Tag Archives: Drugs

Strike Out 2/2

We’re driving in the middle of the city after having just stopped at Starbucks to grab some caffeinated motivation for the day ahead of us. It was a long night yesterday as I was on the SWAT standby for an hour past my regular off-duty time. After the anti-climactic end to the situation I was able to go home and almost got enough sleep to make it through the next day. The hot coffee in my hand is helping to fortify my resolve as the morning commuters are exiting the freeway and the busy urban downtown area starts to come to life.

My coffee-inspired day dreams are interrupted by the computer on the console as it gets toned out and a call location drops almost on top of the icon representing our ambulance. The dispatcher comes up and tells us we have a patient with a laceration at the city police department on the second floor in the interrogation rooms. I’m actually looking right at the city police department building as the disembodied voice of the dispatcher is giving me the call information.

We pull up to the front doors as I load the gurney with all of my equipment and bid farewell to my warm coffee. I know we’ll be up on the second floor and the interrogation rooms are quite a ways on the other side of the building. Coming back to the rig for a Band-Aid could take a long time so it’s best to just take everything with us on the first trip.

A detective is waiting for us and proves to be a decent escort through the maze of the police intake and booking area as we make our way back to the interrogation rooms. The detectives aren’t really saying much but I can read their body language enough to know that something bad happened.

The detective opens the door to the little room and I’m faced with a complete blood bath. The tiny room looks like a set piece for the TV show Dexter with blood spatter covering the walls, desk, and floor. There’s a man sitting at the table with his hands cuffed to a metal ring on the desktop. Under his hands there is a fresh pool of blood.

I turn to the detective. “What the hell happened?” This is obviously the kind of high profile situation where Internal Affairs will get involved because someone messed up really badly. That explains why the officers were being so quiet and not telling me anything. The less I know about the facts the better it is for everyone when the investigation finally gets going.

The detective has a quiet voice as he fills me in. “So, did you hear about the hostage situation last night? Well, this is the perp from that scene. We had him in the room all night waiting for the morning shift detectives to come on duty. He asked for a soda. Someone gave him a can of Coke. He drank it, tore it in half, and cut his wrists with the sharp edges. We found him like this an hour later.”

“Wow!” That’s all I can say. I mean really, this is such a jacked up situation on so many levels I just don’t know where to start. The officers know how bad this is and they really don’t need the Paramedic to point out the sequence of stupidity that led to this bloody outcome. Whatever, I’m not here to judge, I’m just here to clean up the mess, as usual. But seriously, paper cups might be a good idea.

The man at the table hasn’t moved since I entered the bloody room but I can tell it’s the same man I talked to last night through the bars of the police cruiser. “Hey, are you okay?” Fine, it’s a stupid question but I have to start somewhere.

“Fuck you!” Seriously, are we going to play this game again?

Last night I could walk away from this guy based on the fact that he wasn’t visibly injured and refused all assessment. Today I can’t do it. I’ve got to check his wounds, bandage up what I find, and get him over to the hospital for medical clearance. He will eventually return here and be put on suicide watch.

I’m in the interrogation room and my partner, Anna, is handing me supplies to clean him up a little so I can see how bad the cuts are. As it turns out he missed the artery and all of the blood is just slow trickle stuff from the veins. He’s going to need some sutures and he’ll have some very impressive scars in a month or so when it all heals. Regardless of his medical outcome he just accomplished his third strike last night. He’ll be seeing the inside of a prison for the rest of his life, whether or not he manages to end his life a little early.

Three Strikes Laws are statutes enacted by state governments in the United States which mandates state courts to impose life sentences on persons convicted of three or more serious criminal offenses. In most jurisdictions, only crimes at the felony level qualify as serious offenses and typically the defendant is given the possibility of parole with their life sentence. These statutes became very popular in the 1990s. Twenty-four states have some form of habitual offender laws.

The name comes from baseball, where a batter is permitted two strikes before striking out on the third.

The three strikes law significantly increases the prison sentences of persons convicted of a felony who have been previously convicted of two or more violent crimes or serious felonies, and limits the ability of these offenders to receive a punishment other than a life sentence. Violent and serious felonies are specifically listed in state laws. Violent offenses include murder, robbery of a residence in which a deadly or dangerous weapon is used, rape and other sex offenses; serious offenses include the same offenses defined as violent offenses, but also include other crimes such as burglary of a residence and assault with intent to commit a robbery or murder.


