The call is for a man on the ground, not injured just needs help getting up. Been there all night. The front door should be open. The stink hits us when we go in. There he is lying on the floor in a nearly empty house, shit on the rug, shit crusted on his underwear. The stink isn’t just from the recent shit. It’s from the filth of the house – a house that hasn’t seen a cleaning in some time. The man’s name is Joe and he is Veteran of World War II. We’re glad he says his knees hurt because it gives us a good excuse to take him to the hospital. He says his son checks on him every now and then. His legs are red and painful to the touch. There is a yellow green fungus growing on his arms. My preceptee gets a bucket of soap and water, and we cut off his underwear and scrub him off some before rolling him on a board and then lifting him up onto our clean sheets. We roll him off the board, and put a Johnny on him, and lay a fresh bath blanket over him. My preceptee tries to secure the straps while we are still in the house, but I say, “Outside.” I have smelt worse, but it is early in the morning, and my cough is on the verge of becoming a puke.

He is a nice guy and we chat on the way in. On good days he can walk he says, others he uses a wheelchair. He hasn’t been out of the house for awhile. He doesn’t know his son’s number. He thinks it might be on the record at the hospital.

Later in the day we get called for another assist. An eighty-eight year old woman living alone fell and needs help getting up. She’s not hurt. The key is in the shed in the back. When I go into the shed, it is like walking into the 1930’s. There is a old wooden Flexible Flyer sled with rusted runners and a scythe leaning against the wall, and some kind of old combustion engine. Not much else. I can’t find the key, but when I come out I see another smaller shed attached to the house and I try that one. There’s the key.

The house is well kept, but it is like it is frozen in the 1950’s. There is one of those old enormous radios, a TV in a cabinet, and instead of a computer on a desk, there is an old Royal typewriter. Wood floors, old farmhouse type furniture, a metal rabbit holding a door open, an old, weathered edition of the Encyclopedia Britannica in the bookcase.

We find her upstairs, sitting on the floor. She has been there since last night and hasn’t eaten. She didn’t want to bother anyone, but she was getting hungry and she just couldn’t get up. On the wall is a photo of a man in a World War II pilot’s garb, and a picture of him in dress uniform and his bride arm and arm, smiling. I see the resemblance to the woman. His buddies would have envied him marrying a girl who looked like her.

We help her up, and she is a little wobbly, but can stay on her feet. We help her downstairs and fix her some macaroni and cheese and a glass of orange juice. She raised five children in the house she says, and had a sister living there too. Her husband died over forty years ago. Someone from the family calls her everyday, but when we ask if we can call her daughter, she says, heavens no; she doesn’t want to be a bother. In the midst of all the old photos I see one that looks new. It is one of those Photoshop jobs – A generic cover of Rolling Stone with a young teenager on the cover holding a guitar. It says “Artist of the Year.” She says her grandchildren come and see her all the time. Talking with her she has a little bit of dementia – she is after all eighty-eight.

Afterwards we talk about her, and how comfortable or not we were leaving her alone. I say at least her house was clean, there was food in the kitchen, and it seems her family looks after her. Better to be alone in your own house than sitting in some nursing home hallway next to people in wheelchairs with their heads bent, mouths open, drooling.

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We’re on the third floor of an apartment building whose elevator doesn’t work. In the tiny efficiency apartment, layered with dirt, an old skinny man with dreadlocks says he didn’t call us, and why are we bothering him. The man’s body reminds me of a Biafrin child’s it is so emaciated. We’re here because a man who follows him as part of a church outreach group has decided he is just too sick to stay by himself.

“You got to go,” the thick-necked man says. “You can’t stay here. You got to go and get cleaned up and get checked out. We leave you alone, you’re going to die.”

“Give me my peace,” the frail man says.

The room is piled with papers, opened bill envelopes, a stack of several cases of Ramen, some half-full bottles of cranberry juice. I see a paperback copy of a book called “Ellison’s Key’s to Success” on the windowsill. On the bed is a library edition of Ellison’s How to make your first Million.” On the wall I see a taped photograph of a healthy man in a purple velvet shirt standing with two smiling younger men wearing earrings.

