Section 8

sec·tion

1 – one of several parts or pieces that fit with others to constitute a whole.

2 – a type of Federal assistance provided by the United States Department of Housing and Urban Development (HUD) dedicated to sponsoring subsidized housing for low-income families and individuals.

3 – category of discharge from the United States military for reason of being mentally unfit for service. The meaning of Section 8 became known in households worldwide as it was used often in the 1970s TV series M*A*S*H, in which the character Corporal Klinger was constantly seeking one.

As we’re responding to an address in the hood, lights and siren running in the background, my partner Brent and I are playing the prognostication game. It’s a way to alleviate the monotony of the day a little by trying to guess the actual nature of a call from the minimal information on the MDT (mobile data terminal), which is often inaccurate.

The prognostication game is a way of staying sharp. We take into account the time of day, socio-economic make-up of the neighborhood, whether it’s a house, apartment, or “corner of” call, and if the call was initiated by cell phone or land line. In our busy county each crew runs around 1000 calls a year so we start to see trends pretty fast.

The prognostication game is also a means for bragging rights between partners – we keep track over a period of time (a shift, or a week) and the loser buys the winner coffee. The only downfall to the game is you have to be willing to drop the pre-conceived assessment immediately when you get there and your actual assessment points in a different direction.
The dispatch notes on the MDT only tell us we’re responding to a 47 year-old female with shortness of breath. I nailed the last one with the 35 year old male having abdominal pain with a pre-arrival diagnosis of pancreatitis aggravated by alcohol consumption. This time, I’m going with the easy odds of an asthma exacerbation. Brent has about the same odds with the guess of a panic/anxiety attack.

We arrive on scene to see the BRT parked in the parking lot of a high density federally subsidized housing project. We call it Section-8 housing in reference to the portion of the U.S. Housing and Community Development Act of 1974 which provides a subsidy for low income families and individuals. The neighborhood is largely African American and the frequency of asthma in urban areas like this is quite high; that’s why I went with the easy odds this time.

As we walk into the ground-level apartment we see the patient sitting on the sofa with fire fighters doing an assessment. In unison my partner and I stop, mid-stride, and our jaws drop.

We stand there, dumbfounded, staring at the decor. One whole wall of the apartment is covered with NASCAR matchbox cars, still in their packages and perfectly aligned – tacked to the wall with edges touching. There must be 300 cars on the wall.

On the adjacent wall is an altar with a picture of Jesus flanked by pictures of Dale Earnhardt and Dale Earnhardt Jr. The holy trinity, really? All pictures are of equal size and displayed with equal prominence. Sitting on the altar are shoebox sized models of the number 8 car and the number 88 car aligned with their respective drivers. What, no car for Jesus?

In the kitchen are two cats, one sitting on the counter the other sitting on the ground. Both cats are fixated on a cage on the kitchen floor with four birds that nervously jump from perch to perch.

There’s an angry looking, heavy-set white woman, probably not related to the Hispanic looking patient, standing near a day bed that’s covered in cash. A four foot square tapestry hanging on the wall over the bed with a picture of a white tiger has the caption, “The Eye of the Tiger” under the image.

I’m starting to think my asthma guess is out because of the chaotic nature of the furnishings. There are some interesting contradictions in the décor which could speak to the mental stability of the occupant. I mean seriously, who puts a bird cage on the floor when you have cats? Which animal is being tormented more by the close proximity? And being a NASCAR fan is great, although I’ve never seen one in this neighborhood, but deifying the drivers??

Someone with a psych history is more likely to have an anxiety induced hyperventilation. Brent was probably right on this one…

The thing is, Paramedics are trained observers that profile. Maybe that’s not a politically correct thing to say these days but I believe it’s true. The city police won’t use the “P-word,” but the FBI likes it so much they made a division of people who specialize in it.  Paramedics often get only half the story on any given situation, we are often lied to by our patients, and many times the patients have no idea what’s going on. So we have to fill in the blanks. That’s why we play the prognostication game – to exercise our mental abilities to fill in the blanks.

