For the first time I can remember we had no snow in December (and none through the first 15 days of January).  We of course did have the freak October snowstorm that left many of our communities without power for over a week due to the heavy snow landing on the trees still fully leafed, breaking branches and knocking down power lines.

 Nearly every day has been beautiful – the kind of days that make you wonder what you are doing sitting on a street corner in an ambulance instead of being one of the people riding by on a bike or jogging.  I think to myself, damn, I should be taking advantage of this weather.  You think about doing something when you get off, but of course when you get off, it will be dark out, the same darkness that was there in the morning when you put on your uniform.

Friday, it was really busy.  We were getting hammered.  No sitting on the street corner watching the pretty young joggers go by.  It was one call after another.  Can You Clear for a 911?  I don’t think we posted at all other than for a brief period in the morning when we first came on.

So there I was in the evening darkness again, standing out at an MVA scene, back boarding a patient and I’m thinking, why am I freezing?  I am cold, and the wind is bitter, and I notice I am just wearing my grey FTO shirt, no jacket or anything, no gloves on or hat on my number #2 razor cut head.  Then I think, it’s because I have been so damn busy today, I haven’t even had time to put on my jacket.  Sitting in the warm ambulance in the morning eating my oatmeal, I had taken the jacket off and stuffed behind my seat, and then we never left the hospital without going to another call, and I never had time to stop and say, maybe I ought to put this jacket on account of it is 20 degrees out.

 This morning, I spilled out of the house with my unzipped jacket on, but no gloves or hat – they were somewhere in my car.  It was so cold, the car had a hard time turning over and when it finally did, the thermometer said 10 degrees.  I was running late which is rare for me, and I had to run back inside the house to find some gloves because I could not find the pair I thought was in my cluttered car.  I got another pair, came back out and raced off to work – the car stalling one time, but thankfully starting back up.  I made it in with two minutes to spare (I like to arrive 15 minutes early). 

 I wondered to myself.  How could I have not known it was going to be so cold?  How did I not know steam would be coming out of my nostrils like I was a lineman for the Green Bay Packers?  Couldn’t I have laid my clothes out better last night?  If I had known it was going to be this cold, I would be wearing long johns and one of my Under Armor run outside in the cold shirts that keep the heat in.  I would have had my gloves and hat inside all warm and accessible.  I would have moved the boxes and clutter in the garage that I have been meaning to move all fall so I could put the car in it overnight and not have to pray as it weakly turned over.

It’s almost ten in the morning now and the sun is up and out and our heater is cranking away.  Still I have my jacket on and hat on.  Not looking forward to the day I come out of the house and have to use the shovel.  I can see why old people move to Florida.  But it would be hard to quit my jobs and start over down there.  I have a vision now.  I imagine picking up all of Hartford and flying it down to Florida held up by gigantic blimps.  You could set it right down next to the water maybe Key West Way.  It wouldn’t matter so much then that when you got home after work, it would still be dark.  You could sit out in shorts and a tee-shirt, out on the dock, sipping a cold ale, and feeling the gentle ocean breeze on your skin.  When Spring rolled around, you could pick Hartford back up and fly it North escorted by flocks of  robins.

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It has been almost a year since I was rotated out of my suburban post. I still occasionally do calls in that town, but I have largely lost touch with most of my regular patients of the last decade.  Last week, I was taking a patient from the hospital back to one of the local nursing homes in that town. I was driving and sitting up in the passenger seat with me was one of the nursing aides from the home.  I asked him how he liked working at the manor, and he said he did, and then I asked how my friend Jimmy Ryder was doing.   “Jimmy?” he said, “You mean the Viet Nam Vet, the little guy?  He’s gone a couple a months now.”

I asked for details, but he had little.  He didn’t know if he died in the hospital or in his bed, or if the ambulance came or not.   He just came in one day and Jimmy’s bed was stripped.

I wrote this about Jimmy Ryder five years ago.

***

It’s Christmas eve. We get called to one of the local nursing homes for rib pain. The room number sounds familiar. As we wheel our stretcher through the lobby, “Good King Wenceslas” plays through the speakers.