“You really should go in to the hospital and get checked out,” my partner, a precepting medic says. “You look like you have some gangrene on your feet. That needs to be taken care off.”

“You got to take him,” the man in the doorway says.

“We can’t take him against his will,” my partner says, “But I think he’ll agree with us all that the hospital is the best idea. They can cook him a warm meal, a change of pace from noodles, and get a nurse and a doctor to look you over. How about it?”

“I ain’t got no clean pants,” our patient says.

“Here’s some here,” my partner says. “They look like they’ll do. Let me give you a hand with them.”

The man is still reluctant to go, but my partner who is very patient, keeps at it, and slowly starts to move him along to getting his things in order.

The man in the doorway says to us, “What you all need is a beamer. Something you could just press and beam him to the hospital so you wouldn’t have to mess with all this getting him up, getting him dressed, carrying him down the stairs, everybody watching, just a beamer to beam him right to the hospital.”

“Well, that would sort of put us out of work now, wouldn’t it?” my partner says.

“No, no man,” the guy says. “You’d still need someone to come out and check him out and make certain he needs to be beamed, and that he gets beamed to the right place. You couldn’t put that beamer in the hand of any old fool. You’d need training like you people got. Couldn’t have him being beamed to the wrong doctor or into the wrong century for that matter. You’d still need the paramedics to come out and do their job. All I’m saying is it would make it easier on you and the patients – the getting to the hospital part, that’s all.”

“If you put it, that way, I guess it would be okay,” my partner says, as he gently slips the man’s pants over his blackened feet.

Later, as we carry the man down the stairs in our chair, barely feeling any weight at all, but watching his pained face as he looks at the water-stained stairwell of his apartment building like maybe it is the last time he will be seeing it, I think about the future, about the days when we might have beamers in our jump kits. I imagine myself waving a beamer like a magic wand. Maybe with enough practice, instead of just being able to beam people to the hospital, we’ll be able to treat them right there. Beam their ills and pains away. Beam fresh paint on the walls. Beam the Ramen into roast beef, the cranberry juice into wine. Beam away their hard luck. Beam them back to a happier time.

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You’re a paramedic. You’re on your knees. A naked obese patient lies in front of you, their flaccid head in your hands as you try to position their mouth open. Watery vomit flows from between their lips. The monitor shows flat line. Every time your partner does compressions, more warm vomit spews onto your hands. The room is crowded with first responders looking to you to be in charge. You go in with your laryngoscope, but you can’t make sense out of anything you see. The tongue is massive. There is no neck. The airway is filled with brown watery secretions, and you don’t see the chords anywhere. You suction. You try not to puke yourself, and you think how just five, six minutes ago, you were sitting peacefully in your ambulance, reading a magazine, talking to your partner, eating a hamburger and fries and listening to Lynyrd Skynyrd on the radio, thinking how great is this job.

We’ve all been there.

Yesterday I was sitting in my area, sipping my Diet Coke and reading an interesting book about an EMT in London when I heard another ambulance sent for a “person on the floor.” Sometime later they call our number and say for us to head to the same address to back up that car on a code.

I like being in charge, but I will confess I am much more relaxed going to a code when I am backing up another car then when I am the first one in. When I am first in, I think, I hope it’s an easy tube, I hope there isn’t a lot of vomit and puke and shit to deal with, I hope it all goes smoothly. When I am backing up another medic, it’s like, hey, how can I help you. If there is shit, you’re kneeling in it not me. If the tube is hard, well, you have to deal with it first. I’m just there for support.

The address is clear on the far side of town, so it takes us awhile to get there. There is a fire engine outside. I have my partner check just to make certain it is another medic on scene and not a basic car. I didn’t want to go in without any equipment and have them look at me like where’s your stuff, you’re the medic. Dispatcher replies it is a medic unit.

It is an apartment building. I can hear the commotion behind the door, which is unlocked. And there it is obese no necked man on the floor. Vomit, shit, and the medic right where I have been, kneeling at the head, trying to get the tube, and calling for more suction. The patient is asystole.

“How can I help you?” I say.

He asks for some crick pressure.