If I’m going to a call in the hood and someone is passed out then I’m looking for signs of drug/alcohol use. If I’m going to a call in the affluent neighborhood and someone is passed out I’m looking in medicine cabinets to check for an overdose on prescription medication. It’s just a matter of prioritizing the rule-outs based on observations and high probability odds. Everything will get checked by the time I get to the hospital but I modify the order of rule-outs based on what I see and how the patient is presenting.

The fire medic has been waiting for me to take it all in; I suspect they had the same reaction that we did. Finally I have a look at my patient. She’s breathing very fast with shallow breaths. I see the cardiac monitor; she has a heart rate of 136 with a regular rhythm.
The fire medic tells me she thought she was having an asthma attack and used her inhaler, but she is still short of breath. I look at the O2 saturation on the monitor and it reads 100%. She’s getting plenty of oxygen to the blood so she should be fine. The fire medic watches as my gaze shifts, gives me a shrug and tells me her lung sounds are clear. I’ll recheck the lung sounds when I get her in the rig but right now I want to cut the fire crew loose as I’m not going to need any help on this call. They get run pretty hard in this neighborhood so I try to take over the call fast when it’s possible so they can try to get some down time before the next call goes out.

I introduce myself to Rita, my new patient, and tell her that I’ll be taking her to the hospital. As she’s getting her purse the LT asks her about the money. He’s going to lock up for her but wants to know what to do about the money laying on the day bed. Rita says to give it to the angry looking white woman telling us it belongs to her.

Once I get Rita into the rig I start over with the questioning and examination. I ask if there was any kind of emotional event that precipitated the asthma attack; she says no. I check her lung sounds and they are perfect – no bronchial constriction or wheezing. I have her on my End Tidal CO2 (ETCO2) detector so I can measure the CO2 in exhaled breaths and have a real time wave form on the monitor to see how she is breathing. It also gives me an accurate count of respirations per minute.

Rita is breathing at 44 times a minute with an ETCO2 of 16. Normal readings would be a respiratory rate of 16-20 and an ETCO2 of 35-45 so there is definitely something wrong here. When I ask she again denies any emotional stressors or history of anxiety or panic attacks or any drug use. Looking down at Rita’s hands I can see the carpopedal spasm beginning to cramp her fingers – basically, breathing too fast changes the metabolic balance in the body resulting in cramping fingers and feet.

I tell Brent we can start driving as I’ve done my rule-outs and decided what my treatments are going to be. I start an IV and inject Benadryl into the tubing to sedate her a bit. Benadryl is a drug that’s typically used for mild allergic reactions or seasonal allergies, but our medical director added it to our protocols for mild sedation, which is an off-label usage (i.e., drowsiness is a side-effect of Benadryl). It’s not going to put anyone completely out but it does help to calm people down. I think part of it is a placebo effect in that people see me draw up a medicine and inject it while I’m telling them it’s going to make them feel better.

I turn the lights down in the rig and sit at the edge of the bench quietly doing my paperwork on the laptop. In some cases my treatment for a panic attack patient is to ignore them. Maybe that sounds cold but I have my reasons and often it works. Many times a panic attack is to get attention or to get out of a situation. Well, Rita doesn’t seem to want any attention. She’s staring at the cabinet and not looking at or interacting with me. I’m thinking she wanted out of a situation. Having accomplished that I’m going to leave her to her thoughts while we take the fifteen minute drive to her favorite hospital.

As we’re pulling into the hospital I take a look at the monitor. Rita’s respiratory rate has dropped to 22 and the ETCO2 level has risen to 20. Both numbers are moving in the right direction and Rita has had her eyes closed for the whole trip. After getting her into a room and giving the report I sit down to finish my paperwork at one of the nurse’s desks.

A few minutes later, Rita’s nurse comes out and I catch her eye – I thought of something else. “You know, there’s one other thing.” I tell her, “There were $400 dollars all spread out on a day bed and an angry looking woman who may have been the building manager. I’m thinking it’s the middle of the month so if she was paying rent now it’s pretty late. And even Section-8 housing is more than $400. I bet that’s what caused the attack in the first place.”

The nurse’s eyebrows lift up and she goes back in to ask about the money. Three minutes later she comes out shaking her head up and down. “That was it.”

