Impalpable 1/2

im·pal·pa·ble

1  :  incapable of being felt by touch

2  :  not readily discerned by the mind

3  :  the quality of not being physical; not consisting of matter

I have wrestled with death. It is the most unexciting contest you can imagine. It takes place in an impalpable grayness, with nothing underfoot, with nothing around, without spectators, without clamor, without glory, without the great desire of victory, without the great fear of defeat.

Joseph Conrad

The morning sun illuminates the interior of the church in a kaleidoscope of color from the stained glass windows. I slowly walk up the center aisle towards the coffin that is on display at the front of the sanctuary, with a backdrop of systematically aligned vertical pipes from the organ. A nine foot crucifixion is mounted to the wall and the eyes from the depiction of Jesus seem to follow me as I make my way up the aisle. The candles along the wall are giving off the slight smell of burning wax that mixes with the occasional whiff of recently burned incense. After what feels like a very long and somber processional, I finally reach the front of the church and kneel – as if accepting communion – and place my stethoscope in my ears.

“Hold CPR.” A firefighter rocks back on his heels with sweat dripping from his brow as I feel the neck for a pulse and listen to the chest for respirations and heart tones on the pale, lifeless, body laying in front of me. No heart tones and I can’t feel a pulse, yet I catch the occasional autonomic gasp for air as the body attempts to breathe even when all of the control centers of the brain have been turned off by death. I look at the monitor and see the organized complexes of pulseless electrical activity (PEA) march across the screen, each having failed to stimulate the heart to form a contraction. “Continue CPR.”

The flash chamber of the IV fills with blood as the needle finds a vein and saline is pushed into the body by a pressure bag which is pumped up on the IV bag to force the saline into the vein faster. The standard medications are pushed into the IV tubing at regular intervals in accordance with our county’s protocols, as a CPR machine replaces the tired firefighter and applies perfect compressions at the push of a button. The floor of the church is littered with the remnants of our resuscitation effort: the purple and gray medication boxes, various wrappers, etc.

A man in a white shirt and gray hair is leaning into our little clearing here in the middle of the church and trying to get close to the patien’s head. With tears streaming down his face and a cracked voice of anguish he’s pleading with my new patient not to die. “Mom, you’ve got to come back to us. You can do this. It’s not time yet. Please mom, come back…” I take the IV bag from the firefighter and hand it to the man in the white shirt.

“Sir, can you hold this for me? Hold it up high and make sure it keeps flowing. Thanks.” He continues to plead with his mother not to die but at least he’s standing up and out of my way as I prep my intubation equipment. I tend to think that CPR and drugs have a better chance of bringing her back – more so than pleading – but it seems to make him feel better to be doing something so I’m okay with getting him involved by giving him a job. This is obviously one of the worst days of his life and he’s going to remember it vividly for as long as he lives. He came here to say goodbye to a loved one and watched his mother clutch her chest and fall to the ground not ten feet from the casket of another family member.

Kneeling in the aisle of the church, under the watchful gaze of Jesus, I bow my head – as if in prayer – and insert the laryngoscope into a lifeless mouth. The autonomic reflexes of the body are still attempting agonal respirations as I expose the vocal cords and pick my landmarks to sink the tube into the trachea. Like a surfer sitting in the line-up waiting for the perfect wave, I watch the vocal cords come into view every eight seconds or so. On the next rhythmic exposure I sink the tube home and inflate the cuff while securing it to my new patient. The firefighters begin strapping my patient to a back board to facilitate transport to the ED.

At the next break in CPR I’m feeling for a pulse and watching the monitor as the rhythm changes to the erratic zigzag of ventricular fibrillation. The drugs and perfect mechanical CPR have created an electrical change in the heart – or possibly she’s deteriorating as the heart can no longer create an organized complex. Either way this code just turned into a mega-code and we’re going to chase the rhythm with electricity and different drugs in the hopes of restoring a perfusing heart beat.

I push the charge button on the monitor and the high-pitched whining sound increases in volume until the modulating alarm tells me that it’s ready to deliver a shock.

“Clear.” The simple word is repeated by the others as they move slightly away from my patient. The son is a little confused as he stands holding the IV bag next to me. I reach up and take the bag from his hands and set it on the ground. In the background the monitor’s alarm impatiently reminds me that it’s time to deliver a shock. I let the son know, “You’re fine right there,” and I push the button.

