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Old Paramedics

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I have been getting in and out of ambulances for over 20 years now. That means just what it does. Twenty years ago my knees and back and all my bones and joints were twenty years younger than they are today. I’m in good shape, but still, I find now when I get out of the back of the ambulance when we arrive at the hospital my partners tend to offer me their hand to help me down. I ignore their help of course, but I do admit I’m not jumping down as spryly as I used to.

I read this article — As Doctors Age, Worries About Their Ability Grow in the New York Times this week and it made me think for a moment in the same way I think for a moment when I read the “Will you have enough Money for Retirement?” articles. I think I can put worrying about this off for awhile longer, but I sense that someday these articles will be my front page stories. Just not yet.

The physical deterioration of these years is slow, but undeniable. When I went to nursing school a couple years ago, I found I had to buy a pair of reading glasses so I could see the fine markings on the insulin syringe so I could draw up just the exact amount before handing it to my examiner to verify. On calls now, sometimes I squint to see the tiny vein I am trying to thread a 24 into in. A month or so go when I intubated a patient, I, for a moment saw two sets of vocal chords side by side. During cardiac arrests now I have learned not to relay on my view of the monitor beyond two arms length. What may look like asystole, if examined may actually be a defined rhythm with low voltage. I make it a practice now to print or have the strip printed out and handed to me so I can verify it.

When it comes to hearing, I have always been annoyed with patients who don’t speak up when I ask them questions, but lately I have found myself saying “Huh?” and “What?” more often than before, and finally asking them to please speak up blaming my difficulty hearing on the noise of the engine.

I used to love breaking into locked homes to rescue patients unable to get to their doors to let us in,. I’d divehead first into windows (while getting a boost from my partner) or climb up onto roofs to access second story bedrooms. Now, just as with carrying our heavier equipment, I sometimes defer to stronger more agile partners or responders on scene.

A few times I have seen a tremble in my hand and asked, is this the first hint of a condition that will change my life or am I merely suffering from lack of sleep or caffeine withdrawal? (A reassurance, I just checked both hands, and today as I sit in front of the computer, each hand is as steady as a gunfighter’s, although quite lacking the gunfighter’s speed).

One of my partners is ten years older than I am. Sometimes his slow deliberate way is frustrating to me. His scene clock is slower than mine, but then when I work with younger people, I sense they may feel the same about my pace. I like to think that I move quickly when I have to, but as in a game of softball, I no longer have the reflexes to snare a blazing line drive in the infield.

A few years back I came on the scene of a rollover, a car on its side with a women still in there, although with only minor injuries. While I pondered what to do, considering the best approach, another medic arrived on the scene, and was in the car before I could even say “good day” to him.

I like to think my approach was mature, deliberate and proper, but I do wonder if someday it will tick past the mature deliberate safe response and into the doddering greys of early dementia.

My hearing is not so bad that I can’t at a distance hear the tick tick tick of the finite clock that beats for all of us.

Posted by on January 27, 2011 • Filed under: ems-topics • Tagged: , ,

You gave her 20 Milligrams?!!

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I have written often in the past about pain management. It has become my passion in EMS. To me, it is the most satisfying part of the job – to ease someone’s suffering. When I started we needed to talk to a physician on the radio to get orders to use our morphine. Today we can give up to 0.15 mg kg on standing orders. In others words a 220 lb person like myself could receive up to 10 mg given over (at least) 4-5 minutes and if the pain is unrelieved, another 5 mg ten minutes later. If more pain medicine is needed, medical control must be contacted for permission.

The reason we had to contact medical control when I started was a state law that required “simultaneous communication” with a physician in order to dispense controlled substances. That was interpreted to mean on-line control. After I discovered other states did not have a similar provision and that controlled substances were allowed to be given on standing order in those states, I went about changing our state’s law. I met with the DEA (who are charged with overseeing federal and state controlled substances laws), and with the state medical advisory committee. I eventually testified before the legislature on the issue and they changed the law to allow standing orders. Then once that was allowed, within our region, we started at 5 mg of morphine on standing order and then in time upped it to 10 mg and then to the 15 mg we currently have as well as broadening the indications for pain management to include abdominal pain.

I must admit while I have been very aggressive about pain management, over the years when I hit my standing order limit, I tend to stop there even if the patient is still in pain. Why? I guess 15 milligrams seems like a lot of morphine considering when I started just giving two was a major event. And of course, there is that whole I have to call in and bother the doctor (or maybe have my request turned down) barrier.