It looks like I’m buying coffee tomorrow morning as Brent is winning the prognostication game today…

Home Invasion 2/2

My partner kills the siren as we enter the residential neighborhood – it’s a courtesy to people trying to sleep. No reason to wake the entire neighborhood as long as we can drive safely. He still chirps the siren as we go through intersections, but that’s much better than having it on all the time.

The strobe lights, on the other hand, continue to blaze along our drive. It’s almost midnight so we need the visibility that they provide. The strobes also reveal the realities of this neighborhood – bars on the windows, graffiti on the fences, and dogs that bark at our passing. This neighborhood may have been nice forty years ago but these days it’s deep in the hood.

We finally spot the BRT (big red truck) down the street parked in front of a house. We are responding to a “Medical Alarm: Unknown.” That’s what our dispatcher calls it when an elderly person pushes their medical alarm and the monitoring agency calls 911 for them. I still remember the commercial in the eighties with the little old lady lying on the ground saying “I’ve fallen and I can’t get up.” It became a cliché saying back then but the high frequency on calls just like that have earned it an honored place in the abbreviated shorthand of EMS communication: LOLFDGB – little old lady fall down go boom.

Pulling in behind the BRT my partner and I exit the rig and find the lieutenant (LT). I’ve seen him now and again while working this urban county so we have a cordial familiarity. I also know a few of the guys on his crew, most of whom are young as this is deep in the hood. The old timers can bid to the “vacation stations” in the more affluent neighborhoods because of their seniority. Lacking seniority the younger guys are left with the crap shifts in the bad neighborhoods. They get worked pretty hard – sometimes 20+ calls in a 24-hour shift.

It’s midnight and no one is happy about getting woken up for a call that tends to be nothing. We’ll typically get cancelled off of this kind of call – at least half the time. It usually ends up being a simple lift assist or maybe they pushed the button while at someone else’s home or at a restaurant. The elderly often don’t understand the nature of the technology. It’s not a GPS (yet) and pushing the button only sends responders to the address on record.

LT tells me that they don’t have any more information than we do. It appears that no one is home; no lights on in the house, no answer to the door. They are going around the house to see if there’s a way inside. We can’t just leave when someone activates the medical alarm. They could be having the big one and can’t get to the door. They’ll break in if they have to.

Standing in front of the house with the engine noise of two rigs and strobes flashing I’m watching the firefighters check windows for entry. If they can find me a patient I’ll be happy to jump in but breaking and entering is their specialty, not mine. A neighbor walks up to me, attracted by the commotion.

“That’s Irma’s house, is something wrong with her?”

“I don’t know, that’s what we’re trying to find out.” First responders are always circumspect about giving information to bystanders because of patient confidentiality issues. But this seems to be a concerned neighbor. She tells me that she checks on Irma a couple times a day because she lives alone and is having an increasingly difficult time taking care of herself. I ask if she has a key or if she knows of a hidden key. She answers no to both questions.

I tell the LT what I know and he assigns one of his guys to force a window open. Of course the crap job of breaking and entering goes to the rookie on his crew. You never know what’s on the other side of a window – maybe a guard dog. The rookie is able to pry the window up and climbs inside. After maybe thirty seconds he screams out the window, “She’s got a knife!” What the hell?

LT and the other two firefighters instantly spring into action. LT gets on the radio requesting city PD to respond to our location code 3 while the other two run to the BRT and slide open the exterior cabinets containing tools. They rush the front door with the Halligan (think pry-bar multi-tool) and an axe. Prying the door away from the frame one of the firefighters puts a shoulder to it and breaks the dead bolt free of the hole. The door crashes in and we all rush into the living room.

Standing in the corner of the living room is the rookie; hands in the air, eyes big and round. In front of him is a little old gray-haired lady waving a huge kitchen knife at all of us, while supporting herself on a walker. She’s terrified – almost as much as the rookie. LT is trying to reason with her, “We’re the fire department, we’re here to help, no one’s going to hurt you, put down the knife!”

The neighbor pokes her head in the doorway. “She’s deaf, she can’t understand you.” She comes inside so Irma can see her. LT has everyone back away and the neighbor calms Irma down and takes away the knife. LT is checking on his rookie and I walk Irma and the neighbor into the kitchen to see if anything is wrong with her aside from being so scared.