Electricity courses through my patient’s body and her muscles contract and release tension as her arms splay to her sides. Nine feet above me the lifeless eyes of the crucifixion stare at our futility and the religious parody taking place on the floor of the church. Have I not tortured this poor woman by stripping her to her undergarments, stabbing her in the hands with needles, strapping her to a board, affixing a mechanical compression device to her chest, and finally sending electricity through her body only to create the mirror image of the crucifixion on the floor of the church?

The CPR machine is still doing its tireless job of compressions on my patient’s chest as we put her on the gurney and prepare to leave the house of God to go find the house of Science. Jesus’ eyes seem to watch our little procession of first responders push a gurney past the empty pews towards the back of the church. At His feet lies a casket with another dead body in it.

A priest in full robes stops us at the door. He says some words in Latin that I don’t understand and moves his hands in well rehearsed motions – passing on a blessing for my patient as the rhythmic noise of the CPR machine circulates blood in a lifeless body.

We exit the church and head toward the ambulance, walking past easily one hundred people standing around in black suits and dresses. All I can think as we slowly roll towards the ambulance is that it’s likely that all of these people will be back here in a week to pay their final respect to my patient.

We enter the ambulance and I have two firefighters with me – one squeezing air into the tube and one taking care of the monitor and CPR machine. I’m prepping drugs and reassessing my patient as the doors close and the four of us are finally alone  – away from our somber audience.

As the rig accelerates away from the church I look through the back window to see mourners start heading back inside. Parked alongside the church in the spot that we just vacated, a black hearse waits for its occupant so it can begin the slow transport to the final resting place.

 

 


Guest Post

I recently wrote a guest post for Kelly over at ‘A day in the life of an ambulance driver”. It’s a review of a lecture given at EMS World Expo entitled: Is it Time We Armed Our EMTs?

Go have a read if you want to see something outside of my normal pulpy style of writing.

http://ambulancedriverfiles.com/2011/09/06/gun-rights-were-winning/

Impact 4/4

Driving home I see the text message from my wife telling me that she couldn’t stay awake any longer and is going to bed. I got held over by three hours tonight and it’s well past midnight before I make it home.

I give my wife a kiss and pet the dogs who are asleep in their monogrammed dog beds on my wife’s side of our bed.  Sleepy eyes look up from the pillow, “How was your day?”

“Busy, I’ll tell you about it tomorrow love, go back to sleep. I love you.”

I spend an hour in the hot tub – cool wind in the trees and stars overhead – tying to let the adrenaline dissipate from my system and introspectively looking for answers while listening to the lonely call of an owl sitting in a nearby tree.

Don goes to the middle east, putting his life on the line for his country, while getting shot at by the Iraqi version of bangers in their very real killing fields. In an effort to help his fellow serviceman even more he starts medical training and gets shot at by local bangers – the very people whose freedoms he swore to protect – in the domestic version of the killing fields.

Of all people to shoot at, why shoot at EMS? We are the best chance a banger has when they get shot. We are their ONLY advocate and our single purpose is to make sure they don’t die – a job that we have become quite proficient at over the years. In the summer months of this year 204 people were shot in the urban city that comprises most of my county. Of those 204 people only 11 people died. That’s a survival rate of 95%.

In the world of modern medicine we are able to keep the elderly alive long past their bodies’ ability to function – giving their families just a little more time with grandma and grandpa. That same modern medicine seems to also be keeping the violent offenders alive through multiple life threatening altercations and solidifying their personal self image of indestructibility – thereby prolonging and intensifying the violent behavior. In the dark ages a ruffian would have died from infection following a minor cut in a knife fight. Yet today I have many patients with multiple laceration and GSW scars that tell the tale of escalating violence – and by extrapolation an escalation of PTSD, dissociative violent behavior, depression, and many other mental afflictions. It’s possible that the ability of the physical body to cope with trauma has out-paced the mind’s ability to cope with the effects of the same trauma.

As I lay in bed – wife and dogs sleeping peacefully near me – I wonder if my mind has the same limitations to cope with the trauma that I bear witness to – and occasionally participate in – on a daily basis.

One week later Jim tells me that the victim in the GSW that we worked was a friend of his neighbor. He was attending a Quinceañera party – the celebration of a Latina’s fifteenth birthday where she transitions from childhood to being considered an adult. He had a perforated right lung and ruptured pancreas as the bullet had a straight trajectory in a downward angle from right mid-axially, bouncing off of the left iliac arch. He spent three days in the ICU under sedation. Upon waking up he told the nurses that he wants to meet with Jim and I to thank us for saving his life. That should be interesting.