Gently shone the moon that night, thou the frost was cruel.
When a poor man came in sight, gathering winter’s fuel.

In the East Wing, the nurse hands me the paperwork. “Mr. Ryder says he needs more Percocets. He’s requesting transport.”

Mr. Ryder (Jimmy to me) is a tattooed biker, an emaciated COPDer with a long white beard. Almost sixty, he can’t weigh more than a hundred pounds. He sits in his wheel chair, in his Rebels motorcycle jacket, wearing an oxygen cannula.

“I’m in real bad pain,” he tells me in his whisper of a voice. “Fifteen on the scale.” He nods as if to say it is the truth.

“Well, we’ll check you out when we get you out in the ambulance,” I say.

It seems he fell a couple weeks ago and cracked a rib.

I have taken him to the hospital at least ten times over the years. The night medics have taken him more. Nearly every time it is self-dispatched. He agitates the nurses until they call his doctor who after several calls relents and tells the nurses to go ahead and call an ambulance just to get him to stop pestering them. He gets pneumonia a lot and complains of the chest pain. It is always “real bad,” he says. He goes to the hospital and gets sent back a couple hours later. He is rarely admitted, and in those cases it is usually for a COPD exacerbation.

While I don’t like to categorize patients in this way, he does fall into the “pain in the ass” category. But a patient is a patient, and none of my paychecks has ever bounced, so I’m not really complaining. They’ll be turkey with all its fixings on my feast table tomorrow. And besides, there is always something to be said for the familiar.

I see Jimmy nearly everytime we go into the nursing home. He is usually sitting out in his wheelchair in the main TV area. I say “Hey Jimmy! How’ya doing?” as I push the stretcher past going for someone else on the wing.

He lights up and says, “Not too bad, hanging in there.”

That’s the jist of our relationship.

Today in the ambulance, I have an EMT student do vitals as we start toward the hospital.

She chit chats with him.

“You’ve got all your Christmas shopping done?”

“Yeah, I just bought stuff for myself,” he says. He tells her Dial-a-Ride took him to the Mall. His favorite store is Spensers where he gets a lot of novelty gag items.

“I buy presents for myself sometimes,” she says. “How about you?” she asks me.

“I’m pretty much done.”

“Well, unless you’re going to the drug store when you get off, you’re out of luck. Time’s run out.”

“I’m in good shape,” I say. I think to myself if I get out in time, I’ll probably make a quick stop at the liquor store where I’ll buy myself some Christmas beer — a case of Red Stripe. I always ask for a case of a specialty beer for Christmas. Last year it was Presidente from the Domminican. This year I want Red Stripe from Jamaica. My girlfriend was going to buy it for me, but she is still hung up at the hospital. I told her not to worry about it. I’d get it myself. There is a liquor store that doesn’t close till eight on my way home. I’ll drink the beer slowly over the course of the year, taking one out every now and then and drinking it slow. I’ll buy other beer during the year, but this case — my Christmas beer — I’ll stretch out.

Jimmy looks up at the EMT student and says, “This guy over here, me and him go back a long way.”

“He’s taken care of you before?” she says.

“Yeah.” He nods at me and then says, “He’s probably one of my best friends in the world.”

I melt a little inside at his words. It also makes me terribly sad. I think of all his biker buddies — Hoss and Snake and Big Steve — and wonder if they are enjoying their winter’s fuel at the Iron Hog without him tonight or if maybe they are all either in the cold ground or solitary in nursing homes themselves.

Jimmy looks up at me now, his eyes locking on mine. “I’m in real bad pain,” he whispers urgently. “Fifteen on the scale.”

-Christmas 2006

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On February 1, 2012, our regional (NorthCentral Connecticut EMS) paramedic treatment guidelines will go into effect. In addition to incorporating many of the latest AHA changes from the 2010 Guidelines, these are some of the highlights of our changes:

Adult Airway Guideline

The Adult Airway Guideline has been revised to emphasize that the airway gold standard is an effectively managed airway, not always an ET tube.  ET, Combi-tube, LMA and King LT are all considered first-line airways. Capnography shall be utilized on all advanced airways (ET, Combi-tube, LMA, King LT).