I spend a half hour writing notes back a forth with Irma. I find out that she must have accidently pushed he medical alarm, that hangs around her neck, while sleeping and has no medical complaints. She doesn’t want to go to the hospital – she just wants everyone to leave so she can calm down and try to go back to sleep. As I interact with Irma the fire crew tries to piece her door frame back together. They’ve done this before so they have all of the tools – wood glue, nails, etc. It’s not perfect but it will keep her secure until she can replace it, which probably won’t happen.

Irma checks out fine and signs my release of liability form so I can leave her in peace. As I’m walking back to the rig LT and the other firefighters are giving the rookie shit for getting assaulted by a granny with a knife with a walker. He’s probably going to need to change his shorts when he gets back to the station and he’ll be the brunt of jokes at dinner in the station for months to come.

As my partner flicks off the strobes and we drive out of the deep hood I realize that PD never showed up and LT didn’t cancel them. They just didn’t respond. They’ve already reduced the police force by ten percent and we’re starting to see the results on the street.

That’s more than a little disconcerting… 

Home Invasion 1/2

home

1 : A place where one lives; a residence

2 : The physical structure within which one lives, such as a house or apartment

3 : An environment offering security and happiness

 

in·va·sion

1 : an act of invading; especially : incursion of an army for conquest or plunder

2 : an action or process which affects someone’s life in an unpleasant and unwanted way

3 : an intrusion or encroachment

As Irma lay sleeping in her bed the window was slowly pushed up from the outside. A young African American man wearing a beanie hat pulled low over his ears looks in the window. He pushes the window up further to fit his torso through.
Crawling in through the now open window he stands over Irma and reaches down to grab her shoulder. Irma is a heavy sleeper and doesn’t notice. The young man is wearing a dark jacket and pants. He puts a knee on the bed and rolls Irma on her back. He puts his hand on her throat as he brings his face close to hers.

Irma is startled awake and finds herself staring at a stranger in dark clothing kneeling on her bed with his hand on her neck. She lives in a dangerous neighborhood – she’s lived here for 46 years and has watched the slow decline; more gang violence, bars appearing on windows, pit bulls behind locked gates and friends moving away after having their houses burglarized. She’s had this nightmare before but it’s different this time; nightmares stop when you wake up – this one is just starting.

The man says something to her but she’s deaf – has been for years now and the hearing aids just don’t help any more.

She’s prepared for this moment, having run the scenario a hundred times in her head. Irma swats the stranger’s hands away, to his surprise. He didn’t think a woman in her 80s could move that fast. She reaches over to the side table for her knife.

She sits up on the bed pointing the knife at the intruder. He’s scared – not of the old lady in front of him but of the 12-inch kitchen knife being waved in his face. He yells out the window to his friends.

Even more frightened now, Irma grabs her walker with her left hand and stands up. The intruder is backing away from her – the knife has him concerned. In slow shuffling steps she backs the intruder out of the bedroom and towards the living room. She’s having a hard time seeing him – he’s wearing dark clothes, the house is dark, and in the excitement she didn’t think to put on her glasses, even though they were right next to the knife on the side table.

She wants to get to the phone to dial 911. She knows she won’t be able to hear what the 911 operator says but just dialing it will ensure that someone arrives. It’s becoming increasing difficult for a woman living alone with only the occasional neighbor to check on her these days.

Irma makes it into the living room while pushing the walker with her left hand and frantically waving the knife in her right hand. She’s been able to hold off the intruder for the last minute. Suddenly the room is awash with light. The front door has been forced open and men start streaming into the room; the intruder’s friends have broken the door down!

Irma is blinded by the light in the room yet realizes that she’s surrounded by more intruders wearing dark clothing. She is unable to hear anything and she is without her glasses. The men are between her and the telephone. She was scared when she saw the stranger kneeling on her bed, now she’s terrified. This nightmare has turned into a horrible reality.

Inception 4/4

The background music in the gym is interrupted by the front desk with an announcement.