His shooter was arrested one day later and is expected to be charged with assault with a firearm and attempted murder. The motive for the shooting was a gang initiation test to shoot a random person.

The suspect that shot up our ambulance is still unknown…

Impact 3/4

Thwack…..Thwack..Thwack.

“Drive!” I tell Jim to get us out of here now after hearing the metallic impact noises to the back of the rig. The dark streets of the killing fields become a blur as Jim accelerates away from the shooter and adrenaline floods my system while narrowing my field of view to a small tunnel with a blurry periphery – it’s the definition of “fight or flight” response.

I’ve slumped down in my seat a bit, unconsciously lowering my profile in the rig and putting more metal between me and the outside world.

“Anyone hit?” Communication is truncated to just specifics as Jim chirps the siren through a few stop signs and gets us out of the area. “I’m good,” comes the answer from Don behind me – the closest one of us to the shooter. Jim is the definition of concentration as he deftly maneuvers the rig through the hood, “Good.”

I pick up the radio, “Medic-40, priority traffic.” I really hope I’m keeping my voice calm.

“Medic-40, go.” The stoic dispatcher comes back quickly.

“Medic-40, we’ve taken shots to the rig. Relocating now, Code-4, non-injury. Shots fired at our previous staging area with four suspects heading east.”

“Medic-40, copy that, sending PD now, go with suspect descriptions.”

“Medic-40, four suspects, African-American, ages 15-18, one in a white hoodie, three in black hoodies. One black hoodie has white skeleton bones on the front and back.” I think I just described half the population of my mostly urban county.

I help Jim navigate to the well lit commuter train parking lot, hoping it’s a little safer than our last location. I heard our supervisor requesting our location from dispatch who has been watching us on the GPS and gives him our new location.

As we get out of the rig to check the damage, police cars start to show up. City PD, county sheriff officers, and the commuter train officers followed by our supervisor. Descriptions of the suspects are given again and the officers race off to canvas the area. I doubt they’ll find the shooter as all of the suspects were wearing the uniform of the hood: sagging jeans, black hoodie pulled over the head. You can never pin a crime on one person when everyone dresses the same.

An inspection of the back of the rig shows three impact points to the metal. They are small circular impacts that chipped the paint and dented the metal but didn’t go through. Given the distance of the shooter we’re assuming it was a small caliber pistol. Fortunately bangers are notorious for shooting with the gangsta-sidewise grip and usually can’t hit anything. In this case they did hit us and that’s really messing with my head. There was a time when everyone in the hood had an unwritten rule: no kids and no ambulances. It seems that rule is no longer in place – we saw that memorial to the kid today and we just got shot at.

I’ve had my body armor on since the last GSW we went to so I guess I was somewhat protected but it’s really just random happenstance that I was wearing it at the time when I got shot at. Yes, I have good instincts, and take every precaution. But honestly this could have happened anytime of the day or night. The rule of thumb for staging is to be 6-10 blocks away without a clean line of sight to the scene – and that’s exactly what we did. But it’s hard when we’re in the middle of the killing fields and there’s twenty blocks of unsafe hood in every direction. I doubt the shooter had any connection to the assault we were staging for. I suspect it was just a random, spur-of-the-moment crime of opportunity. Like so many things in EMS I I’ll probably never know the reason for this act or even the final outcome. As usual I just showed up for the exciting middle part – however unwilling that participation may have been.

The end result of all this excitement is an hour spent filling out paperwork and making police reports.


Impact 2/4

After missing out on an interesting call we’re still posting near the killing fields when we get a call for a GSW about twenty blocks from the one that went out only fifteen minutes ago. Finally, something interesting!

It’s dark now and Jim is navigating through the hood with our strobes illuminating graffiti covered fences as I map out the call location on my iPad. Given the close proximity and time-frame to the last GSW it’s reasonable to suspect that this may be an extension of that scene or possibly a retaliation by affiliates of the victim. Either way it means the vibe in the hood has changed and this is a very dangerous time to be traveling the streets. I pull my ballistic vest out of my bag and strap in the velcro attachments as I’m giving directions to Jim. It’s not something I wear all the time but it seems appropriate right now.