Strike Out 1/2

strike

1 –  to try to hit or attack something

2 – Baseball; a pitched ball judged good but missed or not swung at, three of which cause a batter to be out

3 – Collective refusal by employees to work under the conditions set by the employer, a work stoppage

4 – to be unsuccessful in trying to do something

 

out

1 – to a finish or conclusion; the game played out

2 – a means of escape; The window was my only out

3 – used in two-way radio communication to indicate that a transmission is complete and no reply is expected

As the car passes the officer he recognizes the driver as a known felon. They’ve been briefed on this guy – armed and dangerous, two strikes down in a three strike state, gang affiliations with narcotic distribution. The plates on the car come back as stolen and the officer calls for backup before attempting a felony traffic stop. The man in the car knows that he’s been made so he speeds up, trying to outrun the officers. Every officer in this part of the city starts to converge on his location. When he finds himself boxed in he exits the car and starts shooting at the officers in their cars as he runs down the quiet neighborhood street. Seeing another officer blocking his escape route, he realizes that he’s trapped. He makes an abrupt turn and runs up to the nearest house. One kick to the front door and he makes entry into someone’s home. The officers hear screams as he takes a few hostages and yells threats through an open window. The officers surround the house but pull back as they initiate a SWAT call-out for a hostage situation.

The Bear Cat rolls past me and slowly drives up the street to park in front of the house where the suspect has barricaded himself. The six SWAT officers in the armored truck are positioned to report on any changes in the house and they will be used as a rapid reaction force if the suspect does something stupid like killing a hostage. Their job is to hold the scene at a forward position and react as needed to buy the rest of the team some time to formulate a plan.

From my vantage point in the incident command center I can see the SWAT commander setting up his game plan: floor plan of the house on a white board, arrows showing expected direction of attack, frequent radio communication and the occasional cell phone call. The SWAT snipers, dressed in woodland camouflage, begin the long and solitary walk to disappear into the neighborhood, with Remington-700 Police Sniper Rifles slung on their backs and a M4 duty weapons slung in the front. They quickly vanish from sight, undoubtedly taking up overwatch positions from rooftops a few streets away.

The SWAT Medic that is embedded with the team comes up to my rig and we make a game plan on various extrication scenarios and transport options. We’ll work under force protection protocols and enter the warm zone if necessary to initiate prompt treatment and extrication of wounded. If the suspect decides to force the officers into shooting him I’ll go in afterwards and make a field pronouncement. If he’s really stupid and starts shooting the hostages I’ll handle the initial triage and treatment while my partner calls for the appropriate number of units for transport. I’ll utilize the SWAT members to help extricate victims to the curb for the responding units to transport to the hospital.

The police helicopter finally shows up and starts doing lazy orbits of the house from 800 feet in the air. The pilot has the FLIR (forward looking infrared) turned on the house so he can see any movement. It’s sharp enough to pick up a hand on a window and discern our uniforms with the patches on the shoulders or the characteristic lack of heat signature where the ballistic vest insulates the torso. Unfortunately it’s not sharp enough to pinpoint heat signatures in the house. By now the snipers are in their overwatch position and I hear their quiet radio transmissions as they report on activities in the house as seen in their magnified scopes atop the rifles.

The rest of the SWAT officers start showing up to the command center that was hastily carved out of this quiet street in the middle of the hood. Their duffle bags of gear have been laid out like dominoes on the sidewalk. Officers who drove their personal vehicles into the hood stroll up to the duffle bags and begin their transformation from average citizen to door kicking SWAT officers. Black uniforms, heavy ballistic body armor, communication ear buds placed under headphones, and finally weapons loaded and made ready. The SWAT commander walks around to the troops showing a picture of the suspect as they prepare for the final showdown.

Whoomp! Whoomp! Whoomp! The continued noise of the forty-millimeter grenade launcher has been rhythmically pounding the house with tear gas for the last ten minutes. They systematically hit the house room by room – filling the interior with gas – until they have the suspect and hostages pushed to a back bedroom where there is no escape. I count 35 gas grenades before it finally goes silent.

The SWAT officers – who have collectively just heard a dispatch on the radio – turn in unison to walk down the street towards the house for the final assault. The K9 officer falls in with them and someone grabs a Halligan tool for door breaching. I’m going over scenarios in my head for possible outcomes in the next few minutes. I may end up with more patients than I can handle, with trauma that I can’t fix here on the streets. I could end up with wounded SWAT officers or a dead suspect or a random bystander shot in the mix. Maybe an officer twists his ankle on entry or gets a dog bite while going through back yards or a sniper falls off of a roof. Hell, anything could happen, I’ll just have to wait here and deal with the consequences as they come.

The tear gas grenades have been quiet for fifteen minutes now and the bulk of the SWAT officers turned the corner towards the house ten minutes ago – it’s been quiet since then. Out of the darkness from the direction of the house comes a lone patrol car backing slowly towards my rig. The officer steps out and walks up to my window. “Hey, we’ve got the suspect here, can you check him out real quick before we take him downtown?” Really, just like that and it’s over?

I walk around the back of the police cruiser to the back window which is rolled down. I can see a man in his mid-30s, hands cuffed behind his back, calmly siting in the back seat. I can talk to him through the bars on the back window. “Hey, are you hurt?”

“Fuck you!” Not exactly the response I was looking for but okay I guess it’s something.