Acute Coronary Syndromes/Chest Pain

Perform a 12-lead on all possible cardiac patients as soon as possible. If 12-lead shows a STEMI, contact hospital (with medical control) for STEMI alert as soon as possible. Early notification and activation of the cardiac cath lab has been shown to significantly improve patient outcomes.

Paramedics should perform 12-lead prior to administration of NTG. If 12-lead shows inferior STEMI, do not administer NTG prior to performing a right sided ECG. If right side leads reveal possible right ventricular infarct, establish a large bore IV. Giving NTG to patients with right ventricular infarction is contraindicated.

The use of nitrates in patients with hypotension (SBP100 bpm) is also contraindicated. Dropping a patient’s blood pressure may preclude them from receiving proven life-saving drugs in the ED such as beta-blockers and ace inhibitors.

Morphine should be used with caution in patients with unstable angina and NSTEMI.

Afib/Aflutter

For unstable atrial fibrillation/aflutter, if patient is on no meds for tachycardia or on Ca+ channel blocker, Diltiazem will be first line. If already on beta blocker then Lopressor will be used.

Lopressor standing order will be 5 mg IV q 5 minutes x 3 doses if needed.

Acute Pulmonary Edema

Lasix/Bumex, Morphine and Nitropaste have been removed. CPAP and NTG SL are now the mainstays of CHF treatment.

Ativan 0.5 mg up to a max of 1 mg may be given on standing order for patient with extreme anxiety if the medic judges that lessening their anxiety will enable them to better tolerate CPAP.

Systolic Blood pressure < 100 mm HG contraindication for CPAP  is removed. Use caution when using CPAP with hypotensive patients.

Pain Management

Standing orders dosing for Fentanyl and Morphine have been increased. Patients may receive up to a total maximum of 3 mcg/kg Fentanyl up to 300 mcg or 0.2 mg/kg Morphine up to a max of 20 mg on standing orders. Maximum single doses are 100 mcg Fentanyl and 10 mg Morphine. Wait ten minutes between full doses. Dosing cycles for patients over 65 should be should be cut in half with the patient receiving a half dose, followed by the second half dose, if necessary five minutes after the first half dose.

Fentanyl maybe given intranasally under the following dosing regime. Administer Fentanyl IN, initial dose 1.5 mcg/kg (100 mcg max single dose), may administer a second dose 1.5mcg/kg (100 mcg max single dose) if needed after 10 minutes, for a total maximum dose of 200 mcg.

**Administer half a single dose in each nare**

Torodol has been removed.

Altered Level of Consciousness

Dextrose can be given in any concentration. D50, D25 or D10. Dextrose should only be given in the amounts necessary to return patient to baseline. Studies have shown a lower concentration and gradual administration may be better for patients than the standard 25 gram D50 IV push.

Nausea/Vomiting

Phenergan has been removed from protocol. Ondansetron should be used as the front-line anti-emetic agent. Metoclopramide may be preferred in patients that are more calm and relaxed but are allergic to Ondansetron or where gastric emptying is desired.

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The headline in the paper catches me by surprise. “Iraq War Officially Ends.” With all the speculation leading up to the Invasion 10 years ago, the debate over weapons of mass destruction, then the shock and awe invasion, the fall of Bagdad, the Mission Accomplished banner, the resulting urban combat, the ICDs, flags flying at half mast. The Jessica Lynch story, the Iraqi prison scandal, the capture of Saddam, more urban combat and ICDs, more flags flying at half mast, it seems odd that the war is over just like that. There are no celebrations I know of, no couples kissing on Main Street, nothing seems to have changed. It is on the front page right there, but it has all the impact of a story buried deep in the paper. It is over? Was there a big battle we won or did we just decide enough is enough?

We get dispatched to the VA for a patient seeking detox. There are Christmas decorations in the lobby. A staff member wears a Santa hat. The doctor fills us in on our patient. The man admits to drinking a fifth of vodka a day. He apparently drinks nonstop. He is seeking detox. A nice man, the doctor says.

