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1 : Having a probability to low to inspire belief

2 : Not likely to be true or to occur to have occurred

3 : Too improbable to admit of belief

We must fall back upon the old axiom that when all other contingencies fail, whatever remains, however improbable, must be the truth.

Sir Arthur Conan Doyle; His Last Bow, 1917

My pager is giving my hip an annoying tickle as it goes off for the third time in quick succession. Having just printed my paperwork out for the hospital I’m on my way back to the rig as Scottie comes through ED the doors.

“They’re screaming for us. We got a call on the west end.”

“Yeah, I know, let’s do it.” I throw my hood up to brave the rain from the ED to the rig. It’s been raining for the last three days and I’m starting to get a little tired of it. The rain seems to bring a special kind of stupid to the urban streets that are my workplace.

“Medic-40, we’re en route, please show us delayed for time versus distance and weather conditions.” Scottie’s being just a little cheeky to dispatch; they know we’ll be delayed to the call – hell we’ve been delayed to just about every call today. The freeways are parking lots, the roads are slick, and we’ve been level zero (no available units) for the last four hours. We’re responding to calls that are way outside our zone and it just takes a little longer to get there safely.

Scottie’s taking surface streets to the call as getting on the freeway would be an exercise in frustration. It’s been dark now for a few hours and the traffic is starting to get better as we drive through the hood. The rain is keeping the regulars off of the street and it looks a little deserted. Strange how sometimes I almost miss the normal funk of the hood.

With every surface covered in water the urban landscape is reflecting our strobes back at us in a thousand little twinkles that is suggestive of the current holiday spirit. Some houses even have holiday lights up – though here in the hood it’s not as prevalent as it is in the more affluent parts of the county.

It’s taking a long time to get to this call and it’s interesting to have so much time to think while on the way to the call. I recall the idiocy of my last patient who had a toothache. She lived less than a mile from the county hospital and she called 911 for a ride to the ED. Unbelievable! I was happy to escort her straight to the chairs in the lobby. I hope this call isn’t as benign as I look at the MDT for call information; you are responding to a 46 year old male who is dizzy. Awesome! Over half of my patients are dizzy. I’ve actually stopped asking people if they feel dizzy when they stand up because I always get the same answer – yes.

Scottie weighs in with his pre-arrival diagnosis of “straight up fucking drunk,” and I go with drug use as we near the call location. We call this neighborhood “the weeds” because of some of the street names. It’s actually a pretty scary place to go – there’s only one way in or out of the neighborhood, and it’s guarded by armed gang bangers. Even the local PD doesn’t go there unless they have more than one unit responding. We usually stage outside the neighborhood until they tell us it’s okay to come in but this is just a medical call so it shouldn’t be too bad.

We pass the liquor store with gang bangers standing outside oblivious to the rain. They call it “posting” – they observe the cars that enter their turf to make sure no one from the outside is selling drugs in their area – and to spot rival bangers. They see our rigs come in a few times a day so they don’t even turn an eye as we pass. Turning on to the street we see the fire engine with its lights blazing quietly parked in front of a house.

“I’m just going to walk up and see what we have. Let’s not take the gurney out unless we have to.” Working in the rain affects every aspect of doing our job – from driving to protecting our equipment to patient care.

The fire crew looks exhausted as I walk up to the stoop of the house where everyone is trying to stay out of the rain. I know they’ve been getting run as hard as us or even harder – they can run calls faster than we can since they seldom go to the hospital with patients.

“Hey guys, whatcha got?”

“So, this is Lester, he’s forty-six. He’s been feeling dizzy since yesterday, falling down, having trouble walking, and slurring his speech.” Looks like another win for Scottie… “He’s also got a little swelling to the left arm but otherwise vitals are stable. Are you guys good?”

“Yeah, we got it. Stay dry.” They want to get out of here and back to the fire house. I can’t blame them and this seems like an easy call. Granted, I’ll have at least a dozen things to rule out on this patient; stroke, trauma, overdose, cardiac, diabetic… But I won’t need to take their medic for a ride as I can do whatever treatment is needed by myself.

