1 : Relatively undeveloped; primitive: a rude and savage land
2 : Exhibiting a marked lack of skill or precision in work: rude crafts
3 : Lacking education or knowledge; unlearned
1 : marked by lack of proper caution : careless of consequences
2 : utterly unconcerned about the consequences of some action
1 : to withdraw one’s support or help from, especially in spite of duty or responsibility; desert
2 : to give up to the control or influence of another person or agent
3 : to walk away from
Standing over the patient, who’s sprawled across the stoop of this shabby two story house in the impoverished urban sprawl neighborhood of the county, I kneel down to slide back his eyelids and expose pinpoint pupils. Pulling the stethoscope from around my neck and placing it in my ears (more to drown out the yelling of the family members on scene than to hear better) I place the bell on the side of my patients throat. The stethoscope can assist in hearing respirations when they’re shallow and far between. Tilting my head as I’m waiting an eternity for the next respiration I can see the fire engine that responded to this house light up down the block, siren doing the long slow whine, as it accelerates away from me towards a fire. My new patient has a respiratory rate of four per minute. I’m not happy.
I’ve been working in this new county for months now after getting signed off by my FTO to work as a Paramedic with an EMT partner. We were called to this house for one of the most ambiguous calls in EMS: “man down, unknown.” As we pulled up to the house with the BRT in front I see three firefighters carrying their gear back to the rig with a degree of haste. One of the firefighters looks at me as he’s storing the cardiac monitor into a sliding compartment of the rig. I see him through the windshield as our tires stop moving. He gives me the flat, thin lipped, look of angst. I’m still fairly new in this large county so I don’t know all of the firefighters yet — that will take years, much less do I know their personalities. Before I can contemplate the expression more he turns and climbs the fold out stairs into the rear passenger compartment of the engine.
Walking up to the house the fire lieutenant is walking out of the yard. He rips off the EMS copy of the fire sheet which should list the patient demographics, vitals, medical history, current medications, allergies, and treatment rendered. This fire sheet has two things filled out: a name and a birthday. As the lieutenant is passing me, headed towards the front seat of the BRT, I’m asking what’s going on with the patient. Looking over his shoulder, never missing a stride, “I don’t know, maybe an OD. We have a fire in our district, are you guys good?” I may be new but I can recognize a dismissal when I hear one. It’s obvious they are leaving regardless of my complaints. I’m just going to have to deal with what’s in front of me. No, I’m not good, I’m really god damn far from good!
Pinpoint pupils, decreased respirations, any new paramedic student knows the signs of a heroin overdose and how to fix it. That’s not the problem right now, the problem is he’s 220 pounds of weight that’s fixing to be dead weight if I don’t do something soon. The family is yelling at me. “Where the fuck did they go? Why ain’t you helping my boy?” The patient’s mother is understandably upset and getting all up in my face about it.
“I promise you I’m not going anywhere and I’m going to help him. But you’ve got to work with me so I can do that. Does he use drugs?” I’m still pretty new in county, I must sound like Mr. Rogers to her with my proper English and pronunciation. Can you say “white bread?”
“Hell no he don’t use drugs! He been clean for three year.” Okay, whatever! Regardless of her answer I know what needs to happen here.
“Okay, well, he’s looking pretty sick right now. Can I get you three to help us move him on the gurney?” It’s a beautiful day in the neighborhood, a beautiful day in the hood…
With the help of three family members and my partner we move him to the gurney. I get him strapped down and moved into the rig where it’s a better working environment, and safer. I tell my partner to leave the lights on and get us out of here, but not too far, and don’t tell dispatch we’re transporting. Kevin is an experienced EMT in the hood and knows what that means: put a little distance between us and a potentially dangerous situation, then pull over so I can do my on-scene treatment. He gets us maybe ten blocks away with a couple of turns and pulls over to the curb, jumps out and comes back to help me work this guy up in relative safety.
While Kevin was relocating our rig I was completing the first steps of an assessment that the fire medic should have done. Decreased respirations at four per minute, fast heart rate (trying to compensate for the lack of oxygen), blood pressure still okay (he’s in compensation mode for the moment). I administer 1 milligram of Narcan by way of a nasal atomizer. Narcan binds to the opiate receptors of the cells at 100 times the efficiency of opiates. Basically, it blocks the opiate from being able to effect the cells and completely reverses the effect in a matter of seconds.