“Medic 40, copy code three, 1055 Main Street for a 62 year old male; chest pain.” I trip on the stair climber and fall back catching my hand on the rail…

Lying on the bench in the back of the rig, “non-breather” on my face, my respirations have returned to normal and my fingers have stopped being numb and rigid. Still in a tormented dream state I’m recalling the telephone conversation with my soon to be ex-wife. She moved a few hundred miles away and just told me that she was pursuing a relationship with a colleague whom she met on a business trip last year and presumably met again this year. It seems that was the inception of her decision to end the marriage.

As the reality of the situation sinks in I’m even more determined to follow my desire to become a Firefighter/Paramedic and help people for a living. I’ll use this as a galvanizing experience to help me focus during my studies.

My original premise stands true; there was no miscalculation, although my emphasis has changed a little. Contributing to the human condition and helping people does make me feel good and increases the quality of my own life. My initial exposure to this world came from the desire to go into the fire service. I owe a debt of gratitude to the people who were on duty and working out that day when I happened to be at the gym.

Yet over the last two years I’ve gravitated to EMS and wanting to function as a Paramedic on an ambulance. I love the pre-hospital medical aspect of EMS, and that’s not available to fire medics. It’s a new field that’s growing and changing every year and as the profession matures it’s going to need the help of dedicated, intelligent people who are here by choice, not as a fallback position.

From the radio in the front of the rig I hear the dispatcher giving out a call. “Medic 40, copy code three, 1055 Main Street for a 62 year old male; chest pain.” I’m startled awake and nearly roll off the bench, catching myself on the gurney…

I slowly open my eyes to see the rain drops on the windshield, tinted brown by my sunglasses. I smell the grapes from the last call as I reach for the mic on the dashboard.

“Dispatch, Medic 40. We’re en route.”

Inception 3/4

I’m leaving my boss’ office after just handing in my resignation. It was one of the most agonizing yet necessary decisions of my career and I’ve been thinking about it for weeks. I really don’t know where I’m going after this or what I’m going to do but I know it doesn’t involve working in this field any more. I gave him a six week notice with the knowledge that it’s going to take at least that long to find and train someone to replace me. To my surprise, he told me that today would be my last day and they’ll pay me the six weeks as severance.

Although I didn’t see this coming, I understand the rationale. As a senior manager in the company I had a number of people reporting directly to me, working on a dozen or so projects in various stages of completion worth tens of millions of dollars. They can’t risk someone at my level being a negative influence on those projects – either on the employees or the clients – so it’s better for them to end the relationship as soon as possible.

It’s been a fun ride and I’ve worked with some amazing people. It started thirteen years ago, fresh out of college, working in a very rainy city in the corner of the country. I got a job designing coffee shops for an up and coming – soon to be international – coffee shop chain. I started incorporating three-dimensional visualization into my projects back when 3D was in its infancy. My animations of the new generation of coffee shops attracted some attention in Hollywood and I was offered a job working for an entertainment company on a sound stage in one of the back lot studios.

Working for a Hollywood studio was a fantastic experience; passing the biggest celebrities while walking to lunch on the back lot, doing animations and design presentation for the biggest producers and directors (ET phone home), and working with talented designers from the House of the Mouse was an amazing experience. Over the years I moved up in responsibility and bounced from studio to studio for advancement. I went from designer to art director to creative director and finally to project director. But almost ten years in the Hollywood entertainment world had taken its toll.

The backstabbing politics of the job were unbearable. The projects were up to a year long, with so many changes in direction and people weighing in on what the final outcome should be that keeping a project on budget and maintaining design integrity was extremely difficult and nerve-wracking. I had worked myself out of having fun and into dreading having to go to work. Creating a project is a blast when you’re on the ground level and your job is creation. But I’d been promoted out of that – now my days were full of budget reviews, personnel issues, and client meetings. I definitely made the right decision to leave yet I have no idea what I want to do now.

I’m at the gym on a stair climber, spacing out due to exhaustion. I’ve got nothing else to do during the day so going to the gym seems like the best use of time. I’ve never been to the gym at this time as I’ve always worked a nine to five (more like seven to six) work day plus half of the weekend. I’ve been on the stair climber for maybe a half hour and I’m starting to get a little light headed when I notice a group of people working out together.