I kneel by the head, carefully avoiding the secretions and try to apply some pressure on the neck to help bring the chords down into view. It doesn’t help. I take the tube from him and have him use his own hand to manipulate the neck to see if he can find the chords, and then I’ll put my hand there. But the mouth is filling with fluid, and he has to reach for the suction. I suggest he try a bougie, and while he gets that, I bag the patient with the aid of a firefighter. The medic tries to bougie, but it goes all the way down. He tries again to tube, but is clearly frustrated. I admit thinking glad you were here first, and not me.

There is a point of frustration. You can’t get the tube, you can’t get the mouth suctioned, poor IV access, and you just know the person is slipping across that line from which they cannot come back. You feel so helpless and frustrated. I think it is particularly hard for him because he is a new medic – one of our most promising ones – it’s not a situation any medic wants to be in.

I say, “Let me try.” And he gives me the laryngoscope while he goes to look for an IV.

I go in, and it’s like, I can’t see anything. “I need suction.” The mouth is full of blood and brown water. I suction away and look around and can’t see anything that looks like anything. I try the bougie, but it slides all the way down. I slip the tube over it, but it’s no good. I yank it, and then there I am, at the airway of the obese, no necked, vomiting person and I can’t get the tube, and its like I am back to square one – all my prowess out the window – all my I’m a veteran medic I always get the tube pride slipping away — and I’m thinking I wish I was back reading my book and sipping my Diet Coke.

Then I look at the laryngoscope and realize it is a Mac 4, not the shorter Mac 3 I always use, and I remember how when I was new, I often went too deep with the Mac 4, and that was why I switched to the 3. The person with no neck often has chords very anterior, and a Mac 4 isn’t always the best choice. So I switch blades, and I ask for a pillow, which I put under the patient’s head, and get him in the sniffing position, and I go in again, and I look for my landmarks and I see the epiglottis, and I lift up and out, and then amid the red and brown I see the bottom of the chords. I pass the tube, blow up the balloon, and yank the stylet. Nothing in the belly, equal breath sounds on both sides. I put on the capnography, but the machine says line blocked. I get a fresh capnography filter, but then the old one is stuck on the top of the ET, the top connection of which pulls out. So I just open up a fresh tube, pull off the tip and stick it on top of the tube in the man’s throat, and then attack the new capnography filter. With the first bag is a beautiful wave form.

I look at the number. It is 52!

Someone who has been asystole this long – we’re talking at least twenty minutes – considering his neighbor found him not breathing – you would expect to see the number around 4 or 5. 18 to 15 would be excellent. 52 is so high I don’t know what it means.

The patient is still asystole. The medic now has an IV in the patient’s left arm and is starting the epi and atropine. I have the firefighters take over CPR and counsel them in the new CPR, push hard, push fast, push deep. I have the monitor set up so they can see the wave form they are making with their compressions. I have them switch every two minutes. And they are pounding the compressions. Excellent CPR. Likewise, I have one of them be certain and bag only eight times a minute, and just a quick small tidal volume. We use the monitor to guide them. One of the EMT’s is getting the patient ready for transport, but I suggest that since he has been asystole this long, we just do 20 minutes and out. We all agree. Lives alone, lengthy medical history, unknown down time, if twenty minutes of ACLS doesn’t bring him back, transport is futile.

He is still asystole after the first two epis and atropines. Still I am puzzled by the high ETCO2 number. The research says the higher the initial ETCO2, the better chance to resuscitation, but he is so high he is past the good high level, into the bad high level. I can’t understand it.

A firefighter asked if it looks like we will need the police, who take care of the dead bodies. I say, yeah, go ahead and start them. It doesn’t look like he is going to come around. And then I see the CO2 go even higher. Its 70, then 80. We stop CPR. There looks like the beginning of a rhythm there. There is a rhythm.

“Check for pulses.”

“I’ve got a pulse.”

The rhythm is clear now. We do a blood pressure 190/ 110. I’ll take it.

Back from the dead.