The nasal atomizer is just a first step to bring his respirations up and buy me some time, I don’t expect that such a low dose will fix the situation, especially with the lower absorption rate from the nares. Kevin jumps in the back and helps me in getting an IV established.
“Damn, this dude is built, and freak’n heavy — he must spend a lot of time in the gym!. Check out this bicep, I’ll have no problem getting an IV with these veins.” A beautiful day in the hood…Kevin gives me a smirk.
“Do you want me to restrain him, he might come out of it combative?” Hank, my FTO, told me to listen to the experienced EMTs in the county. They may not have as much medical training as I do but they know the streets and the people who live there.
Using the leather restraints Kevin secures his hands while I finish setting up the Narcan for intravenous administration. Now that I have my monitor and oxygen set up I can track his respirations using a measurement of his exhaled CO2 levels. He’s breathing six times a minute with a shallow waveform on the monitor; the heroin is repressing his respiratory drive. The intranasal dose was just to buy me a little time for the intravenous dose that will reverse the condition.
The concern is that when someone’s high gets turned off they can get angry, combative, go into withdraw, or vomit. All of this could happen or none of it. It depends on their tolerance, level of addiction, and how fast I administer the Narcan. That’s why I’m sneaking up on the level needed to reverse the heroin by slowly injecting a half a milligram at a time and waiting for the effect.
After two milligrams of IV administration the man’s eyes pop open like a light being turned on and the monitor immediately shows an increase in respirations to 20. He looks down at his restrained hands, then around the ambulance and he finally starts to get his bearings. I look down at the pitiful example of a fire sheet to see his name.
“Antoine how do you feel?” Big round eyes staring at me, pupils dilated back to normal, as he slowly gets up to speed with where he is and what’s going on.
“I’m a’rite, what the fuck happen, why the fuck my hans tied up, you a cop?” Kevin’s still with me in the back in case things get out of hand. I explain to Antoine that he passed out and his family called us and that I’m a paramedic not a cop. I get the cop thing a lot, even out of uniform — I think it’s the hair cut. Now that he’s starting to understand what’s going on he calms down, especially when I tell him we’re going to the hospital and not the jail.
I tell Kevin I’m good and we can start heading to the ED. He moves back up to the front of the rig and starts driving us to the closest ED, it’s maybe 10 minutes away so I’ve got a little time.
I recheck all of Antoine’s vitals — he checks out fine. The Narcan did its job — I just have to get him to the ED before it wears off. It has a fairly quick half-life, much faster than the heroin. Back in the rural county where I used to work that was a concern as we could have a thirty-minute transport time that would require re-administration to keep the effect. In this county it’s not too much of a concern as we’re always pretty close to a hospital.
Antoine is acting fine and seems to have a reasonable disposition so I offer to take off the restraints. “You gonna be cool if I take these things off you?”
“Yeah man, I cool.”
I take off the restraints and start working on my laptop to try to get some patient information before we get to the hospital, since he’s talking now. I ask him if he did his normal amount of heroin or if he overdid it today. He tells me it was a normal amount but he hasn’t had any for a while, he’s been in jail for three years. Duh, prison-ripped, I should have spotted it. That’s why Kevin smirked at me, this guy doesn’t exactly have a membership to 24-hour Fitness.
Looking at the fire sheet I recognize the date of birth. “Hey man, it’s your birthday today.”
“Yeah, see, I think thas what happen. I wen to the store an saw some my boys. They know I jus got out an is my birthday so they hook me up.”
It’s all starting to make sense now. He’s been away for three years; he’s got a clean system. There’s plenty of drugs in jail but it’s difficult to consistently do heroin intravenously in jail because it requires a syringe. He’s muscular because he works out all the time since there’s nothing else to occupy his time. The heroin hit him hard because of his level of fitness and clean system.
Antoine is quiet now and as I’m doing some paperwork I think about the deplorable actions of the fire crew. I get it; they’re firemen and firemen fight fires. This department jumped on the ALS (advanced life support – paramedic) band wagon kicking and screaming. They didn’t want to get involved in medical calls but they were forced into it by the county EMS agency. They still have the mindset and culture that their primary function is to go to fires even though ninety percent of their calls are medical. The paramedic on an engine is in a tough spot sometimes. That’s why he gave me a look of angst when they left.