They’re across the room so it’s hard to see the logo on their shirts but they all match. They are men and women of various ethnicities and ages and they’re doing very intelligent lifting. Not like the muscle head in the corner grunting at the stack of weights on every lift. These people are working their core and have perfect posture. They intuitively move to spot each other without having to be asked. They are working as a team and covering each other’s backs at all times. Finally, one of them turns so I can see the logo on his shirt: City Fire Department.

It’s like someone slapped me in the back of the head. Quite possibly that’s what I’ve been missing in my professional experience – an actual team. Not a bunch of individuals with their own agenda but a group of people covering each other’s backs while working towards the same goal – a short term project with a definable measure of success that supports the greater good – the ability to help people in need.

Inception 2/4

My mind is chaotically bouncing around thinking of everything and nothing all at once. I recall the morning five years ago when I returned home from working a 24-hour shift on my BLS (basic life support – EMT) unit. I’m new to EMS at this time and still getting used to the idea of working for 24 hours straight. I’m exhausted as I step through the front door to see my wife, recently back from a business trip, sitting at the kitchen table very distraught; something’s wrong.

My wife fully supported the midlife career change to EMS and the lifestyle change that came with it. She sees that I’m a happier person now that I feel a contribution to the human condition. The change in career was meant to bring a better sense of accomplishment into my life and therefore our relationship. Perhaps I miscalculated; possibly outside influences were at play and maybe I wasn’t getting the whole story. Either way she is steadfast in her decision; we are getting divorced. We spend three agonizing days in calm yet emotional discussions, all of which end with the same inevitable outcome.

After calling out sick (family emergency) for a few shifts I finally have to go back to work. I’m a walking wreck of an EMT. I can’t concentrate on the patients, my driving is atrocious, I space out while doing paperwork, and I’m forgetting nurses’ reports as soon as I receive them. Fortunately I’m primarily doing inter-facility transports (skilled nursing facility to hospital and back) so it’s not exactly emergency situations, yet it still deserves more concentration than I’m able to give right now.

Finally we get a break and make it to a post. I’m exhausted from not sleeping for the last week. All of our belongings have been divided and the paperwork has been filed. In a week I’ll be starting a six-month Paramedic Didactic program. I’ve been working up to this for a year now and I was very excited to get started. Now I’m not sure if I can keep my mind together and actually concentrate on the material at hand with my life crumbling around me. Even more concerning are the financial obligations that will have to be met on my own, with an income that is now just a fraction of what I was making just two years ago.

Sitting in the front seat of the rig I can see my breath coming in fast and shallow wisps, fogging up the window. I’m thinking of my marriage of fourteen years being over and wondering if I’m going to survive the coming years mentally, emotionally, and financially. My fingers start to numb and get rigid, I’m breathing at least thirty times a minute and I’m starting to shake. Oh my god! I’m actually having a panic attack!

I tell my partner I’m going to lie down in the back for a few minutes. As I enter the rear doors of the ambulance I pull a non-rebreather oxygen mask out of the cabinet. Putting it on without hooking up the oxygen, I lie down on the bench and close my eyes. The exhaled CO2 is now being taken back in after every breath; I’ve turned the non-rebreather into a “non-breather” in an attempt to re-balance the Ph level in my body. It turns out that the old cure for a panic attack (hyperventilating) of breathing into a paper bag actually had some science behind it and this EMS off-label remedy is working – I feel my hands start to relax. The exhaustion finally overwhelms me and I drift into a tormented half-awake dream state.

Inception 1/4

in•cep•tion

1 : the establishment or starting point of an institution, activity, or idea

2 : the beginning of something, such as an undertaking; a commencement: origin

3 : Inception; a movie released in 2010, directed by Christopher Nolan, starring Leonardo DiCaprio

There is one skill that is shared by Paramedics across the country and around the world: the ability to sleep – anywhere, anytime, even after seeing some of the most disturbing things imaginable. It’s an acquired skill that is necessary for survival and longevity in this profession. As we work our twelve, twenty-four, and even forty-eight hour shifts the “power nap” becomes a tool for staying sharp to handle the next set of challenges brought upon us by the call of the dispatcher on the radio. We have the ability to tune out the ramblings of the dispatcher and sleep while sitting in the front seat of the rig, sunglasses hiding our closed eyes, until hearing that magic call sign that is unique to our unit. Then we snap awake to hear the instructions of the dispatcher as we’re sent to the next call.