“Did you get taken down hard or is the tear gas hurting your eyes?” It’s not the first medical assessment I’ve done through the bars of the back of a police cruiser.

“I said FUCK YOU!” Maybe I’m just asking the wrong questions.

“Are you saying that you don’t want any help from the Paramedics and you just want me to go away?” I think they call that a leading question.

“No, I don’t want anything from you. FUCK YOU!” Okay then. Somewhat of a limited vocabulary but he’s made his wishes quite clear.

I stand up from the window and address the officer who has been standing by waiting for me to complete my medical assessment. “He’s all yours.”

 

 

Flight of Fancy Postscript

post·script

1 – a note, paragraph, etc. added to the end of a letter or at the end of a book, speech, etc. as an afterthought or to give supplementary information

Three days after leaving my mostly urban county by helicopter the young man in question was extubated and regained consciousness with no lasting deficits. The trauma surgeons in my county trauma center made the right call in sending him to the specialists at University Hospital. And, as much as I may have some misgivings about the use of an air ambulance in an urban setting, I believe it was the right choice of transportation.

Most forward thinkers in the pre-hospital setting are fairly skeptical of the use of helicopters for all but the extended transport times in rural settings. A flight time of twenty minutes can easily be extended to over an hour when all factors are taken into consideration; travel time to the scene, landing and unloading, assessment and loading the patient, landing and unloading the patient at the hospital. In many cases where the benefit may be minimal the right answer is to drive the patient and get to definitive care faster.

In this case I believe the use of the helicopter was warranted given the time of day and general unstable nature of the patient. In the midst of morning rush hour the normal drive time of 48 minutes would be extended to nearly two hours even with the use of Code-3 lights and siren. The geographical choke points of bridges and waterways create near gridlock traffic situations where an ambulance literally has no place to push the traffic out of the way.

It’s easy to get jaded in a busy urban environment like this. My initial impression of this escapade was that of skeptical acquiescence. The decisions about where and how this patient is transported are very far beyond my control once the doctors put things into motion. It’s also easy to lose a little bit of feeling or caring for someone who intentionally put themself in danger to satisfy the cravings of an addiction. Violence and trips to the ED are unfortunate byproducts of the environment for people who engage in this lifestyle. Just as a Paramedic may have very little sympathy for an injured drunk driver – we may have the same lack of compassion for someone who intentionally drives into the hood at four in the morning to score drugs. As a byproduct of their misadventure lives are put at risk while driving Code-3 and flying helicopters in a very busy airspace. That is a risk we will take when an innocent life is on the line yet it’s hard to justify when we are put in that position by someone’s poor choice of lifestyle.

Yet my impression of this patient changed a few days later when an officer involved in this case told me that the patient had bounty hunter credentials on him at the time of the shooting. Was he actually trying to clean up the streets rather than contributing to the problems in the hood? I don’t know, I will likely never know, but it does serve to remind me that it is not our job to judge people. We are here to fix who we can, keep them alive as long as we can, and deliver them to definitive care with all haste. That’s what it is to be a Paramedic.

 

 

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.


Gangsta Rap 3/3

The police officer sees us on the security camera and pushes the button that activates the large sliding metal gate. We drive in to see the parking lot full of police cars and head towards the sally port – a secure transfer spot for taking prisoners in and out of the city jail.

Five officers are waiting for us as Kevin and I step out of the rig to see why they called us to the back of the jail today.

The officer with the stripes on his sleeve approaches me and gives me the story. “Hey guys, so we picked this guy up on being drunk in public. While we’re getting him booked he starts talking about being suicidal and wanting to kill himself. So instead of booking him we put him on a green sheet to get checked out at EPS.”

“Did he actually do anything to hurt himself or is it just talk?” I’m just trying to see if I’ll have any injuries to deal with or is it just verbalizing suicidal ideation.

“No, he didn’t do anything – he actually wants to go to EPS. Go figure.”

“Has he been violent with you guys?” Trying to gauge the need for restraints or not.

“No, he’s been good, but he’s a big guy so we kept him cuffed.”

“Sounds easy enough. Do you want us to come in and get him or do you want to bring him out?”

“You can hang tight here, we’ll bring him out.”

We’re in the mid-county, more affluent cities, so there are more available police officers than in our Big City. In these cities it’s common to have four or five police cars respond to a single incident where as in the Big City they are stretched so thin it’s hard to get just two cops even when we need them.

The officers return from the sally port escorting a man in handcuffs. With one officer on each arm, and three more keeping watch, the man is doing a slow shuffle towards me as I wait next to the rig. He’s got his eyes closed down to slits which gives him a menacing look yet also allows him to surreptitiously observe his environment without others seeing the direction of gaze – prison yard stealth. With his shifting gaze he never looked past my blue uniform, which matches the police officers, to see who I am.

“Yo, Lil’G, what the hell you doin’ down here?!” The officers stop mid-stride as they didn’t expect to hear “street speak” coming out of the clean cut paramedic standing in front of them.