Technically he’s the highest medically trained person on the engine and he makes all of the calls pertaining to patient care. But in reality he answers to the lieutenant. The lieutenant didn’t want an engine from outside of their response zone coming in to be be first at the fire. The first engine to arrive first runs the fire scene. So if they are late to the fire they could end up hosing off adjacent structures or setting up supply lines instead of kicking down doors and battling the beast. There’s also a rivalry between stations — if you can steal a fire from another crew in their zone then you get bragging rights.
The actions of the lieutenant put the patient at risk, put my safety at risk from the angry family, and put his paramedic’s license on the line. It’s called abandonment; you can’t just decide you have better things to do after you’ve started working with a patient, you have to follow it through. It’s the law. Now, technically, they could say they gave me a handoff; a fire sheet with a name and birthday. Yet had the patient coded I would have had to call in another crew to help me work it up. Fortunately everything worked out fine but that’s not always the case. Just when I think I have things figured out; EMS has a way of surprising me and challenging my belief structure.
As we’re pulling into the ED I’m thinking about my life four years ago and wondering if I made the right decision. I walked away from a successful career in an unrelated field to begin the process of becoming a paramedic. I had this crazy idea that I wanted to help people and make a difference in the world. I traded in my conservative casual office attire for a uniform and started working with people ten years younger than me for less than half the salary I was used to bringing home.
Since then I’ve delivered babies, watched people die, and found myself in the midst of gang violence, drug abuse, and so much more. Most times it’s rewarding, sometimes it’s astonishing, but every day brings something new. Many of the people from my old life thought I was insane for making the switch yet a few understood. Looking down at Antoine I know I made the right decision.
This is going to be an interesting journey…
1 : The act of awaking, or ceasing to sleep
2 : Rousing from sleep, in a natural or a figurative sense; rousing into activity; exciting
3 : to cause to be aware of
Is human life just a dream, from which we never really awake, as some great thinkers claim?
William Shakespeare –The Tempest
We arrive at the same time as the BRT which is taking an angled position across the street to block the intersection with their rig. This provides a degree of protection from traffic. We saw the patient laying in the crosswalk, flat on his back, not moving as we drove into the intersection. He looked like a GSW victim; bloody, laid out, no movement.
Jake, our ride-along EMT student, is excited as it’s the kind of bloody mess of a call that he was hoping to get today. EMT students are required to ride in an ambulance as part of their course completion. The majority of them are here to get their certificate so they can apply to fire departments. Maybe half will go on to be working EMTs, less than a quarter of them will become Paramedics. Along the way a few will get picked up by fire departments. It’s not uncommon in this area for 3000 people to apply for a 15-person academy in a fire department so the odds are definitely against them.
Throughout the morning Jake maintains a constant monologue about the fire departments he wants to apply to, where he wants to work, and the exciting things he did in the fire academy that he went to last year. We listen to him while suppressing smirks at his naivet. Jake quickly became disinterested in the mundane calls of the day; the old lady with weakness for three days, the Crohn’s disease patient with abdominal pain, the pregnant woman with abnormal discharge who is worried about her baby. All of them could have taken a cab to the ED, or made an appointment with their primary care physician, but that’s not what happens in this county. They call 911 because they feel entitled to immediate transport and evaluation at the ED. Anyone who doesn’t think we already have universal health care should spend a day with us and see the reality that we see every day.
My partner Brent and I exit the rig with Jake in tow and approach the patient as the fire medic is approaching from the other side. The patient seems to be a man in his thirties. I kneel down to listen for breath sounds while I’m feeling for a radial pulse; both are present but weak. The fire medic rubs up and down the patient’s sternum with his knuckles to see if he is responsive to painful stimulus; no reaction.
We start cutting off bloody clothing as one of the fire fighters is holding c-spine to prevent further injury to the neck and spine. Brent goes back to the rig to get the back board and straps. Jake is cutting up one of the pant legs. He’s never done this before and he takes slow deliberate cuts with the trauma shears. The fire medic and I strip the rest of the patient’s clothing in the time it takes Jake to do one leg.
Now that we have him stripped the injuries are obvious. Bilateral deformity to the knees, facial and head trauma in the front with matching trauma to the back of the head. The fire captain comes up after talking to some witnesses in the crowd that is growing on the sidewalk.