There’s no porch light on the house so I move out of the way of the street light so I can see Lester a little better. In the dim light I can see he’s what I call an urban outdoorsman (homeless). He’s pretty wet and very tired looking – his eyelids droop like those on a sleepy hound dog. He’s had a rough life and it’s taken a toll on his body.

“Hey, Lester, I’m going to be taking you to the hospital. What do you say we walk over to the ambulance so I can check you out a little more?”

“Okay, but I’m a little woozy, don’t walk so well.” That’s some serious slurred speech, I hope this guy didn’t stroke out yesterday when this started. I’m really hoping Scottie nailed this one as a drunk.

Just watching him stand up it’s obvious that we’ll have to get the gurney wet and use it to get him to the rig. As Scottie is going back for the gurney and the fire engine is leaving I kneel down to look at Lester a little better and see if I can smell any alcohol. His face is emotionless but he just smells like a homeless guy – I don’t get the smell of recent alcohol at all.

Scottie and I load Lester onto the gurney and into the rig where we have a better environment for an assessment. Scottie is working on the computer as I go through my normal routine of assessing vitals and starting the rule-out process.

Top of the list is stroke but Lester has no weakness on one side or the other – he’s just all over weak. His blood pressure, blood sugar, heart, breathing, lungs are all good. All of his vital signs are within normal limits. There’s no head trauma that I can find but there is an untreated cataract in one eye, making pupil assessment difficult – but from what I can see his pupils look fine. Next I get to the arm and ask him questions as I compare the two arms.

“Has this happened before, I mean the swelling?” The left arm is easily thirty percent larger than the right and when I touch it I can tell there are ridged lumps and pressure under the surface – almost like it’s going to burst. The skin is absolutely stretched to the max and doesn’t give at all when I press down. The skin temperature is hot – noticeably hotter than the right arm.

“Yeah, it comes and goes. Sometimes it swells up for a week or two then it goes down. This is pretty bad though.” His slurred speech is making it difficult to understand him but he’s answering appropriately and showing no signs of intoxication or being altered.

I roll his shirt up to expose his shoulder and see the inch long surgical scars from multiple cut-downs. It’s a sign of heroin use. As people inject heroin to the veins over time the veins atrophy to the point that the user will eventually run out of veins and resort to injecting the heroin into the muscle. The impurities of the heroin will cause an abscess to develop in the muscle and because of reduced circulation the body can’t purge the abscess. This leads to sepsis as the infection spreads. The only solution is to have a doctor cut into the muscle and clean out the infection. The result is a multitude of perfectly straight white scars covering Lester’s shoulder.

“How long you been shooting up?”

“Maybe twenty years. I’ve been using heavy the last three or so.”

“You right handed?” If he’s shooting up with his right hand then the left shoulder would be the more infected.

“Yeah, but I switch it up.” He understands my questioning and where I’m going with it.

I expose his right arm and feel the muscle. Sure enough there are some abscesses in the upper arm but nothing like the left one. He may switch it up but he hits the left shoulder more than the right. As I’m switching between shoulders I notice the scar just below his Adam’s apple – a sign of a tracheostomy.

“Why did you get a trach?” I’m really starting to feel bad for Lester as I continue to find evidence of a hard life on the streets. His drooping eyelids, lack of emotion in his face, dizziness with frequent falls, and slurred speech are starting to add up to a very sick man – quite possibly one of sickest people I’ve seen in a long time.

“I had botulism two years ago. Spent eleven days on a machine that breathed for me.”

“Were you dizzy with slurred speech when you had botulism?”

“Yeah, pretty much the same thing.” Well, there you have it, looks like he’s got it again. I seem to remember a doctor saying that diagnosis is 75% history taking and right now that seems to be the case.

Historically the toxins that cause botulism have entered the body by contaminated food – usually a byproduct of improper canning methods. Yet recently there has been a notable increase of botulism cases in intravenous drug users – specifically the users of black tar heroin that shoot up in the muscle.