Once we removed the initial need to call for orders to give controlled substances, the use of morphine went up drastically. But here I recognize that the same need to call the doctor (to go beyond the amount we are now allowed on standing orders) has been holding me up from taking care of my patient’s pain.

So I have decided, be damned, if the patient is still awake, breathing and in pain, just because I have hit my standing order limit, doesn’t mean I shouldn’t call in for more. All I have to do is pick up the radio and ask to talk to a doc. How hard is that?

Now I am saying to my patient (provided they are still reporting significant pain):

“I’ve given you all the pain medicine I can under standing orders. To give you any more, I will have to call the ED doctor on the radio. Would you like more pain medicine?”

If they say yes, I call. Simple as that.

My last three cases (all presenting with 10 of 10 pain):

A 50-year-old two hundred and twenty pound female with a spontaneous hip dislocation received 20 of morphine with one milligram of Ativan on top (at the suggestion of the on-line doctor).

An 83-year-old one hundred and fifty pound man with an anterior shoulder dislocation received 14 milligrams of morphine.

An 82-year-old one hundred and sixty pound female with an obvious hip fracture received 15 milligrams of morphine.

In each case, I called and got permission for the additional dosing from the ED physician. And in each case, the ED nurse when I told her the amount of morphine I had given repeated it aloud with an exclamation point on the end in a voice loud enough for everyone within fifty feet to turn and look at us.

My answer has been the same in every case.

“I didn’t give it to the patient all at once. I gave it incrementally over thirty minutes. I spoke with the physician before giving the final dose, and by the way, the patient is still awake, breathing and in pain.”* I wanted to say IN PAIN, but I have better manners.

*although admittedly less than when I arrived.

I know from comments on previous posts that there are some systems out there that our more aggressive than ours and allow up to from 20 to 40 mg on standing order.

We will be meeting as a region shortly to review our current guidelines and I will be pushing for us to be able to give an additional 0.5 mg dose on standing order beyond what we currently do, thus setting our total maximum on standing orders to 0.2 mh/kg or 20 mgs. Keep pushing those limits out a little at a time.

In another note, while fentanyl has been approved in our protocols for the last year and a half, our service will just now be receiving it starting in a few days. I am anxious to try this drug out on my patients and see how it compares to morphine. The medics I know who have been using it, almost universally prefer it to morphine due to its quicker onset.

I also want to add that I regularly discuss my pain medicine adventures with ED doctor friends and other paramedics looking for feedback. I did recieve this caution from one about the problem giving too much morphine to an elderly patient with a dislocation who will likely need procedural sedation in the ED in order to relocate the dislocation. Having that much morphine on board makes his decision on what drugs to give the patient a little more difficult and will require a closer monitoring of the patient. This is one reason he is such a strong proponent of fentanyl because the fentanyl doesn’t last as long as morphine enabling him better control in the ED in these cases. That being said, he stressed if the patient is in severe pain, you need to take care of that pain. I followed up on the patient with the shoulder dislocation. Over the next two hours the patient recieved three milligrams of dilaudid in the ED and then 5 of valium for the relocation attempt that was successful, greatly reducing the pain.

.

Posted by on January 25, 2011 • Filed under: ems-topics • Tagged: , , ,

Paramedics and EMTs

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Back in 1995 when I started working fulltime as a paramedic in the city, paramedics got to choose their own partners. This was great for the paramedics and could also be great for the EMT partners. You worked three twelve hour shifts together and you always knew what to expect. You picked someone you were compatible with, liked and could work together without too many issues. Partners rarely called in sick or booked off for fear of leaving their partner with someone they couldn’t stand. On a bad call, your partner was right there. You were going to tube someone. You reached back and your partner laid the right size tube in your hand. You had each other’s back. You took care of each other.

While my first partner was assigned to me because I was new and medical control felt I needed a strong partner and an IV tech, once he moved on, I was free to choose my next partner. I remember then I was approached by another medic who offered me his partner. They had worked together a long time and had finally come to a place where they needed a change. The medic wanted his partner taken care of so he sought me out. That was how I originally became partners with Arthur, who I have written about extensively. The other medic and I shook on the deal and I gave him a Snickers bar in ceremonial payment. Years later when I moved on to another shift, I found Arthur his next partner. My payment in return was a mini Snickers bar. Arthur was upset that he had apparently lost value. I took the rap. I’m sorry, I said, I wore you out. Your the worse for the wear and tear. At least he kept a decent shift and a paramedic partner and didn’t have to hump transfers all day.