When we’re maybe fifteen blocks from the scene the dispatcher tells us that we’re clear to enter and police have secured the scene. Making the last turn to the street we see the fire engine and six police cars that were parked in a hurry. I tell Jim and Don to get the gurney as I want to get to the patient quickly – this is going to be a stat call and I want to be able to visualize any wounds before the patient gets bandaged up or put on a back board.

Walking up to the scene an officer meets me and accompanies me to the victim. We have to push past a crowd of people who look as though they were having an outdoor barbecue with party tents and folding tables and chairs. I can see the firefighters kneeling in the grass with officers holding back the onlookers. Secure scene my ass! There are way too many random people standing around just feet from my victim – and me.

I’m happy to see Darren, my neighbor, who’s the lieutenant on the fire engine that beat us to the scene by thirty seconds. “Hey KC, good to see ya. We’ve got a twenty year old male, single GSW under the right armpit, no exit wound. We’re working on getting him boarded now.” I thank him as I head over to check out the patient.

Darren’s crew is as dialed in as they come for this kind of call. They have the patient stripped to his boxers, the oxygen mask has already been applied, and they are about to slide the back board under him as I kneel down at his head. A quick greeting to the patient tells me that he’s alert for now and that his airway is good. I give a quick listen to lung sounds to confirm that he’s moving air and feel for a radial pulse which tells me he still has a decent blood pressure. All good so far.

I inspect the wound, which is just where Darren said it would be, and I start looking for additional wounds or an exit wound. As I run my hands down the ribs on the opposite side from the GSW I feel a lump under the skin that moves around when I push it. Fuck me! That’s the bullet! It entered under the right armpit, mid-axillary, and is now resting right next to the left floating rib. That’s directly through the kill zone!

There are basically three possibilities: straight trajectory through the torso; ricochet trajectory bouncing off of bones to end up on the other side; or the luge option where the bullet entered at such an angle that it skated to the other side following the ribs in a circumferential trajectory and bypassed the internal organs. I really hope it’s the last option.

We have him loaded in the ambulance and start transporting in an incredible four minutes and thirty seconds. I brought Darren’s fire-medic with me and I have Don in the back with me. Treatment is fast and methodical from two medics that have done this many times: bilateral sixteen gauge IVs, Asherman chest seal over the wound to reduce the chance of a sucking chest wound producing a collapsed lung, keep re-assessing and go find a trauma surgeon.

After all of the basics are covered I turn it into a teaching case for Don. In an ambulance, traveling with lights and sirens, bumping down the road, I’m walking Don through everything we did and having him re-assess. I have him take a blood pressure in the most challenging of environments using all of the tricks I’ve shown him today. I quiz him on the anatomy that is in danger given the different possibilities of bullet trajectory. I have him feel the abdomen that is now filling with blood and appreciate the rigid distention that only comes from internal bleeding. He then feels the bullet under the skin as I guide his hands and I watch Don’s eyes get big and round. And finally I point to the trends that we’ve been watching over the last six minutes; skin signs going shocky, heart rate increasing by fifteen percent, blood pressure dropping by ten percent, respiration increasing, oxygen saturation dropping. I’m explaining shock and compensation as I roll into the trauma bay filled with this year’s new crop of doc-lings and the rest of the trauma team.

If you wish to make an impact for one year, plant corn; if you wish to make an impact for a generation, plant a tree; if you wish to make an impact for eternity, educate a child.

Anonymous

Impact 1/4

im·pact

1 : the striking of one body against another

2 : the violent interaction of individuals or groups entering into combat

3 : to have an effect upon; a positive impact upon the community

Words can never adequately convey the incredible impact of our attitudes towards life. The longer I live the more convinced I become that life is ten percent what happens to us and ninety percent how we respond to it. 

Charles R. Swindoll, 1934

We’ve been staging for the assault in progress for almost a half hour and all three of us are starting to get a little tired of just sitting in one place as we wait for PD to secure the scene so that we can safely enter. Normally we would be parked behind the fire engine, as they stage with us, yet this call came in as a Code-2 so we’re running it solo. The police are stretched pretty thin right now as they’re working on the aftermath of two shooting scenes within twenty blocks of us.

My military EMT ride-along is in the back and I have a float EMT partner as Kevin and I got split up today by scheduling. After the excruciatingly slow pace of the day we finally got an interesting call an hour ago – for a GSW that occurred about 20 blocks from our current scene. We rocked that call to perfection and I’m going over the specifics with my ride-along as we sit waiting for a secure scene.