Lil’G’s eyes pop up to full round and he drops the prison yard stealth mode as recognition sets in. He gets a big smile on his face, “Yo, T2, it’s my boy. Ya’ll did me right, you called my boy to come get me.”

“Lil’G, you all right man. You gonna be cool if I get you outta those cuffs?”

“Yeah man, I cool, you my boy.” I can smell the alcohol coming off of his breath and hear the slight slur to his speech.

I turn to the officers holding on to his arms. “I’m good guys, you can un-cuff him. We’re old friends.” They catch the irony in my voice.

Lil’G happily climbs up into the ambulance as I chat with the sergeant for a few minutes.  “I usually see him up in the Big City around the seventies. I’ve never run into him down here.”

“Yeah we haven’t seen him before. I’m happy to send him up to EPS and out of our city.” It’s the classic small town sheriff giving the trouble maker a bus ticket out of the city.

“I hear ya’. We’ll take care of him. See you next time.”

I climb in to sit on the bench next to Lil’G and pull out the fat person blood pressure cuff to fit around his enormous guns.

“Lil’G, you losing some weight? You’re looking skinnier than the last time I saw you.”

“Yeah man, I going through some shit, you know. Not eatin’ much. I lost my daughter two week ago, she dead.” He’s introspective and just a little bit sad. I’d say that’s justified.

“Oh man, I’m sorry to hear that.” I’m curious about the circumstances but I honestly don’t want to talk about it too much with him. Remembering his bipolar diagnosis I know he could cycle on me and you just never know where that’s going to go.

In an attempt to steer the conversation somewhere else. “You got any new raps for me?”

“Yeah man, I got a rap for ya T2, it’s my story.”

I’m a play’a… that’s my number one life style.

I’ve been a play’a… since I was a li’l child.

I grew up… havin’ hard times every day.

I had to choose a road… but didn’t know which way.

 

Started kickin’ it with the fellas… on seven ohh.

Makin’ money… cuz that was the way to go.

Smokin’ dank, full tank… get an even high.

Even had three ho’s… on my side.

 

Two was cool but one… thought she was a gangsta.

But I didn’t know… I was fuckin’ with danger.

She kept on tellin’ me how down she was… you know.

She said she didn’t give a fuck… about five-ohh.

 

Till the day on the ave… we was kickin’ it.

Wasn’t nothin’ else to do… but get lit.

Straight hands to a gangsta… whole nine yards.

Till the sucka tried to pull… my damn playa’s card.

 

I threw a left… and connected to the fool’s jaw.

The punk fell an’ tried to walk… but he had to crawl.

I split the scene… and went to the fuckin’ sto’.

On the way back… I ran into the Po Po.

 

Shit was cool… so I didn’t want to bail.

Fuck the po-lice… I ain’t going to jail.

I cocked my nine… then I fired at the dirty mack.

I started trippin’ and my mind… started to un-fold.

I’m in the middle of a shoot out… damn I’m told.

 

As curiosity was fuckin’… with my damn head.

Bullets kept flyin’, people dyin’… and bodies bled.

I dropped my nine, then I reached… for my four-four.

Empty one clip, then I headed… for my car door.

 

I couldn’t believe my eyes…

It’s my mind’s surprise…

I’m the only black nigga gonna stay alive.

 

Jesus Christ… this mutha fuckin’ gang.

Po Po try an’ jack me… and playin’ wit my fuckin’ brain.

But I ain’t going down… I’m not a sucka.

You want me… you gotta kill me mutha fucka.

 

Bill Gates… and the rest a the klan.

Ya’ll can suck my dick… cuz I’m a crazy ass black man.

But in the mean while… I’m just as versatile.

That’s my life… gangsta life… that’s my life…style.

My name is Lil’G… and I’m out.

Lil’G is a very real man and the above rhymes are his words. I apologize for the graphic nature and language yet I think it’s important to keep it authentic as an accurate  representation of how his mind works. It would be easy to dismiss this as typical gangsta rap but I think it goes deeper than that. This is a man who has been in and out of institutions – criminal and psychiatric – since he was young. He may have actually picked up some coping mechanisms to deal with the turmoil that haunts his waking moments and it manifests with introspective communication in the only way he knows how. Just as his bipolar mind cycles from emotion to emotion his physical body will cycle from street to institution until both are exhausted. There is no escape for his mind or body from the streets that created his life…style. 

Gangsta Rap 2/3

Kevin and I are dumb-founded. It was actually a good rap, despite the disturbing subject matter, and Lil’G seems to have some talent. I’d much rather listen to him rhyme than watch him tear the place apart.

“Lil’G man, you got some talent, you write that when you’re in prison?” I’m honestly curious.

“Nah man, I gots too much to do when I’m in the joint.” He’s dismissive with a wave of his hand.

