From a Streetcorner, 3am

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

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

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

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

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

Vignettes

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

She is not happy.

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

She does not agree.

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

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

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

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

"Shut up!"

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

"Shut UP!"

"Ma'am, I--"

"Shut up shutupshutupSHUTUP!"


* * * *

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

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

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

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

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

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

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

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

* * * *

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

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

"'zis'sh an airplane?"

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

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

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

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

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

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

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

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

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

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

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

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

"Oh hell, whatsh this?"

* * * *

He is old, but not that old.

He is naked, lying on the living room floor.

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

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

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

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

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

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

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

Sunset

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

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

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

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

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

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

Truths

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

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

We deal with the slowly dying.

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

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

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

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

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

Streets

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

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

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

* * *

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

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

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

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

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

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

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

"Suicide? And how--"

"Committed suicide on my icepick, he did."

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

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

* * *

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

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

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

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

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

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

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

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

* * *

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

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

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

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

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

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

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

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

Well, then.

Entry

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

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

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

"You wanna?" I ask.

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

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

... nothing. The bathroom is empty.

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

"The, uh, second door?"

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

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

Overdose

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

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

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

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

Oh, dammit.

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

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

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

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

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

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

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

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

Empathy

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

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

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

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

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

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

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

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

He looks sullen. "Nothin'."

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ten minutes later he walks out, AMA.

Cover

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

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

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

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

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

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

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

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

However, this is what the dispatcher heard:

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

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

Ninety seconds have elapsed since I dropped the radio.

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

Motion, and lights.

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

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

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

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

Bird

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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