Four young men in the hooded sweatshirt/baggy pants uniform of the hood walk past the rig and down the dark street behind us. One of the black hooded sweatshirts has the white bones of a skeleton on the front – the harbinger of death. My partner is keeping an eye on them in the side mirror when one of them raises his hand pointing at us from fifty feet away.

Thwack…..Thwack..Thwack – three metallic impact noises come from the back of the rig. Don, my ride-along, yells over to us, “Oh shit! They’re shooting at us!!!”

While checking out my narcotics, computer, and miscellaneous equipment from the deployment coordinator I’m told that I have a military ride-along today and head off to the lounge to pick him up for his training day in the hood. He’s an energetic man in his late twenties named Don. I spend a few minutes getting him familiar with the rig and explaining expectations for the day as Jim, my EMT parter for today, shows up.

As usual we seem to have a heavy dose of “third man syndrome” today as it’s very slow and I’m only getting the absolute mundane calls – a fall from a ladder with minor injuries, the febrile seizure, the sixteen year old girl with a tummy ache consistent with menstrual cramping, and an old man who had a seizure in a skilled nursing facility. I do my best to involve Don in everything but there’s really not that much to do on these calls and we have over an hour of posting between each one so we get a chance to talk all day.

Don tells me he’s been in the Army for six years with a tour in Iraq and one in Afghanistan. He switched from infantry to a medical focus and is getting his EMT certification so he can feel like he’s helping his fellow servicemen on future deployments.

Jim and I tell him about calls that we’ve been on and talk about treatments and patient presentations. We pass the time by quizzing Don on how he would do assessments and treat fictitious patients.

We’re finishing up a call and hear another unit get dispatched to a GSW (gun shot wound) with possibly two patients on scene. It’s too far away for us to jump the call from the other unit but the dispatcher sends us to a post that’s near the scene. If there happen to be two patients then I’m sure we’ll be sent in for the second patient so maybe our luck is turning for the day.

I explain to Don how we call this area the killing fields as it’s a flat, 60 by 40 block area of the county where a lot of assaults and gang violence take place. I point out a street memorial – stacks of stuffed animals surrounded by candles and flowers – for the three year old child that was the unintended victim of a recent drive-by shooting. Then we pass by the street where the four officers were killed a few years ago by a banger with an assault rifle. Don’s having a difficult time believing this is happening right here in America. He’s a combat veteran who is no stranger to violence but he didn’t know it existed to this degree in the forgotten urban wasteland of my mostly urban county.

He tells us of his experiences in Iraq where his convoy was often shot at while driving from one base the the next and how IEDs (improvised explosive devices) were a constant source of annoyance and often death.

I hear the unit that responded to the GSW start transporting Code-3 to the trauma center without having called for an additional unit. It appears that there was only one patient and our “third man syndrome” is still in full effect.


Dia de los Muertos 3/3

The urban city life is far behind me as I take the off-ramp from the freeway to my quiet neighborhood. I’ve outdistanced the commuter train and the only traffic at this time of night are the workers who got held late in the city and are only just now returning to their bedroom community. I see the late night basket ball game at the well lit community park; black, white, asian, and middle eastern players all having a competitive game in racial harmony. I smell the water in the air as I pass the manmade waterfall that signifies the entrance to my master planned community. A mini-van has pulled over to the side of the road and a woman is taking a night time picture of her children standing in the lights with the waterfall at their backs. I chuckle at the van parked at the side of road as I feel the weight of the night lift and flappy paddles drop the gears down for the turn into my cul-de-sac.

Making the final turn into my house I push the button on the rear-view mirror that activates the garage door. The cleansing light of the garage washes over me while the horizontal shade of the door slides up to the ceiling. The turmoil, dirt, vomit, blood and death of the day are washed away replaced by the anxious squeals of the dogs who await my opening of the door and the multitude of interesting smells on my uniform after a day in the hood.

Having just left Jimmy in the ED – cashing in the last of his frequent flyer miles – I am more than ready to go home. I have some paperwork still left to do but I don’t care at this point; we’ve already been held over by an hour and I just want to clock out so I don’t get another call.