Every time I gets pulses back, I think, you know, it really is sort of amazing. Everyone has that look of wonder about them. The fire fighters are smili
ng and nodding to each other. I think of all the parts of the code, the people who have the deepest connection with the patient are not the medics who get the tube and give the drugs; it’s the compressors, because they are the ones whose hands come closest to the patient’s hearts. Their bodies lean into the patient, they drive their strength down into the chest and then as they lift up, the patient’s heart recoils as blood rushes into it. The compressor pushes down again as their sweat falls down onto the patient’s skin. Yeah, they are the ones who are closest to the line between the living and the parted. I rarely do CPR, but I remember how in a recent code I took over CPR briefly to demonstrate how to really pound, and I drove myself into the patient, and I pounded hard, and then all of a sudden we had the patient back, and I felt like I had accomplished magic — a feat of both wizardry and will. I think the firefighters were feeling that. You go to work, you grind through the tediousness of the day, and then briefly, you have a moment where your hands have helped return life to the dead. And you think, wow, what I have I just done? It’s a feeling that verges on holiness.

So we package him up, get him out to the ambulance. As we go through the lobby, the cops are coming in. They look confused. They were sent for a body. “We got him back,” we say. They nod — good news for them too. I drive – in the back is the original crew and one firefighter. I go easy, no lights or siren. At the hospital, he is satting at 100%. Pressure of 150/70. Pulse 72. Normal sinus on the monitor. ETCO2 -45. The doctor tells us good work.

Whether he makes it out of the hospital and makes it out without neurological damage remains to be seen. He was down quite awhile, but you never know. I talk to the doctor later, and he says the patient has a history of hypercapnia – too much carbon dioxide in the blood, which explains his high ETCO2 readings. He probably stopped breathing due to a hypercapnic breathing event as opposed to a heart problem. That may be why once we got his heart beating, it was able to sustain him.

I have been doing this a long time now, and while there are still calls that rattle me, the truth is, you do learn over the years, you get better at your job, you’re calmer, you have the experience to stop and say, okay, why am I not getting this tube? what can I do differently? Your past patients give your future patients the gift of your experience with them. I still have some patients who I want to pay back, who I want to be a better paramedic to in their future reincarnations – a premature baby, a woman in asthmatic arrest, a child struck by a car. I know every medic has the calls they need to do over, to do better to show what they have learned, to pay the past back.

Give us our chance to save them. Let our hands do in the future what they could not always in the past. Touch us when we reach toward their stilled hearts.

***

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It’s been over ten years I’ve been working in the city. Driving around in the ambulance, you can see the changes. None of the book stores I used to stop at are still in business. The barbeque place in the north end where they sold cornbread muffins for twenty-five cents is gone. The Lion’s Den – the Jamaican vegetarian restaurant — where you could smell the marijuana smoke coming from the backroom when you went in to buy soy patties – burned to the ground and was demolished. One of the city hospitals closed. The nursing homes all have new names. People still shoot each other and do heroin and call the ambulance for dumb things. There are still a lot of drunks, but none of the old ones are left. We don’t respond in the south end anymore – another company does. The fire department is a first responder now instead of the police who rarely ever came in the first place. Instead of navy blue uniforms we wear light blue shirts. There are more medics on the road these days where before there were just a few of us. We never did transfers unless they were ALS; now transfers are a regular part of the day. I’m as apt to be doing a dialysis run as I am responding to a motor vehicle.

I ‘m working with a guy who has been around almost as long as me, and we are talking about how some girls who were pretty when we started are now on the heavy side, how some medics who were sparks are now burnt out, how some new stuff is good – like all the overtime — and some is bad – like how the out-of-town dispatchers don’t know the streets. We talk about how you can never rely on anything to stay the same. All you can do is try to do your job and treat your patients decently. The seasons come, the seasons go.

The afternoon is slow. We are posted in an area near the edge of town. Instead of posting on the specific street corner that represents the area we are covering, we are about a quarter of a mile away at the maintenance entrance of a park, right next to a small pond. It is a beautiful August day – blue sky, a slight cooling breeze. We shut the engine off. I open the door and stretch my legs out. My partner goes over and sits on a bench. We are the only ones there. Five minutes later we get a page. Effective immediately per the PD we are to move to the assigned area. We look around and don’t see anyone. I look at the maintenance building, at the windows to see if anyone on a phone is looking out at us. Someone obviously complained to the police about us being in the park.