“Okay, per witnesses, this guy was crossing in the crosswalk when a car traveling at a high rate of speed did a hit and run. They said he went airborne and landed in the crosswalk.”
Looking down at the blood covering the white lines on the pavement I’m confused. “I don’t get it Cap, how did he get hit from the side and end up further down the same crosswalk?”
“No, he was in the other crosswalk, went airborne, and landed in this crosswalk.” Damn, that’s big air!
I stand up to see the street better; two lanes each way with a turn lane in-between. It’s at least 100 feet from crosswalk to crosswalk. That gives me an idea of the speed of the car and level of trauma that was inflicted on this guy. Given the wound pattern it appears he turned to face the car as most people do, and the bumper broke both legs. He folded face first into the hood causing the facial trauma, then was launched across the street landing on his back and causing the trauma to the back of the head on the concrete.
We get him secured to the back board and loaded into the rig. Throughout the process he hasn’t moved or reacted to anything we did â€” he’s completely out. We’re conscious of the time spent on scene – as this is a code-3 trauma activation we want to hold our scene time to under 10 minutes.
The fire medic looks up at me from outside the rig. “You want a rider?” I tell him yes; I have Jake in the back with me but he really can’t do much to help. I can use another medic with me. He jumps in and I tell Brent to get us out of here.
As we’re rolling towards the freeway I’m setting up my intubation kit while the fire medic is working on an IV and Jake is trying to take a blood pressure. He’s never taken a blood pressure in a moving ambulance with road and siren noise – it’s an acquired skill and he’s got to start somewhere. There’s blood in the mouth, I suction it away and insert my laryngoscope. Visualizing the vocal cords, I pass the tube into his trachea. I inflate the cuff, which secures the tube in the trachea, and attach a bag to squeeze some air in to confirm placement.
The patient, still a John Doe (JD) to us, suddenly starts moving all extremities at once and shaking his head. He’s trying to scream but there’s a tube in his throat so all that comes out is air with a fine mist of blood. I’m trying to hold his bloody head steady with one hand while holding the tube with the other hand to stop it from getting dislodged. Jake and the fire medic have their hands full holding arms and legs. It’s not a seizure – the movements are purposeful, yet unorganized. It’s the flight or fight response of an injured brain manifesting in a combative outburst. JD doesn’t mean to be combative – heck JD isn’t home right now – it’s just the autonomic part of his brain trying to do something, anything, to protect from further damage.
It takes all three of us to subdue him. I’m holding the head and tube, trying to preserve some semblance of c-spine precautions and stop the tube from being dislodged. Jake is holding his legs which are kicking even with bilateral fractures at the knees. The fire medic is using leather restraints to secure JD’s hands to the backboard.
As we’re pulling into the ED I decide to remove the tube. If JD’s moving enough air to be combative then he can breathe on his own – the ED may well re-tube him but that’s up to them. I might have sedated him but that’s contra-indicated for traumatic head injuries, not to mention I couldn’t reach the drugs while all three of us were holding him down.
We roll him into the trauma room where a team of 15 nurses and doctors is already waiting for us. It’s a teaching hospital – one of the best – so a brand new resident gets my attention and says, “You can talk to me.” I’m sure they teach the “baby docs” to say that every time. It always kind of makes me chuckle.
I give the baby doc a full report on my treatment and JD’s condition. All the while JD is screaming and flopping bloody appendages around as they pull him off the board and baby doc orders the RSI kit (rapid sequence intubation – sedate him, paralyze him, and tube him). That’s one that’s not in our protocols but it’s the only way to handle JD right now.
As I walk out to the ambulance bay I encounter a dirty look from Brent as he’s scrubbing the cabinets of the rig to get the blood off. “Sorry dude, we tried to keep it clean.” I’ll do my paperwork fast so I can get back and help with the decontamination of the rig.
While doing my paperwork I’m explaining to Jake the pathophysiology of coup-countrecoup traumatic brain injuries. He’s using some wipes to to try to get the blood out of his white polo shirt. He’s not as talkative as before; the constant diatribe of his accomplishments have dwindled to a morose silence. I don’t think he’ll be one to work as an EMT or go on to be a Paramedic. The reality of our mundane calls interspersed with the insane call isn’t for everyone. I suspect he’ll continue testing for the Fire Department and given the odds that may not work out the way he expects.
I finish my paperwork and head back to the rig to help with the decontamination.