Lester, our favorite dispatcher, clears us to go home and I jump in the driver’s seat and tear out of the ED, through the hood, towards the freeway. If only my ambulance had flappy paddles! Kevin is beside himself with happiness to be done with the day. “Yes! We are finally done!” And everything stops working…

The lights are dead, the engine is off, the power steering is off, the brakes are gone, and we’re doing 45mph down a residential neighborhood deep in the hood.

It always comes in threes…

I put all of my weight into the brakes while torquing the steering wheel for all I’m worth just to coast into an empty spot on the side of the road. There we sit, dead rig, stuck in the hood – parked on the side of the road with tennis shoes adorning the phone lines and random hooded bangers walking the streets. I look at the dash and see that the problem is obvious; the odometer reads 213,356.7 miles. This rig has served it’s time and is ready to cash in it’s own frequent flyer miles for a retirement spot in the corner of the back lot of deployment.

A phone call to the supervisor and to Lester to let them know where we are makes me feel a little better. The supervisor tells us the tow-truck will be about an hour and we should just hang tight until they show up. Another unit, who was posting close by, comes over for moral support and parks next to us – safety in numbers. Twenty minutes later our supervisor shows up. Two ambulances and an SUV are parked in the hood and colleagues get a chance to decompress from a long day. I finish the day getting a chauffeur driven ride back to deployment with a nearly toothless tow-truck driver – at least I’m able to finish my paperwork by the time we arrive.

I open the door from the garage to the house. I’m bathed in the bright light of a happy home and three dogs eagerly vying for my attention. My wife gives me a huge hug with a kiss. “Welcome home love.”

Dia de los Muertos 2/3

Leaving the urban areas behind I accelerate into an increasingly empty freeway as the lights trail off, replaced by trees and scrub brush hills. There is solitude in the darkness, yet the open roof allows judgment from above as I navigate the quiet freeway home. With a crescent moon overhead I see the airliners strung out in their landing pattern like white Christmas lights hanging in the sky. I feel the rush of wind as I pass the big rigs hauling goods to far off destinations. Cold wind is still on my face, and I have a tightness in my chest when I breathe deep, so I allow my breaths to become increasingly shallow – it’s just easier that way. I wonder what he thought just before he took the last breath of his life.

“It’s Jimmy, looks like his asthma is acting up again.” Kevin pulls us up to the bus stop where Jimmy is sitting down and sucking hard on the Albuterol treatment provided by the fire medic.

We’ve seen Jimmy every few weeks over the years. Sometimes it’s drunk in public, sometimes it’s his asthma, or weakness, or hunger, or just a little cold. On occasion we even get the calls from the cell phone heros who think he’s dead yet keep driving so we have to show up and wake him up in the morning. Although he’s usually not in any serious distress he does have every chronic problem in the book: hypertension, CHF, diabetes, asthma, COPD, previous heart attack, etc. He’s an urban outdoorsman (a.k.a homeless), and a frequent flyer. It seems like he’s been in the county forever. The fire medic doesn’t even bother with a hand off because we all know him.

As I load Jimmy into the rig I hear the fire engine accelerate away from us. Jimmy’s having a hard time holding the Albuterol treatment so I convert it to a mask for him as I tell Kevin to start transporting – I’ll do everything en route to the ED because he’s looking pretty serious.

As I lean Jimmy forward to listen to his lungs I can actually hear the fluid level increase – filling up his lungs as I work my stethoscope higher on his back. FUCK ME!!! The asthma exacerbation triggered a flash pulmonary edema episode. Uncontrolled high blood pressure and congestive heart failure are pushing blood into the most porous organ in the body – his lungs. He’s drowning in his own fluids!

Just as I pull out the CPAP (continuous positive airway pressure) and affix a nebulizer to it, I see Jimmy’s head slump to the right. Fuck! Can’t use CPAP on an unconscious patient.

Looking out the window I see that we’re basically on the same block where my last patient checked out on me. I tell Kevin to upgrade to Code-3 and let them know we’re coming in with respiratory arrest. I switch the nebulizer over and attach it to the BVM (bag valve mask) and squeeze the football to try to oxygenate the lungs that have decided they are going to stop working tonight.

One minute later we’re at the ED and I’m watching his heart rate slowly drop; 60, 50, 40. “Start compressions.” The doc states the obvious – Jimmy just coded. Fifteen minutes later they are throwing the “Hail Mary” drugs at him in an attempt to counteract years of abuse to a body plagued by addiction and street life. Twenty minutes later I’m finished with my paperwork and the ED tech, Nick, walks up. “Man, I hope you’re going home now because I’m tired of working codes tonight.”