This isn’t quality sleep by any means – it’s a light sleep in which the mind wanders, decompresses, and explores, freed of conscious direction. With the constant cycle of adrenaline and boredom throughout the day, the body takes this time to process toxins and stimulants through the kidneys and liver to attempt to return to a metabolic equilibrium. The byproduct of this kind of sleep is vivid, chaotic, and sometimes insightful dreams.

After the week I’ve had and the last call that took almost three hours to complete all I can think about is closing my eyes for just a few minutes to recharge. I’m on my fourth day in a row; twelve on followed by twelve off for four days puts me at the end of my endurance level anyway, and the last call pushed me over the edge.

I’m in the rural corner of my mostly urban county. It’s a suburban area with farms, quiet neighborhoods, and vineyards. A big rig full of grapes left this area headed towards one of the big wine processing plants. The freeways were slick from the rain as the big rig was cut off by a minivan, causing it to jack-knife on the freeway. The freeway was instantly covered with literally tons of grapes. Multiple secondary accidents happened within seconds of the first one. My partner and I were one of many units that arrived on scene to try to make sense of an accident stretching across more than a hundred yards of fruity smelling freeway, with multiple patients and injuries ranging from shoulder pain secondary to seat belt straps, up to life threatening internal injuries requiring a helicopter ride to a trauma center.

We found ourselves pushing gurneys through mounds of grapes, doing multiple rapid assessments, triaging the worst injuries for immediate transport, calling in additional units, coordinating a landing zone on the freeway and finally leaving the scene with three patients with minor injuries – we were the last ambulance out of there.

We arrive at the ED and I spend an hour doing three sets of patient care reports. I’m exhausted, wet from the rain, and all I can smell is grapes, which is actually refreshing compared to the normal EMS smells that assault me on a regular basis. As we arrive at the post back in the rural corner of the county I put on my sunglasses, turn down the EMS radio and stare at the rain drops on the windshield as my eyes slowly shut.

Reckless Abandon

rude

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

rec•less

1 : marked by lack of proper caution : careless of consequences

2 : utterly unconcerned about the consequences of some action

 

 a•ban•don

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 — 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.

Rude Awakening

rude

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

4 : Ill-mannered; discourteous: rude behavior

5 : Abruptly and unpleasantly forceful: received a rude shock

awak·en·ing

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 — 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.

Reception

re·cep·tion

1. the act of receiving or the state of being received

2. a manner of being received; a cool reception

3. a function or occasion when persons are formally received; wedding reception

I hear the dispatcher call our unit number, preparing us to receive a Code-3 call. Medic 40, copy Code-3. Respond Code-3 to 123 Main Street for a 242, assault – possible stabbing. Your scene is not secure, please stage out.

The sun went down maybe an hour ago so the strobes on the rig are creating high contrast shadows on the surrounding traffic and graffiti covered fences as we speed through the hood to the call location.

Sitting in the dim light of the back of the rig I’m considering treatment and transport decisions for trauma victims. The call came in as a “possible stabbing.” I’ve run a few pretty severe stabbing calls but not in this large urban county. Having just moved here from the predominantly rural county where I trained this is a slightly different call than I’m used to. Treatment is basically the same but I now have designated trauma centers for patients who meet the criteria.

Sitting up in the passenger seat is Hank, my FTO (Field Training Officer). It’s his job to evaluate my performance on the call and ensure that I’m sufficiently acclimated to work independently in this county. Hank is a twenty-year medic and much of that time has been spent in the military with multiple deployments to the Middle East. He’s seen more trauma calls in a year of service than most medics see in a career so this is pretty run-of-the-mill for him.

As for me, the actual trauma doesn’t freak me out either. I look at it as a series of tasks that need to be prioritized and completed by the time I arrive at the ED. What does freak me out is being evaluated – having every move scrutinized. Sometimes I’m my worst enemy in that respect – I seem to make mistakes when being evaluated that I normally never make on my own.