Botulism is a paralytic illness that initially affects the twelve cranial nerves causing paralysis of voluntary muscle groups starting at the head and working to the feet. The drooping eyelids, slack facial muscles, slurred speech, and uncoordinated extremities are all classic signs of the impending paralysis. Eventually the lungs are paralyzed and the patient can’t breathe on their own. That’s why Lester was put on a ventilator last time. Once the antitoxin is administered it can still take a few weeks to eradicate the bacterium – during which time respiratory failure is a very high probability.

I was already feeling bad for Lester but the reality of his situation is even worse than I had anticipated. It looks like the next few weeks are going to be hell for him. He’ll have another round of cut downs to clean out the festering abscesses on both arms and he’ll probably end up on a ventilator for a few weeks during which time they’ll be administering methadone to prevent him from going into withdrawals from heroin while his body recovers.

I can’t do anything substantive for him except make sure he gets to the right hospital. I’ll take him to the county hospital because they are prepared to deal with this kind of patient. Some of the other hospitals might find it easy to turf him with a referral which he’ll never make. At least I know county will see him through the next few weeks.

Sitting in triage at the county hospital Lester looks really sad. Granted, his face is partially paralyzed but the reality of the situation is starting to sink in. There’s a violent person restrained to the gurney next to us and she’s causing quite a commotion. Three county sheriffs are helping the paramedics to hold her down as the nurse injects a sedative. She’s swearing at everyone and screaming about how her rights are being violated. How about my right not to get my eyes scratched out while trying to help you?

“Hey Lester, it’s a little crazy in here today because of the rain. You gotta trust me though – this is the right place for you to be.”

“I know.” The slurred response is a sad acceptance of reality.

Lester was placed in critical room #2 – basically the lower the room number, the more critical the patient – it doesn’t get much more critical than Lester. I was back to the same hospital 24 hours later and saw his name still assigned to the room. I walked up and had a chat with his nurse because I’ve never had a patient still in the ER a day later. Usually they either get turfed, sent to the regular nursing floor, or to the ICU.

His nurse tells me they are treating his condition aggressively as it is an advanced presentation of botulism. He has had a decreasing respiratory drive and they’ve been keeping him in the ER to wait for respiratory failure. They are better prepared to keep and eye on him and put him on a ventilator when the time comes. They don’t want to  risk sending him to the ICU too early. They gave him the antitoxin last night but he still has a long road ahead of him. 

According to the CDC:

In the United States, an average of 145 cases of botulism are reported each year. Of these, approximately 15% are foodborne, 65% are infant botulism, and 20% are wound-based. Adult intestinal colonization and iatrogenic botulism also occur, but rarely. Outbreaks of foodborne botulism involving two or more persons occur most years and are usually caused by home-canned foods. Most wound-based botulism cases are associated with black-tar heroin injection, especially in California.

The respiratory failure and paralysis that occur with severe botulism may require a patient to be on a breathing machine (ventilator) for weeks or months, plus intensive medical and nursing care. The paralysis slowly improves. Botulism can be treated with an antitoxin which blocks the action of toxin circulating in the blood. Antitoxin for infants is available from the California Department of Public Health, and antitoxin for older children and adults is available through the CDC. If given before paralysis is complete, antitoxin can prevent worsening and shorten recovery time. Physicians may try to remove contaminated food still in the gut by inducing vomiting or by using enemas. Wounds should be treated, usually surgically, to remove the source of the toxin-producing bacteria followed by administration of appropriate antibiotics. Good supportive care in a hospital is the mainstay of therapy for all forms of botulism.


145/310,000,000 = probability of getting botulism once.

Multiply that number by itself = probability of getting botulism twice.

That number is 0.000000000021878%

Twisted 3/3

“Did she just say ‘car vs train’?” I’m asking Louis as the radio was a little scratchy while the dispatcher gave us the call information.