The drawback to having paramedics choose their partners was the issue of seniority for the EMTs. A medic might pick a new hire for their primo shift while a ten-year EMT might be stuck working a lousy shift. As the EMTs gained power in the union and with the service takeover by a new company, things changed. A six month bidding system was put into place. Not only did you have to rebid for your shift every six months, but you were assigned with whatever EMT won the bid for the EMT half of the shift. Needless to say, there were some mismatched pairings.

A couple years after that, I was lucky enough to gain a position in a contract town. While I still worked multiple overtime days in the city, I could pick and choose my overtime shifts to work with partners I liked. Working with someone you like wasn’t like working at all, it was getting paid to hang out. Spending a day with a disliked partner sometimes wasn’t worth the wages you were paid.

Being in the suburbs working with volunteer partners now poses its own challenges. Instead of one partner who knows your routine, you can work with multiple partners in the course of a day, much less a week. I come in at six AM and have one set of partners. At eight I might get a new partner or two, and then again at one. On my sixteen hour days, a new set of partners would also come in at six in the evening.

This can be a problem when I leave the ambulance in one condition after a call, and then on the next call find my new partner has rearranged things. The BP cuff is no longer on the bench where I like it, but zippered up into a BP cuff case and placed in a cabinet out of reach. The worst is the oxygen. I leave the portable oxygen open. A new partner comes in, checks the oxygen and then shuts it off, but doesn’t bleed it down. We get a patient, I put them on a cannula, and it is not until we get to the hospital when I disconnect the cannula do I realize the tank had been turned off.

But really, it isn’t so bad. In practice, I often have one partner for ten of the twelve hours, and since I have been out here for over ten years now, I have gotten used to most of my partners and they have gotten used to me. Some of the partners I have out here I have worked on and off with the entire time I have been out here. Thus more often than not, we are in sync.

I think it is more difficult for the EMTs to get used to the four different medics who work with them. All the medics like their stretchers put together differently. We all put electrodes in a different spot. We all have our own ways of working a call. Unless a patient needs immediate treatment, I prefer to get them out to the ambulance and on to the hospital, doing everything on the way. Some medics let their partners jump all over the patient taking vitals, asking history questions. Me, I prefer to be the one who asks the questions. I can’t stand it when a partner walks over me when I am interviewing the patient.

I pretty much insist on doing calls my way. I have been doing this for over twenty years now and have become fairly set in my style. Sometimes I will ask a partner for advice or a better idea on logistical issues, but for the most part I am comfortable with my own solutions.

Working as a single medic, I am always in charge. The calls are mine unless I turn them over to my partner to BLS it. Once I do, they are free to do the call the way they want. That said, I often will do the BLS call myself instead of turning it over depending on the patient’s issue and the partner I am working with. Some of my partners prefer to always drive, so when working with them, I tech all calls all the time, ALS and BLS.

Years ago, I saw a very funny cartoon which showed how people in EMS viewed each other. I don’t remember the whole cartoon, I just remembered how the EMT viewed the paramedic. The paramedic was drawn as Darth Vader.

I like to think I am benevolent. I rarely ever raise my voice or express displeasure. And when it comes to driving, I let my partner handle that. Unless they are driving like a mad person or unless they ask for directions, they control that aspect. I know some medics not only run the calls, but also do all the driving to the calls and from the hospitals back to town. The only time they don’t drive in when they are teching an ALS call.

This all is not to say that medics can’t learn a lot from their partners. A new medic particularly would be wise to listen to a more road experienced partner. The saying “Paramedics save patients, EMTs save paramedics” has a great deal of truth to it. A partner who knows what they are doing and what is expected of them can make or break a call for you. Even today, sometimes a partner will point something out to me I might have missed, and I am grateful for that.

A medic needs to know what their partner is capable of and plan accordingly. If you don’t think you can trust your partner’s blood pressure reading, then don’t trust it. Only assign them do what you know they are capable of. You can have them do anything, but you need to verify anything you are uncertain about. If a call goes bad, the medic has to take the rap. Publicly blaming a partner is not an excuse.