We get in the ambulance and drive up the road to the posting location and park on the asphalt in the sun. The AC is running, but we are in an old car and the engine is really loud. I try to do the crossword puzzle in the morning paper, but it’s late in the week and as you get toward Friday, it gets much harder. I don’t make much progress.

We go on a couple calls. On a motor vehicle, as we arrive lights and sirens, the cops give us the cut sign. They say they canceled us – it just never made it through the dispatchers. Then we get the dispatch. We’re canceled.

Dispatch sends us over to Main Street for an ETOH. The man who called leans out from a third floor window under a flag of Puerto Rico and points across the street to the baseball field and says, “He’s over there under the tree. He drinks too much. You need to take him to detox.”

We get back in the ambulance and drive over to the field, get out walk along the tree-lined fence, until we come to the entrance, and then walk over to where we see a man in a Yankees tee-shirt sitting with three forty ounce beers. He’s a got a big grin on his face. He’s just cracked open the first one and has two full ones sticking out of a paper bag.

“What’s up?” I ask.

“Drinking beer in the park,” he says.

“You know why we’re here?”

“Cause I’m not supposed to drink in the park?”

“No, that’s not our business. We’re here to see if you’re okay, if you’d like to go to the hospital. Do you need detox?”

“No, I just want to drink my beer. Did my uncle call you?”

“Is he the guy in the third floor window?”

“Yeah. He kicked me out of his apartment. He drinks more beer than I do.”

“Well, just because he wants you to go to detox, we can’t take you against you will, but you realize, if you pass out, we can come and take you.”

“I understand.” He smiles. He sees we are no danger to him.

I’m looking around at the lush green field, the beautiful August day, the beer which is cold right from the store. I look at my partner and I know he’s thinking the same thing I am. “If we weren’t on the clock,” I say, “We’d love to join you. You have a good afternoon. Don’t outdo yourself, and if you ever aren’t feeling well and need to go to the hospital or want detox, just give us a call. And if you do pass out and your uncle calls, we’ll have to take you in. Understand?”

He smiles again, and extends his hand. “You guys are alright,” he says. “It’s a deal.”

We walk back to the ambulance, get in, and then drive back to the apartment building where we call up to the guy in the window. “We can’t take him,” I say. “It’s America. He’s alert and oriented. He’s got rights.”

The man, who we can see has a long-necked bottle of beer of his own in his hand, shrugs and thanks us for trying.

“He passes out, you call us back, and then we’ll come and get him.”

He waves, and sticks his head back inside.

I don’t know about my partner, but when I get home I have a few cold ones myself and sit out in my back yard and enjoy the summer evening.

Time passes. Sometimes you need to stop and enjoy the seasons.

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Hello Everyone. I hope you are all having great summers. I am writing this entry today because I lack the energy to write well about a funny call I did recently.

I have been working quite a lot — 84 hours in seven days this past week –and am finding it hard to keep up the quality of this blog and my daily blog at Paramedic: A Year on the Streets. I am not yet ready to give up. I am hoping this is just a lull and I will catch a second wind. It has been almost two years since I have been blogging here, and 20 months at the daily blog. During that time I have noticed some of the bloggers that I have been following have disappeared off the internet. I don’t know if they got burned out, or had complaints or if they left the field.

I like blogging in that it captures my day and events I might forget about or not remember as clearly. But to do that well I need to be able to see freshly every day. A problem that I think comes with working so much is I tend to just want to get through to the next call to the end of the day, and to the next day and to pay day when I spend probably too much time looking at my check.

When I started as a medic I told myself I would never let myself get to the point where I needed to work overtime to get by. Well, so much for the that. It’s what a house and a divorce and a will to see the world before you croak will do to you.

I have been spending a lot of my time lately on my Capnography blog at Capnography for Paramedics. What started out as just a place to put the information I had found on my own has become a near obsession. My physiology background is shamefully weak so I have been struggling to get a handle on everything and then put it into simple language. I agreed to teach a class on Capnography this coming September when I knew very little about Capnography, but knew if I agreed to teach the class I would have to become an expert. I have enjoyed learning. Everyday I hope to get a new capnography strip or story or read about a new study. I am working hard on my powerpoint presentation.