“Too much to do? What, you working out all the time? Gotta build up those guns?” Referring to his biceps. Yet a tickling on the back of my neck reminds me that we didn’t exactly search him before he got in the ambulance with chest pain a few minutes ago. I hope Kevin did the “EMS pat down” as he put the monitor leads on him.

“Nah, I don’t work out in the joint. I’m too busy keepin’ an eye on all those niggas. Don’t never know when some fool’s gonna come up and try to stick me. Gotta be ready for a smack down, you know?”

After what seemed like an eternity PD shows up. Fortunately they pulled up to the front of the rig and I’m able to brief them before Lil’G notices they are here. The officers walk around the back of the rig so Lil’G can see them and it’s obvious by his expression that he’s not surprised. He knew this was happening all along. He’s been in this situation before and knows the drill just about as well as we do.

After a quick conversation and some paperwork the green sheet is finished and we can start to transport to the Emergency Psychological Services (EPS). Lil’G will get a psych evaluation and maybe stay a day or two for observation. It all depends on how he answers the questions.

It’s Kevin’s tech so I’m up front driving to EPS while Kevin finishes off the paper work. It turns out that no restraints or sedatives were necessary as Lil’G seems to want to go to the EPS. I can only imagine the life he’s led up to this point and how it may actually be comforting for him to rest in a relatively safe institution for a few days.

Growing up in the hood he presumably had few positive role models. He must have been in harm’s way often and exposed to some traumatic events. Just as a soldier comes back from a war with PTSD, I can imagine that life in the hood can create the same effect. Then at a formative age he’s placed in prison with its strict routine and lack of freedom accompanied by the ever-present danger of prison violence. Past traumatic experiences have created at least as many mental/emotional scars as physical ones.

Yet even with these obstacles this man has made it to his forth decade of life, which is rare for people in his situation. He seems to focus his energy on his rhymes, which he presents in all modalities of communication, with a harmony of visual/kinesthetic/auditory artistry. A man with limited education and vocabulary is able to access his inner emotions and express his feelings, dark and violent as they may be, to others and himself.

Pulling into EPS I hear the disturbing rhymes from the back of the rig.

I chop your head off… let it roll in a buck-et.

I punch your eyes out… so I can skull fuck-it.

 

But I aint trippin’ nigga… I won’t beg.

I drink the blood… from a bull dog’s left leg.

 

I told you once nigga… I ain’t even trippin’.

You get found nigga… by three old men fishin’.

 

We can do some shit… I might bust your brain.

But on the tip of my shoes… I’m leavin’ doo-stains.


Gangsta Rap 1/3

gang·sta

1  :  black slang; a gang member

2  :  a type of rap music featuring aggressive misogynistic lyrics, often with reference to gang violence and urban street life

rap

1  :  to hit sharply and swiftly; strike

2  :  a criminal charge; a prison sentence

3  :  music; to talk using rhythm and rhyme, usually over a strong musical beat

4  :  to have a long informal conversation with friends

Violence is a part of America. I don’t want to single out rap music. Let’s be honest. America’s the most violent country in the history of the world, that’s just the way it is. We’re all affected by it. That’s one of the frailties of the human condition; people fear that which is not familiar.

Spike Lee

“Ya’ see, I didn’t really call you here because I was havin’ chest pain. It nothin’ like that at all. Ya see, I thinkin’ about killin’ myself.” As the fire engine accelerates away from us Kevin and I have a very different call on our hands than the one we thought it was going to be just a few seconds ago.

Getting called to the middle of the hood for chest pain is a common enough thing and we answer these calls on a daily basis. Today we happened to be just a few blocks away when the call information arrived on the Mobile Data Terminal (MDT). I turned the ambulance around and we were on scene in less than two minutes.

Sitting on a chair in front of an urban church outreach center was a man in his early forties. The pastor and church volunteers are comforting him as we walk up to see what’s going on. Holding his chest he tells us of the pain he’s feeling and how he wants to get checked out at the hospital. It’s an easy call and the assessment and treatment are so rote that we fall into auto pilot as we go through the motions.

Seeing the fire engine approaching from down the street I write the man’s name and birthday on my glove and hold my hand up high so the fire lieutenant can copy it down for his records without having to exit the engine. In seconds they are off to the next call and we are alone with the patient. Of course, that was before I knew the true nature of the call.

After our patient drops the bombshell on us, Kevin and I take a collective deep breath and one look between us confirms the sudden detour this call has taken. In our business suicidal ideation is taken very seriously. A person who is truly suicidal, who has ceased to care about their own life, may not care about other people’s lives. Therefore, we can be in danger when dealing with these people.

Our new patient, Lil’G, is quite a formidable man. He has scars on his face, one of which is consistent with a knife wound. He’s 240 pounds of compact, short, boxer’s build with huge upper body development. He’s seriously built like a smaller Mike Tyson. He jokes with Kevin because he had to pull out the fat person blood pressure cuff just to fit around his huge biceps. He does a muscle man flex and smiles showing me a gold tooth. I’m feeling very uneasy about this. I give Kevin a look that he understands. “I’ll be back in a second.”