The patient, wearing brown fatigues, is sitting in a chair in the exam room. He is a giant – I’m guessing six six, two forty – but he struggles to get up from the chair. His body is stiff and his face contorts with pain as he moves. He hasn’t had a drink for three hours now, and already I can see the shakes in his big hands. We help him on the stretcher and try to get him comfortable. He says laying flat is best. He seems tense. I can see scars along his head and neck. He tells me has four purple hearts. He points out where shrapnel is still in his body. I ask him questions about the war. He was in both Afghanistan and Iraq. He was says he was part of an elite team that was there even before the invasion. He talks about dressing up like a sheik, wearing his beard long, gathering information. He tells funny stories about giving suitcases of heroin and bottles of Viagra to war lords for information. He had been in the army since he was he was 18. Almost twenty-five years.

For him he says it was all about his men. He has no interest in politics. Whether Washington or the chieftains he bribed for information and support, he says the nature of politicians is to change with circumstances to ensure their own survival. His loyalty was to his men, but with his injuries, he says he is of no use to them anymore. He is out now on 100% disability. “I haven’t been home but for two days since I got out,” he says. “I couldn’t stay there and let them see me like this. I live on the road now. I’ve got pain constantly and I can’t close my eyes without nightmares. I never drank till I got out. Now I can’t stop. I need help bad.”

I give him some fluid to ease the dehydration and 2 milligrams of Ativan to help with the withdrawal symptoms.

At the hospital, he thanks me, and I quickly thank him.

The paper can say what it wants. War doesn’t end.

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The young woman says her knee has given out. She thinks it is dislocated, but you can’t tell because you can’t even see the knee. She says she is five hundred pounds. She can’t get up on her own. One ambulance crew can’t do it. Try pulling her up by the arms and you will pull them right of their sockets. And if the sockets held, your backs wouldn’t. Also, we are on the third floor. No elevator. Tight corners in the apartment, lots of heavy furniture.

But then help is here. Now there are four of you. Throw in 10 mg of morphine and you have the start of a plan. The patient has said if you can just get her up to her feet, she may be able to hop down to the ambulance. Wishful thinking perhaps. Ever the optimist, I am. And if she can’t hobble, if you can get her to her feet, you can at least have her in a chair while you figure out your next move.

You go to old reliable to get her up. Get a board under her, strap her to the board. Sure she is hanging off both sides, but that’s what double belts are for. But first, you splint the knee. How do you splint a knee that wide. A KED — wrap it around the knee like it is a torso. Now, its time to lift. Put one person on each side, one arm under the patients arm and the other holding a hole in the board. A third person at the feet to keep the person from sliding off the board as you lift it. And you, squatting down at the head end, and with a big grunt lifting, driving your legs up, as the two on each side, pull. Leverage. You have her standing in no time, and the four of you hold her up. My leg! My leg hurts! she says. So you quickly go to Plan B. The two chairs you have placed just to the side, and you quickly unstrap her and pivot her onto the chairs, where she now rests and lets out her breath. And then you turn and look behind you and see eight family members crowded into the room – every one of them holding a digital camera or video recorder, recording your every move.

You look at them and hold your hands up? You say nothing. You think what’s with the cameras, people, seriously? Is this to make fun of your sister? Is this to sue us? I admit that while I love my job and love the people of the great city where I work, in this moment, I am profoundly disappointed in these individuals.

The other medic on the call speaks to them professionally and succinctly and they put the cameras away. I am still shaking my head.

Come on, people.

***

The bottom line on the call was an hour and a half scene time, and only with an assist from our first responder friends at the fire department (who had not been dispatched to this call) and a hunt for a Stokes basket large enough to fit her into and with much pushing and hauling and moving of furniture and turning tight corners and going down a narrow stairway with wobbly wooden stairs, did we finally make our way outside. The other medic ended up taking the patient in, while I attended to and transported an injured responder. I haven’t yet found out whether or not the patient’s knee was dislocated. And as far as I know, we haven’t turned up on You Tube.

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