Posted by on January 23, 2011 • Filed under: ems-topics • Tagged: , ,

How to Make Up The Stretcher

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Okay, new partner, here’s how I like my stretcher made up:

A clean sheet tucked under all sides, but not necessarily tied. A hospital chuck folded across the middle of the stretcher and tucked in. By the foot, I want a wool blanket, a bath blanket, a sheet, and a Johnny top (hospital gown). By the head, a pillow ( with fresh case) and a towel.

I want the bottom sheet tucked in, but not tied because if it is tied, it will be harder for you to take off, and if it is harder for you to take off, then you may be more apt to just leave it on there for the next patient, cleaning the used sheet by brushing off any dirt with your gloved hand, rather than putting down a fresh sheet.

Sure, I have been guilty of using the same bottom sheet from one patient to the next, but I want you to be a good EMT today. And if you are a good EMT, it will reflect well on me.

Once we meet the patient, depending on their condition – if I am going to be doing a 12-lead ECG, listening carefully to their lungs, or putting in an IV, then if convenient, I try to get them to take off whatever they are wearing for a top and clothe them in a fresh hospital gown. If the patient is female, I will try to have a female relative, friend or a medical person help them change. Sometimes I will hold the gown up like a curtain and let them change themselves and then slip their arms into the gown. Sometimes I do the change on scene, sometimes I wait until we are in the ambulance. The reasons for the gown are to enable me to do a better exam, make doing a 12-lead easier, and sometimes just to get them out of their damp or dirty clothes and into something fresh and clean. It also spares them from having to be undressed at the ED and snaking the IV bag through their clothes. The only cases where I remove the bottom portion of their clothes are trauma, childbirth, a definite STEMI (in a STEMI this step speeds time in the ED and enables quicker access to the groin for cath lab cannulation), or if their clothes are so damp or soiled as to be a threat to the patient.

When it is time for the patient to sit or be placed on the stretcher, I will have you take the second sheet and spread it open on top of the first (tucked in) sheet, with the sides dangling down so once the patient is on the sheet, we can each grab a side of the sheet, and adjust the patient to the most comfortable position.

I often fluff the pillow before they lay their head on it. It is a silly gesture, but one appreciated by the patient. Sometimes I apologize for no chocolates. I may finger you as the culprit – a little humor to lighten the mood.

Once on the gurney, the patient is then covered with both the sides of the sheet and a bath blanket. If it is cold enough, the wool blanket goes on top. The patient is then belted to the stretcher. I use three straps. I admit I am not fond of the shoulder straps and make a resolution to use them more often. They are excellent for holding a patient in place, but like the top strap, they are usually always undone by me to allow access to the patient during care. I need to remember to reconnect them once transport starts. Safety first.

The final item – the towel. This — particularly in winter or foul rainy weather—I use to wrap around the patient’s head to keep them warm and dry. If someone says our patient now looks like Mother Theresa, that’s a good thing.

Posted by on January 20, 2011 • Filed under: ems-topics • Tagged: , ,

2010: A Year in Paramedicine

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Last year I went through our electronic run forms and calculated my stats for the year. I have done the same again this year. Here are the 2010 results with (2009) in parenthesis. I did not include the calls I did with the commercial ambulance who came into town when I did not have a volunteer partner. Since I used their run forms, I have no accessible record of them. I would guess I did no more than 10-15 ALS calls with them, and do not recollect doing anything particularly unusual with them.

Observations from the data below:

I had by far my fewest annual number of intubations ever. My three ROSCs all came from PEA/asystole thanks to epi and good CPR. All three died in the ICU. I continued my concerted emphasis on pain management and comfort care. I increased my use of Solumedrol and also used Magnesium for severe asthma for the first time (It worked great!) Other than that, it was pretty much business as usual here in town.

451 Calls (466)
153 (156) Calls where medication was given
6 “Workable” cardiac arrests (all medical) (9)
3 ROSC (3)
0 Survivors to hospital discharge (0)
4 intubations (8)
2 LMAs (2)
0 defibrillations (2)

Drugs

Zofran – 49 (41)
Morphine – 43 (37)
ASA – 28 (36)
Nebs (DuoNeb, Albuterol) – 26 (21)
NTG – 20 (27)
D50 – 12 (19)
Solumedrol – 11 (7)
Atropine – 6 (11)
Epi 1: 10,000 – 6 (9)
Benadryl – 5 (4)
Cardizem – 3 (3)
Ativan – 2 (3)
Narcan – 2 (1)
Dopamine – 2 (1)
Metoprolol – 2 (0)
Versed – 2 (0)
Adenosine – 1 (2)
Epi 1:1000 – 1 (1)
Magnesium – 1 (0)
Tylenol – 1 (0)

Did not use: Amiodarone (2), Bicarb (1), Calcium, Tetracaine, Haldol, Vasopressin, Lidocaine, Lasix, Torodol

I am sure there are more sophisticated ways to data mine, here is what I did. Ran total number of calls. Ran total number of calls where medication was given. I then reviewed each medication call and tallied the meds I gave. The results below represent meds per unique patient. I may have given a patient three squirts of Nitro, but I tallied it as 1. As tallied above I gave Nitro to 20 different patients. I did not count oxygen or saline as drugs.