“Hey, where you goin’?” He’s quick with predatory instincts, watching every movement – nothing escapes him.

“I just have to get the computer from the front.” It’s a half truth which I hope he doesn’t see through.

Walking up to the front of the rig I turn on the portable radio on my belt. Opening the front door I grab the computer and turn off the rig radio which can be heard from the patient area in the back. I stand in front of the engine compartment so I can keep an eye on Kevin through the windshield as I call in to dispatch on my portable.

“Medic-40 go ahead.” The radio crackles back to me.

“Medic-40, please send PD to our location, code-2, our chest pain call just turned into a 5150 with suicidal ideation. We’re code-4, for now.” The code-4 tells my dispatcher that we are not currently in danger. The ‘for now’ tells her that I don’t know how long that’s going to last.

I’m standing outside of the back doors as Kevin is doing further assessments on Lil’G. Kevin knows the drill: we have to stall as long as possible so PD can get here to write up the green sheet (5150). Without it we have fewer of the options we may well need in this case, like restraints and chemical sedation.

I’m watching Lil’G as Kevin continues with the 12-lead EKG. Lifting up his shirt I see the multiple GSW (gun shot wound) scars.

“Lil’G, how many times you been shot?” Anything to distract him and buy us some time.

“Yo, I been shot four times, stabbed two, and sliced up a couple. It’s hard man, growin’ up in the 70s.” He’s not referring to the decade – to him the 70s are the street numbers in his corner of the hood.

“You ever do time?” I’m thinking prison ripped could explain the boxer physique.

“Yeah, I did six year, fo’ bangin’. You know; sellin’ a little, had sum ho’s, and a little bit a shootn’.” He’s not talking about shooting up with heroin. “Yeah, I got a strike on me.” In this state it’s three strikes for felony convictions and you’re in prison for good.

Kevin’s still trying to stretch out the assessment as I’m typing on the computer. “You got any medical problems?”

“Yeah, I got PTSD, bipolar, paranoid schizophrenia, and depression, but I ain’t takin’ no meds for it.” FUCK ME!!! I’ve got a bipolar psych patient who’s off his meds, built like Tyson, and thinking about killing himself. I really need a raise.

Lil’G could shred both Kevin and I if he put his mind to it. Not to mention tear the ambulance apart. We’re walking a fine line here and we have to keep him on the good side of his bipolar disorder. I’ve watched manic bipolar patients cycle from happy to violent a dozen times in the course of a single transport. If this guy cycles on us we’re fucked.

Despite the lethal potential of Lil’G he’s actually pretty engaging. He has a fast wit and keen observation skills. He decides I look like the silver terminator from Judgment Day, in reference to my hair style and clean cut white boy appearance. Seeing as the terminator impersonated a cop through most of the movie I’m not sure I like the reference.

“Yo man, that’s your new name, I’m gonna call you T2.” He has a full bodied laugh with muscles rippling to the diaphragmatic contractions. Great, I have a street name.

And just like that Lil’G cycles on us. Yet not to a violent nature – quite the contrary. Right there in the back of the ambulance he starts rapping. With perfect tempo and surprisingly colorful depictions he tells us what’s on his mind in the only way he knows how.

I’m on the microphone… gotta do it quick.

But never give a care… I ain’t scared to hit a bitch.

Gotta hit her from the back… nigga back side.

I don’t give a fuck nigga… it’s time for a wild ride.

 

Call me Lil’G… when you see me.

I see niggas on the street… trying to be me.

I got these knuckles man… I make ‘em laugh man.

Never give a care… put ‘em in a bath man.

 

Gotta do it good… cuz you know what’s right.

I never give a care nigga… cuz I’m hell’a tight.

I come from 69ville… nigga eight-five.

Never give a care… boy I don’t duck and hide.

 

I’m born on the east side… I’m going east bound.

You a block head… whose name is Charlie Brown.



Ignis Fatuus

ig·nis fat·u·us

1 : a phosphorescent light that hovers or flits over swampy ground at night, possibly caused by spontaneous combustion of gasses

2 : something that misleads or deludes; an illusion

“Some say his sweat can be used to clean precious metals and he appears on high-value stamps in Sweden. All we know is – he’s called The Stig.” A man in a white racing outfit and tinted visor accelerates an impossibly expensive sports car away from the starting line as he speeds around an air strip turned race track somewhere in England.

The crackle of the radio interrupts our moment of down time. “Medic-40, copy Code-3 for an unknown.”

Lifting the iPad off of the MDT I see the call information appear as Scottie acknowledges the dispatcher that we’re en route. Pressing pause on the video of our latest down time obsession, Top Gear (BBC version), I switch to the mapping application and plug in the new address. Scottie isn’t wearing a white racing outfit but he’s doing a good approximation of The Stig as we race our ambulance through the hood. I pull up the street view on the iPad to see the street level photographs of our destination.