I have also been working more on one of my novels that I excerpted recently. I will probably post more chapters soon. Unfortunately it has taken a back seat to the capnography which is under deadline.

Recently the ambulance service where I work as the contract medic opened its EMS Commander position. I thought about applying. The pay isn’t what I make in overtime, but it was decent for a salaried job. And it was a way off the street in the daily grind sense. It was a job I could do when I am older or if I get hurt. I have lots of ideas about how to make the EMS system better, and it would have been fun to have a playground to try them out on.

But I didn’t apply. Mainly because I love being a paramedic, and in the new job I don’t know how much I would have been able to work — maybe only in a supplemental way. And I would have had to have quit the company I work for now due to conflict of interest provisions. Also, not being able to work overtime I would see a decline in income. And you can’t overrate the ability to have the time be your own when you are not responding to calls. I mean right now I’m at work, I’m on the clock and I’m sitting here working on my blog. How good is that!

Maybe some time down the line I’ll be ready for a step off the street, but now I want to stay here.

Thanks for reading my blog and I hope I will try to get to that funny story soon.

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They said she was vomiting and nauseous and having seizures. I asked what the seizures looked like and the patient’s friend who had witnessed them, said the patient shook all over with her arms and legs out. It didn’t sound like a seizure. She said they had done all kinds of tests, but hadn’t been able to diagnose anything. In the ambulance, I was putting in an IV when all of a sudden her head goes to the left, her arms and legs go out straight and she starts shaking. I am not impressed. “Knock it off,” I say. She stops. She is fully coherent. There is no postictal state. She didn’t pee herself or bite her tongue. She demonstrated complete control of her muscles in the way she was flapping. “What were you thinking about what just now?” I ask. “I wasn’t thinking about anything,” she says. “Why were you shaking?” “I don’t know.” “Is that what happened to you before when you had your seizures?” “Yes,” she says.

I have seen many seizures over the years and many fake seizures. I remember when I was a new medic and how this girl had arched her back and started shaking and foaming at the mouth, and how I told them breathlessly at the hospital triage how she had seized. The nurse looked at me like I was an idiot and told me to take her to the waiting room. She was a regular – always looking to fool new medics and new doctors into giving her valium, which is what we gave in those days. Some people fake seizures for drugs, others for attention, others I don’t know why.

I get an idea then. I reach into my backpack and take out my small digital camera. I use it at traffic accident scenes to take a picture to show mechanism of injury at the hospital. The trauma team loves seeing the pictures. The camera is so small it fits right into my pocket. Often I don’t even know I am carrying it. There is a motion picture feature on it. I think if she has another one of her fits, I can record it to show the doctors. Maybe then they won’t need to do any more expensive tests.

But then I think, hold on. There might be some patient privacy rights going on here. I am almost certain there is a rule about filming patients. Probably even if filming their seizure might be of great benefit to the doctor’s. I put the camera away.

The next day I get called for a woman with vaginal bleeding. There is blood all over the floor, in the bathroom, in the bedroom. I see some big clumps that look like maybe they might hold a tiny fetus. I need to focus my attention on the patient and not the clumps. She says all her periods have been regular and there is no way she is pregnant. I’m thinking miscarriage. I have my camera in my pocket. I could snap a few quick shots of the gore – to show them at the hospital. It would tell a better story than my just saying, it was really bloody there. Still, this is new territory and I am not really certain I want to be on the end of “Report at once to the Supervisor” pages.

I seem to remember getting some type of memo about digital cameras, but I can’t remember exactly what was in it. I know it was don’t do the obvious wrong stuff, but I don’t know if it covered the grey areas. I don’t want to chance it.

It is new territory, maybe territory that needs some addressing. There surely is a possibility for abuse, but also a possibility for some good. Cops videotape all their encounters on traffic stops. I’ve heard talk of cameras being put in the back of ambulances. How will this all shake out in the future? I wonder.

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