“Yeah, that was my last call, I’m done. It’s the end of my week – no more patients fixin’ to die on me.” I wave at him as I head out the doors. “Have a good one.”

Dia de los Muertos 1/3

Dí·a de los Muer·tos

1 : the day of the dead

2 : a holiday, particularly celebrated in Mexico, which focuses on gatherings of family and friends to pray for and remember friends and family members who have died

The fabric roof recedes behind my head in silent automation and reveals the stars in the heavens in all their glory. A moment of solitude and infamy which is quickly interrupted by the speeding commuter train on its elevated track, with its onslaught of light and noise, rushing off to unknown destinations. At the end of my shift I sit behind the wheel of my personal vehicle and take a deep breath – finally it’s over – and listen to the engine cycle into a familiar purr to tell me that it’s ready for the drive home.

I recline the driver’s seat to stare straight up at the infinite expanse of the universe and wonder where the three dead souls have gone this night. It wasn’t my fault, I mean seriously, how am I supposed to reverse multiple years of abuse in the fifteen minutes I’m with a patient? Well, the last one was probably my fault, I pushed him a little too hard, but even still – it was his time to die. 

Any why does it always come in threes?

Precision German engineering growls back at me as I depress my foot and accelerate away from the deployment center. Cold wind rushes past my face and street lights streak overhead as the flappy paddles on the steering wheel cycle the gears up in a desperate attempt to distance myself from the memories of a day from hell. Three hundred and thirty-three horses are unbridled at the on ramp to the freeway, with a rapid acceleration, as the increased g-force pushes me into the seat. The cold wind bites at my short sleeves and exposed skin – it’s a little too cold for a convertible ride so late at night – but I did it on purpose knowing full well what to expect. I wonder if that’s what a cutter says as she drags the razor blade in ever increasing depth across her forearm? Does pain and discomfort somehow remind you that your alive and in that revelation then become a celebration of life? Or is it time to check myself into Emergency Psych Services on a 5150 – should I start to worry when the madness actually starts to make sense?

“Medic-40 copy code three for the OD on the transit bus. PD is on scene, Code-4, you’re clear to enter.”

We’re only a few blocks away and Kevin puts us behind the bus and fire engine in just a few minutes. As we walk up to the bus I see a man in his early thirties surrounded by county sheriff officers and firefighters. He’s looking at me in this kind of thousand yard stare as the fire medic shows me the empty bottle of vodka they pulled out of his pocket. It’s the classic “drunk on the bus” and I’ll have to take him to the ED because he can’t even walk by himself. It takes four of us to pick him up and plop him on the gurney and the firefighters take off without even taking vitals or offering to help out.

As I strap the seat belts on my new patient I notice a little bit of plastic between his lips. I reach up and pull out a baggie that’s been chewed down so all that’s left is just a few white grains of powder – obviously an attempt to hide a drug possession from the officers. I hand the baggie to the officer and feel for a pulse; strong in the sixties – good for now. “Kevin, I’m good to go as soon as we load up, this could go downhill fast…”

My new patient isn’t answering questions or even acknowledging that I’m here so my only assessment is what I see on him and the monitor. The most obvious options for the white powder are crack cocaine, crystal meth, or heroin. Crack and meth speed you up; heroin slows you down – I really hope it’s the heroin because that’s the only one I can turn off.

We’re a half mile from the hospital when the vomit and head spinning scene from the Exorcist starts up right there in the back of my ambulance. First thing I notice is the heart rate climbing from 66 beats a minute to an incredible 236 in the course of twenty seconds. As I tell Kevin to upgrade to Code-3 the vomiting starts. Now I’ve got bio-hazard all over the back of the rig (not to mention the stench), and all of my focus is on keeping his airway open to prevent him from aspirating vomit into his lungs. I’d love to throw a line in and hit him with a sedative but I can’t do it at the expense of his airway. Well, I guess it wasn’t heroin.

Two minutes later we have him in the ED. Two minutes after that they are throwing the drug box at him to slow down his heart and attempting a gastric lavage to clean out his stomach. Fifteen minutes after that they are doing CPR – his heart had stopped beating when it gave out from fatigue. Twenty minutes after that the maintenance crew is mopping up the vomit from the floor and trying not to disturb the dead body on the table with the sheet pulled over its head.