“Hey, we’re going to the post office.” All I know is that we’re heading to the post office for an unknown emergency. The call information in the MDT is useless – it doesn’t say what’s going on or why we’re going there.

The fire engine beat us to the call, as they usually do in this area, so we walk right into the post office to see what’s going on. The firefighters are standing in the lobby with a short man in his forties. He’s dirty with black smudges on a shirt that used to be white and he tracks me with his eyes as I walk up.

The fire medic looks up as we approach. “Hey guys, we just got here a minute ago and we’re still trying to figure out what’s going on. Basically this guy has been wandering around the lobby for the last ten minutes and wouldn’t leave when the manager told him to. He’s not talking to us and he seems altered.”

“Great, let’s go to the hospital!” Unlike our friends across the pond in England I don’t have any alternative transport decisions. I’m quite envious of their ability to transport to an urgent care facility, or even schedule a home visit by nurse for later in the day. They can even refuse to transport someone based on no medical merit. I only have three possibilities on each call; transport to the ED, transport to emergency psychiatric services, or have the person sign an AMA (against medical advice) form. Since an altered person can’t sign out it’s obvious that I’m going to the ED and I can do all of my assessment en route.

My new patient, Jose, walks with me to the ambulance. Although he’s not talking to me I  can assess quite a bit just from a little walk. He’s moving all extremities without difficulty, he’s obeying commands as he walks, he’s looking at me when I talk to him, and his skin signs are normal. I’m not getting any smell of alcohol and that’s high on my list of rule-outs given his appearance and the neighborhood.

Scottie passes the computer back to me and starts driving to the ED. All of my assessments are coming back perfectly normal, even his blood sugar and 12-lead EKG. I attempt to check for nystagmus in the pupils but Jose doesn’t get the concept of following my pen and not turning his head. I hold his head straight and move my face to his peripheral extreme and tell him to look over at me. He’s finally able to do it and I see the characteristic pupils bouncing off the side of the eye that is usually indicative of a high blood alcohol level. I feel that I’ve got the best-rule out I’m going to get so I start an IV, put some oxygen on Jose, and start typing in my computer as Scottie gets closer to the ED.

About a mile from the ED Jose looks over at me, “Wh-where are we going?”

“Hey, Jose, we were a little worried about you so we’re taking you to the hospital. What’s your last name?”

He answers yet it’s slow. There’s no slur to the speech but he has a delay almost like he needs to think about the right answer before he tells me. I run him through some stroke tests and he passes without any noticeable deficits.

“H-how did I get here?”

“You were at the post office and they called us. Do you remember seeing me at the post office.”

“Y-yes.” He’s still delayed and has a round-eyed thousand yard stare.

“Why didn’t you talk to me earlier?”

He thinks for a second. “I-I don’t know.”

“How did you get to the post office?”

“I th-think I walked.”

“What were you doing before I saw you?”

“I’m n-not sure.” It must be strange for someone to be missing parts of their memory.

Just as Scottie puts the rig in park at the ED Jose has a revelation. “I th-think I know where I was. I was in the garage working on my son’s go-cart.”

Now I’m the one having a revelation. “Was the garage door closed?”

“Y-yes.”

Jose did in fact have elevated carbon monoxide levels in his blood. The CO bonded to the hemoglobin, pushing out the oxygen, and tricking my machine to read a 100% oxygen saturation. He was actually having a hypoxic event and the oxygen that I gave him helped him enough to start talking again. Although nystagmus is usually a sign of an elevated blood alcohol level, CO poisoning can create the same effect. Jose didn’t present with the typical flushed/rosy skin tone. Yet even if he did I would have seen that as a further sign of alcohol use. The black smudges on his shirt were not indicative of a homeless man yet they are a byproduct of being a mechanic. Sometimes a drunk is just a drunk but sometimes it’s a real emergency. It’s nice every once in a while to be reminded of that.  

We were able to confirm that no one else was in the garage when we called his family. I certainly didn’t want my next call to be for his son. He was discharged a few hours later with strict instructions not to enter the garage.


Tough Love

tough

1 : strong or firm in texture but flexible and not brittle

2 : difficult to perform or understand; a tough assignment

3 : capable of great endurance; sturdy, hardy

love

1 : a feeling of intense desire and attraction toward a person with whom one is disposed to make a pair; the emotion of sex and romance

tough-love

1 : when people intentionally do not show too much kindness to a person who has a problem so that the person will start to solve their own problem

My flashlight illuminates the graffiti covered walls of the parking garage as Scottie and I walk in to look for my patient. “Hello, Paramedics. Did anyone call 911?” Scottie has his light out and we’re doing our best CSI impression as we search the dark parking garage for any signs that something is wrong or someone is in need of help. But all we find are parked cars, dumpsters, graffiti and trash – typical for the hood.