“Sounded like it. I’ve got my money on the train.” Louis pulls his gloves on and flicks on  the lights and siren to get through the traffic, and heads in the direction of our call.

It’s dark and the strobes illuminate the fields and scrub brush of the landscape in this rural corner of my mostly urban county. We’re heading down a well-traveled arterial yet we’ve taken it to the point that it’s turned into a dirt road. I’ve actually never been this far down this road so I check my iPad to make sure the railroad crossing is still in front of us.

Eventually we see the flashing red lights of the fire engine and the heavy rescue rig. They send out the heavy rescue crew when there is a possibility of extrication. It’s like a giant drivable toy box. Every external cabinet holds all kinds of great toys for guys that never grew up: jaws of life, pneumatic spreaders, inflatable bags, etc. Both rigs are parked next to the railroad crossing where a huge train blocks the road. The lights are on in the train and I can see it’s a passenger train by the many heads that are silhouetted in the windows. It’s not one of our light rail commuter trains. This is a heavy rail interstate train with maybe thirty cars.

We park next the the other rigs and start walking down the tracks towards the flashlights that are visible one hundred yards in the distance. As we’re walking I’m using my flashlight to illuminate the uneven gravel that is littered with car parts and huge gouges in the direction of travel.

Once we get to the front of the train we finally see the car – or what’s left of the car. It looks like a hungry train decided to eat the car for dinner and got interrupted half way through. The car appears to have been “T-boned” by the train and it’s looking like a tin can that was stepped on so the middle is flat and the ends are just twisted heaps of metal that were dragged for the last hundred yards until the train stopped.

I catch the eye of the LT as I recognize him from other calls that we’ve been to in the past. “Please tell me no one is in there.”

“As far as we can tell it’s empty but they’re getting the thermal imager to confirm.”

We have city PD Officers and County Sheriff Officers on scene now and I see that the conductor has made it down from the driver’s seat to see the damage. I confirm with the conductor that there are no injuries to the passengers in the train. They had people walk the length of the train in the passenger space and basically no one even knew what happened. The inertia of the train was such that a little car didn’t even interrupt people’s dinner or spill their drinks. That’s great because I had a brief moment of panic thinking that I was going to have to take 100 sets of vitals and have everyone on the train sign out with a release form.

Not only does the thermal imager show that there is no trapped warm body it the car it shows that the engine was cold when the train hit it, so it was parked on the tracks! We have to do our due diligence to make sure we didn’t miss a patient that may have been thrown from the wreckage. Using flashlights and the thermal imager we cover a hundred yards in either direction of the point of impact with no visible hot spots.

As we’re getting ready to clear the scene I ask one of the County Sheriffs why a car would be parked on the tracks at this time of night.

“Yeah, well, it happens a few times a year. Gang bangers from the city will steal or car-jack a car, joy ride all day, then park it here to destroy any evidence and maybe just watch from a distance to see if it explodes. We didn’t find the license plate so we’ll have to run the VIN to confirm – if we can find it.”

Taking the long walk back to the flashing rigs I’m thinking about the utter disregard for human life that someone would have to park a car on a train track. I don’t know what the chances of derailing a heavy train are but had it happened we would have had a serious MCI (Multi-Casualty Incident) on our hands. Even still, the conductor spent a few minutes wondering if he just took a life while driving his train. As a matter of procedure he’ll end up peeing in a cup and handing over his cell phone to make sure he wasn’t at fault for the incident.

I often joke with my wife that I’m in the business of thwarting Darwinism. We save the stupid and negligent people of the world so that they can go on to propagate their genetics and make Mini-Me’s just like them. A thousand years ago they would have been run over by a water buffalo while crossing the trail. Today we patch them up and send them on their way to make more kids. One of these kids has just endangered over a hundred people with a senseless act. I wonder if the genetic pool of humanity is forever degraded as our modern medicine does its magic.

I guess that’s a question for future sociologists to ponder. Meanwhile, we in EMS continue to do our job and hope that in some small way we have the chance to make a difference for the better.

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… 

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.