to not be sitting in a hospital gown on a too-big bed, full of wires and lines.

I wanted to imagine she lived to summer, to Christmas, and I knew just enough medicine to have a pretty good idea that would not be the case. 

* * *  

Late 2012

Six years later, I had mostly forgotten about the little blonde girl.

I had worked as a medic in the city, ran some ugly calls, helped a few people live, watched more people die. I'd gotten my feet wet, and then transferred out to a rural ambulance, working on the mountain. Long transports, sick patients, to be sure, but also lots of down-time. Lots of time to talk.

One night I was talking with my partner, an EMT who was a few years younger than me, and we got on the topic of pediatric patients. And so I told him the story of the little blonde girl, who was so brave, whose fate I never knew. I meant to tell the story as a way of discussing the value – and risk – of making emotional connections with your patients. There's no clear answer, I was going to say. Sometimes it's for the worse, and sometimes it's for the better. 

I never got to the end of the story.

Halfway through, my partner got a strange look on his face, and started grilling me for details. What happened to her exactly? When exactly was it? What was the little town we took her out of? 

What was her name?

Of course, I had long since forgotten her name. I told him what details I remembered, and his expression just got stranger. He looked spooked. Are you sure? 

Yeah, I told him. I think so. Why? What the hell is up, dude?

He said he had to make a phone call, and stepped out of the ambulance station. About five minutes later, he came back in, and sat down, heavily, in a chair. He looked at me, and looked down, and looked at me again. The silence stretched.

"What?" I finally asked. "What is it?"

"My aunt," he said.

"She knew – I mean – before I told her. I just asked her about when my cousin was sick, when she was little. When she had brain surgery. 

"I asked if she remembered any of the names of the crew that transported her to Portland. 

"And she said oh yes, there was this paramedic, he was so sweet, and she told me your name."

"My – what?"

"She remembered you! Told me the exact same story! That was my cousin, man, my little cousin you took care of."

 I found that I was holding my breath, and let it out, slowly. "I – I never found out what happened to her ..."

"Oh, god! Oh, shit, oh – she was – it was just blood, it was nothing."

"... Nothing?" I said faintly.

"Yeah, man. A little aneurysm or something, they fixed it and cleared that blood and that was it. She's fine. I saw her a few months ago. She'll be starting high school next year."

It's All Moments

A man cries on my stretcher.

He's rounding on a hundred years old. A carpet took him down tonight, nothing more. He isn't even seriously hurt. Just hit the wall hard enough to rattle his brain a bit. He's not really confused, just can't quite remember the last six weeks or so. 

His wife died a month ago, and so I hold his hand and listen to him cry, as the loss is made new again.

* * *

A man lies on my stretcher, muscles flexed, teeth clenched, arms rotated peculiarly so his palms face outward, to his sides. Blood streams from cuts on his head and face, and he breathes quickly, noisily, snoring. He doesn't respond to anything we do. The air in the ambulance smells of beer and iron. 

I hand two syringes to my partner and look down at the man's face as she gives him the meds, one after the other. I adjust my safety glasses, thumb the laryngoscope open, and wait for his breathing to stop. 

* * *

A toddler sits in the car seat, which in turn is strapped to my stretcher.  He cries, confused, hot, still coming out of the seizure I fervently hope was caused by a virus. His mother holds his hand, trying not to look scared. As my partners work at assessing him, I stand behind the gurney, patting his shoulder with a blue-gloved hand, telling him softly, "It's okay, it's okay, you're okay, sweet boy." 

Neither he nor his mother speak a word of English, and I cannot stop thinking about how much easier this was before I had a child of my own. 

* * *

I have the same conversation a hundred times.

"Whoa, you're a paramedic? I bet you see some crazy stuff. It's got to be a super stressful job!"

Every time I lie. 

"Eh, not really. Most of it is pretty routine. Little old ladies falling down. Nothing like you see on TV."

Fishing

(Author's note: I apologize for having to share this, but it's the healthiest thing for me to do. I'm sorry you have to read it, and I'm sorrier I had to be there, but that's all eclipsed by how I feel for the family in this story.)

* * * *

And King David was much moved, and went up to the upper chamber of the gate, and wept; and as he went, he cried, "O my son Absalom, my son, my son Absalom! Would God I had died in thy stead, O Absalom, my son, my son!"

2 Samuel 18:33

* * * *

It sounds like an old folk tale. It is not.

Far, far away from anything, up in the mountains, is a high lake, ice-cold and terribly beautiful, surrounded by steep hills, and full of trout. A great place to go fishing. Two brothers sat on the lake, in a tiny boat, while their father watched from shore. And something happened – one stood up too quickly, or the other shifted his weight – and the boat went over. Flipped them both into the water.

* * * *

We're seventy miles away when the call goes out, a long set of whistle tones, eight or ten pairs, followed by the dispatcher announcing a water rescue at a remote lake in the other end of our district. The fire department goes and the sheriff's deputies go and the closest city ambulance goes and our rescue ambulance goes. Screaming down the mountain, around the curves, listening to the chatter as everyone goes enroute and dispatch gives us updates.

"You know," I say, quietly, almost contemplatively, to my partner, as we rip past a semi, "by the time we get there – by the time anyone gets there – it will all be over."

"Yeah," he says. He's junior to me, but definitely has more water experience. Worked River Rescue in the summers before he got on the car. I jokingly call him our rescue swimmer sometimes, like we're a Coast Guard helo or something.

Now he looks out the window, into the growing dark. "Yeah."

* * * *

They swam for shore, as their father watched, urging them on, running for a rope and a life jacket, swimming out himself to meet his older son halfway across. It was maybe a hundred yards to shore.

* * * *

Dispatch updates us that a civillian truck is bringing one patient down to the ranger station. Hypothermic. One other still unaccounted for. The first ambulance says they'll meet up with the truck and take care of the patient. Everyone else – boats and cops and firemen and us – continues for the lake, up gravel roads, single lane, hairpin turns.

We get there a few minutes after the fire rescue boat. They're zipping up drysuits and getting their little zodiac put in the water. We talk to the deputy who's in charge, get the story. The second patient – the younger son – was last seen fifty feet from the boat. Well over two hours ago.

We can see the boat, half-submerged, out in the lake. The water is calm and the whole scene is eerily lit by floodlights and headlights, criss-crossing in the dark.

The deputy indicates a small SUV with a toss of his head, a forest ranger's first-response vehicle. I can just make out someone sitting in the passenger seat.

"Dad's still here. Just so you know."

* * * *

For a mercy, it doesn't take the firemen long to find him, in the clear water. We bring the ambulance gurney down to the water, so they don't have to put him on the ground with his father watching.

My daughter at home is barely a month old, and suddenly I can put myself in this man's shoes, and realize that there is no cutoff for when a parent can stop being afraid for their child. No magic age when they're safe.

And – though I am not a Christian, by any stretch of the imagination – I am reminded of the story of David and Absalom, and the heart-wrenching description of the king crying over his son.

This is far, far worse.

* * * *

Pictures

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

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

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

(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

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

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!