We were sent here Code-2 – no lights, no siren, and no firefighters. The notes in the MDT (mobile data terminal) were sparse and just told me we were responding to a man who isn’t acting right and is in the parking garage. Most people in my mostly urban county don’t act right so this call could be anything or nothing at all. The founding fathers of the 911 system must roll over in their graves each time we bear witness to the daily abuse of the system that we encounter. People will call for an ambulance for just about anything. They consider it the same as calling a taxi – only better because it’s free to them. Either their insurance covers it or if they’re uninsured, the state covers it (or my company doesn’t get paid). In any case, it’s not money out of their pocket like a cab or bus would be.

As we walk up the stairs to the main courtyard of the crappy apartment building, we run into a woman. “Hey, I called you guys for Tyrell.” She’s in her mid thirties, a little out of breath, and just a bit worked up.

“So what’s going on with Tyrell?”

“Okay, so, well, I’m the building manager. I saw Tyrell walking around all agitated, well, just not acting right.” So far this woman is about as helpful as my MDT. “So I took his blood pressure. I’m a dialysis tech, and his pressure was 132/84. But he’s just acting strange and I think his potassium might be elevated.” Really… I’ve watched dialysis techs do some really appalling things over the years so she’s not scoring high marks on my informed witness scale.

“So, why would you think his potassium is high – is he a dialysis patient?” I really hope I’m masking my cynicism.

“Well, no, but people do strange things when their potassium is off, and his blood pressure is 132/84.” Okay, I’m done. Telling me his blood pressure twice doesn’t change the fact that IT’S PERFECT!

“Where is Tyrell?” I’m not going to get anything useful from this woman so I might as well go to the source.

“He’s in 301.”

As we walk up the next two flights of stairs I’m talking over my shoulder to Scottie. “Have you ever noticed that when a man carries a hammer everything looks like a nail?”  Scottie’s still laughing as I rap loudly on the door. “Paramedics, do you need an ambulance?”

The door opens and a cloud of marijuana smoke wafts out of the apartment, quickly followed by a young man in a dark hoodie; presumably this is Tyrell. He’s got the baggy pants that are the uniform of the hood and one hand is always in the process of preventing a wardrobe malfunction. He quickly walks right past me towards the stairs with the stiff leg walk I see in the hood all the time.

I’m talking to the back of his hoodie as he walks away from me. “Hey where you going?”

“The hospital!” Muffled by the hoodie I can barely hear him as he takes the stairs towards the street.

“Okay, so what’s wrong with you?” I’m actually having a hard time keeping up with this guy.

“I jus gots to go!”

At this point Scottie’s patience runs out, and I’m not far behind him. “Well, if you keep walking that direction you’ll be there in five minutes.” He just walks to the back of the rig and stands there waiting for me to let him in. Whatever…

I get Tyrell situated on the gurney and start my regular assessment questions as Scottie retrieves the laptop from the front of the rig. “Okay, Tyrell, tell me why I’m taking you to the hospital today.”

“Cuz I been stiff all day.”

“What do you mean by stiff?”

“Like hard, like down there.” He’s pointing to his baggy pants that are tented at the groin.

“You mean you’ve had an erection all day?” Seriously, that’s where this is going?

“Yeah, for like five hour!” He’s agitated and squirming on the gurney. I’ve been getting him hooked up to the monitor while talking to him and notice his heart is racing at 140 beats per minute.

“What did you take?” I know he has marijuana on board but it’s obvious he’s got other stuff working on his system right now.

“Libigrow.” Never heard of it. I look it up on my iPad and see that it’s one of these male enhancement over the counter drugs that you see advertised on late night TV. Basically it’s just asian herbs, B vitamins, and stimulants – the stupid man’s Viagra.

We’re driving to the hospital and Scottie is taking side streets that are riddled with pot holes and speed bumps. I’m getting bounced all over the back of the rig and I decide to give Tyrell some Benadryl in an IM injection. Our county has a protocol for “mild sedation” which allows us to administer this for anxiety. I’d say this counts.

Tyrell gets extremely nervous when I pull out the large needle for the injection. His eyes are big and round while I’m drawing up the drug into the syringe. He’s obviously terrified of needles. I decide to have some fun with him so I’m playing up the bumps in the back of the rig.

I’m looking at his tented pants and holding the syringe. “Okay Tyrell, I have to give you a shot.”

“Hell no! Not down there man. You not gonna stick me down there?”

“No man, it’s just a little shot in the arm.” Tyrell actual tries to climb into the cabinets on the other side of the gurney as I roll up his sleeve to expose his deltoid. He whimpers like a baby as I stab him in the shoulder.

When we arrive at the hospital I explain Tyrell’s situation to the triage nurse. “Hey, Tyrell, you said you’ve been hard since eleven o’clock this morning?”

“Yeah, but I ain’t hard no more.”

“When did that happen?”

“Before we got here.”

“About the same time you saw that needle?”

“Yeah.”

The triage nurse starts laughing. “Great! You fixed him! Now take him out to the lobby.”

 

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.