Every medic’s experience is going to be different based on the type of service they operate in, their medical control, the hours they work and the population served.

I work in a one-medic in one-primary ambulance system (I get the first call and if I am on a call, the next call goes to the backup commercial service. Once I am available, I get the next call again) in a urban/suburban town (bordering the city) 26 square miles with a resident population of 20,000 according to the 2000 census. 54% African-American, 40% white, 6% other. 1 out of five people are over 65. (A few years ago when we were only inputting demographic and dispatch time information into a computer, I ran a query that showed the average age of our patients was 69. I don’t know how to do that with our new software). There are two “luxury” retirement communities with convalescent homes attached and three stand-alone (non-luxurious) convalescent homes which together represented 19% of my calls. There are many doctor’s offices, and good amount of industry, ranging from insurance companies to a helicopter plant. The population is a mix of lower middle class and middle class, although there are a few upper middle class and wealthy neighborhoods on the north and west sides of town. We transport to four different hospitals with transport times from 10-30 minutes. I worked 40 hours a week Sunday 6-18, Monday 6-18, Tuesday, 6-22 (sometimes Saturday 6-22 instead of Tuesday). Weekdays are much busier than weekends. I took some vacation and days off and worked no overtime. We do no scheduled transfers (although many of the calls I did we call “emergi-fers” calls from nursing homes going to the ED for routine reasons where 911 was called).

Note: I have also been tracking meds given by one of the services I oversee. Here are the top ten meds they gave this year: ASA, Zofran, NTG, Nebs(DuoNeb and Albuterol), Morphine/Fentanyl, D50, atropine, epi 1;10,000, Solumedrol, Benadryl. The same ten as mine, although in slightly different order.

Posted by on January 18, 2011 • Filed under: ems-topics • Tagged: , , , ,

Death in the ICU

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As an EMS coordinator at a local hospital, I try to provide patient follow-up for our EMS providers. Since we are not a trauma center, the two calls people most want to know the outcomes about are STEMIs (ST-Elevation Myocardial Infarctions) and resucitated cardiac arrests.

After doing this for over two years now, I have observed the calls almost always follow the same predictable pattern. The STEMIs are rushed up to the cath lab where they are discovered to have 100% blockages of a major coronary artery. The blockages are cleared and stented, the patients do remarkably well, and are discharged within a few days with instructions to eat heart healthy diets and stop smoking.

As part of our quality assurance process, I praise the crew for identifying the STEMI and providing the hospital with early notification. I sometimes show them before and after photos of the affected artery.

The cardiac arrests rescuitations are admitted to the ICU on ventilators. A few wake up in a day or two and ask for the New York Times but, in most cases, they don’t. With grim prognoses, their families, in consultation with their doctors, often make the difficult decision to let them go. The patients are made comfort measures only, extubated, given morphine for pain, and they die peacefully with their families gathered around them.

I am a firm believer in evidence-based medicine and looking at outcomes. Particularly in a time of tight budgets, what we do should be proven to actually work. I try to stay up on the latest research and in my role as a member of our regional medical advisory council; I use that research to support proposed changes in our care guidelines.

It is often said that the only outcome that matters in cardiac arrest is survival to discharge with intact neurological recovery. A recent study of IV drugs in cardiac arrest showed they made no difference in survival, but did lead to higher rates of return of spontaneous circulation (ROSC) and admission to the ICU. Once in the ICU, those who received epinephrine were three times as likely to die as those who did not. This study and others like it have caused some to consider eliminating IV drugs from our cardiac arrest arsenal along with other items that don’t lead to the ultimate outcome of a patient walking out on their own power. It is as if to say if the person is going to die anyway, let them die where they fall rather than spending so much money on them only to have them meet the same outcome a week later in the ICU.