Morton’s Fork 2/2

Kevin navigates the residential streets to St. Closest while I’m in the back with the sergeant tracking respirations and the fire medic helping me by taking vitals. My new patient, who was dead just a few minutes ago, is actually doing pretty well. He’s got a decent blood pressure, reactive pupils, 12-lead is clear, and he’s got some spontaneous movement in the extremities. I decide not to put him on ice (therapeutic hypothermia) based on his increasing level of consciousness and the knowledge that the ED at St. Closest wouldn’t continue with the procedure over the next 24 hours.

We move him over to the bed at the ED and I give a report to the MD and nurses who are going to continue treatment. They seem a little crestfallen as they are surprised by the level of consciousness of the patient. It’s not like anyone is sad to see a resuscitation but it’s so uncommon for someone to go from asystole to having perfect vitals and be sitting upright in a bed and staring at you that they are at little bit of a loss. Unlike in the movies, where they seem to bring people back from asystole all the time, in real life a flatline most often means game over.

I’ll check back in a few minutes but right now I have a mountain of paperwork to do in documenting all of the things we did and how the patient responded. I walk out of the ED towards the rig so I can start typing on my computer.

Two EMTs from the Inter-Facility Transport division are walking in and one of them catches my eye. “Hey, did you have Brian’s dad?”

“No, I had a code-blue with a resuscitation.” I’m just a little proud of myself for pulling off an improbable field save. They look a little bit confused but continue into the ED. I’m walking to the rig when it finally hits me. Fuck ME! The son was Brian!

I didn’t recognize him out of uniform. He’s been working as an EMT in the county forever, long before I got here. He’s a career EMT in the Inter-Facility Transport division so I seldom see him on the streets or at the ED. I’ve only talked to him a few times and I knew he looked familiar – but I just couldn’t place him.

I’m actually shaking as I tap away at the computer to document the call. I’ve never worked up the family member of someone I know, much less pulled them back from the dead. And having pulled off a minor miracle I took him to the one hospital in the county that none of my co-workers would ever want to go to – much less send their recently dead father to. I feel like I let him down, however paradoxical that feeling may be. I just can’t shake the torment in my mind.

Having finished my paperwork I drop it off in the room and see that Brian’s father is sitting up, talking to staff and family, and upon glancing at the monitors I see that every vital sign in well within normal limits. The other son and his wife thank me as I try to get out of the ED. I’m starting to feel like I need to vomit. I need to move on to the next call and shake this out.

Kevin’s waiting for me and he’s also trying to digest the news as I jump in the driver’s seat and put my hand on the key. I look up through the windshield to see Brian sitting on a bench being comforted by his girlfriend, crying tears of grief with his face buried in his hands. Try as I might, I physically can’t start the engine. I have to bring this full circle and talk to Brian even in his grief stricken state. I’m not sure if he’s going to take my head off or thank me but I have to see this to the end and do it right now. I have never felt so bad after saving someone’s life before and I can’t really come to terms with the emotional upheaval that’s ripping me apart.

Brian stands up as he sees me walking towards him and his girlfriend backs off to give us some room. I’m seriously expecting him to punch me in the throat and I know that if he does I’m just going to stand there and take it – I might actually deserve it.

“Brian, man, I’m so sorry, I had to come here, you know I did…” We’re both crying now standing just a foot apart.

“Thank you! You saved him. Thank you so much.” His huge arms envelop me in a tearful hug. Oh, thank god! I don’t need an ambulance…

“No, you saved him. You kept his heart going until we got there. It was all you!”

The emotional turmoil that I attempt to convey in this retelling may be difficult for those outside of EMS to fathom. It may seem strange but even on a successful field save we try to get out of the hospital before the family members arrive. I don’t want praise for a life saved and I definitely don’t want blame for a life lost. Speaking for myself, though I think other first responders feel the same, I must preserve my emotional detachment so I can make the right decision at critical times without hesitation. I know I did the right thing in my transport decision. But in retrospect I’m glad that I didn’t recognize Brian while on-scene. I may have hesitated longer or possibly even gone against my training. I’ll never know what I would have done but I know I’m now better prepared if the situation ever comes up again – and I have no doubt it will. 

That night Brian’s father was transferred to his hospital of choice with no deficits. After being surrounded by family members for two days he coded on the nursing floor and was pronounced dead. Our resuscitation bought him and the family some time together. Sometimes that’s enough – but in this case I wish the outcome was different.