It’s our second shift together and I’m still in my grace period. Hank is available for questions and will offer suggestions. In the next shift or two he will transition to full evaluation mode but we’re not quite there yet.

Five blocks from the call we see a fire engine with four fire fighters parked in a red zone. We flick off our lights and siren as we pull in behind them. This is our staging area – the place where we’ll wait until the police secure the scene so we can approach safely.

A minute later the BRT (big red truck) comes to life with lights and siren. We fall in behind them to cover the five blocks to the call location.

As we turn the last corner we find that the street is a parking lot of police cars with red and blue lights flashing. Officers with assault weapons strapped to their backs are rolling out yellow police line tape. We can’t get any closer so we pull over and start walking up to see what we have.

Hank sees an officer he knows and asks what’s going on. Continuing to walk towards a reception hall he answers. “I don’t know, our radio just said multiple stabbing vics.”

As the fire and ambulance crew turn the corner of the parking lot it’s obvious this is a total cluster fuck. Thirty to forty young men and women are standing in the parking lot wearing party dresses and variations of rancher style tuxedo attire. Women are screaming in a different language, men are moving with rapid motions trying to find something to fix, and kids in party outfits are crying. Secure scene my ass, this is chaos!

As we approach, a slim man in his twenties staggers towards us, blood on his hand. He sees the blood and wipes it on the salmon colored ruffles of his tuxedo shirt, managing to miss the bolo tie. Hank walks up, seeing the blood stain centered on the man’s back and lifts up his shirt. Dropping the shirt Hank says, “This guy is yours, package him up and I’ll see what else is going on.” As Hank walks off with the fire captain into the crowd I see the Paramedic Supervisor show up. He must have been following the incident on the police radio. This is probably the biggest call in the county right now – otherwise he wouldn’t be here.

Having been given an order by my FTO I tunnel vision into my patient and ignore the rest of the commotion. I take two fire fighters and Hank’s EMT partner to help me evaluate and treat the young man. I lift his shirt to see a two centimeter stab wound in the mid lumbar area, and not more than an inch away from the spinal column – close enough to the spine to warrant strapping the guy to a spinal immobilization board. He walked to us so I know he has use of the lower extremities – I’m not really suspecting any neurological complications distal to the wound but I can’t say which direction the knife penetrated so precaution is the best course of action.

We get him immobilized to the back board with a trauma dressing over the wound. The direct pressure of the board stops the bleeding. Once moved to the ambulance I look out the back and see three more ambulances pulling up behind us. More patients on back boards are being loaded into them as I start two IVs on my patient. Just as I’m finishing up Hank jumps in and tells his partner to drive. Code-3, trauma activation to the trauma receiving hospital that is closest to our location.

Throughout my assessment and treatment my patient has been agitated, yelling in another language to his girlfriend who is sitting in the front passenger seat wearing a matching salmon colored party dress. I can do a decent medical assessment in his language but I can’t follow the rapid fire dialogue between them except for the profane adjectives which leads me to believe he’s pissed off at someone; probably the person who stabbed him.

On the way to the trauma center I can see another ambulance, strobe lights blazing, fall in behind us headed to the same hospital. As we both pull into the ambulance bay I prep my patient for the ED. We take him in the side door to the waiting trauma team. I do a quick hand-off to the resident and head back outside to start on paperwork.

Hank comes over for a critique of the call. Basically I did everything I was supposed to do and accomplished all the necessary tasks in the time that I had with the patient. Finally he tells me what all the craziness was about; a different faction of the family crashed the festivities and things escalated to a series of knife fights. The supervisor who arrived just after us assumed command of the medical responsibilities of triage, transport, and calling additional resources. Ultimately seven people were transported with penetrating wounds and lacerations, four of which were critical enough to qualify as trauma activations.

As I’m finishing paperwork, using a laptop and software that are unfamiliar to me, I wonder what I just got myself into. I had some crazy calls in the rural county that I interned and first licensed in yet nothing like this. I mean seriously; a multiple stabbing MCI (mass casualty incident) with 20 cops on scene with assault weapons?? Acclimating to this urban county is going to be a challenge and in a few weeks I could be responding to a similar call as the only paramedic on scene with no supervisor.

This could get interesting