While I find these arguments persuasive, I am conflicted. Yes, outcomes are vital and yes, we should always avoid unnecessary health costs. At the same time, I do not believe that this means the efforts of those who worked so hard to resuscitate a patient only to see them die in the ICU should be viewed as futile. Our primary job is saving lives, but we are also here to provide hope and comfort, and to be present to act in time of need. Showing a family that help was there, that everything possible was done, and then giving them time to gather and say goodbye to a loved one is something to be proud of. It is hard to measure its worth.

That is what I tell the crews.

Posted by on January 15, 2011 • Filed under: ems-topics • Tagged: , , , , ,

Kevin Andrews

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In EMS, we cannot help but be shaped by our earliest partners. They are the ones who show us the way. I was lucky in that regard.

Kevin Andrews was one of my first partners. This was back in 1989. I was a spanking new EMT — so fresh I didn’t even have my certification yet. Due to an EMT shortage I was working on a waiver that let EMT class graduates work pending the outcome of their state exams. I even wore a “whop kit” – one of those pouches that attach to your belt and hold your tools of the trade. Mine was small and conservative by some standards. I had a penlight, trauma shears, bandage scissors, and a window-punch.

We worked for Eastern Ambulance, a mom and pop ambulance company in Springfield Mass that had the 911 contracts for three suburban towns in addition to backing up calls in the city and doing transfers. On a good day we only had five ambulances on the road. On most we had three. Some of the ambulances had brown bondo on the sides and in one, you could see the road through a hole in the floorboards. On Fridays, we use to all race down to the bank to try to cash our checks. The last to get there often found theirs would bounce. We didn’t have paramedics, just basics and intermediates. We didn’t even have defibrillators then. But we were a close-knit group, and there was more to the job than money.

Kevin was an EMT, but he was respected as any of the intermediates. He’d tried to take the EMT-I exam a couple times, but kept just missing it. He was very street smart, but had trouble overthinking the tests. I, on the other hand was book-smart, but had no clue about the street. With the wrong partner, my life at work could have been made miserable. I was always glad to find myself working with Kevin.

We were both thirty then, but our backgrounds couldn’t have been more different. He grew up in a large family in Springfield in a neighborhood where the drug trade flourished. I was from an upper middle class suburban family and my most recent job was working for a United States Senator until his loss had send me on this personal quest to learn how to help people in person rather than from behind a policy desk.

Kevin was a big strong man with a shaved head who a instructor and black belt in karate. Still he was gentle and soft-spoken, with a ready smile. I never saw him raise his voice or become excited on a scene. He had that calm about him that for all the occupations I have worked in, I have only ever really seen in certain EMS responders — an unperturbed always in control manner that seemed to deescalate any panic around him from patients, bystanders or partner. He always knew what to do, and if he didn’t, he never let that on.

Sometimes we used to stop at his mother’s house where she always made sandwiches for us and we would visit with his youngest brothers and sisters before heading back on the road. He was their clear pride. Out on the street, Kevin would point out to me the drug houses and dealers. What I might have thought was an innocent boy of twelve on a bike, was instead a drug-dealer’s lookout. It was a new world for me.

My clearest recollection of a call with Kevin was on a cold sleety morning in winter when we responded for a woman who had slipped on the ice on the top steps of a church. I could tell right away her arm was broken. I palpated it through her coat and it felt almost as if it were in two separate pieces. I had my trauma shears out in a jiffy, but before I could make my first cut, Kevin had a soft but strong grip on my arm. “This might be the only coat she owns,” he said quietly. “Let’s see if we can ease her arm out of it.” Which is what he did, taking his time not to cause any pain. The woman’s winter coat was preserved and her arm was carefully splinted and he talked to her in a reassuring way that caused me to feel only awe at what I was witnessing. It made me see that EMS wasn’t really about blood and guts and bad car wrecks and doing CPR. It was about taking care of people.

The company went bankrupt a couple years later. By that time I was only working one overnight shift a week. I was back behind the policy desk as the ex-Senator after a year in exile had run for Governor and won. Despite the full-time government job I was not only hooked on EMS and had to get my weekly fix, but I felt like I was a part of a family at Eastern Ambulance and I didn’t want to lose that connection. I hated to see Eastern close. Kevin and most of the others we worked with went to work for another ambulance company in Springfield while I joined a volunteer service in Connecticut.

I saw Kevin periodically over the years. We had a few Eastern get-togethers. Another time he and his girlfriend brought their kids down for a picnic at the condo in Connecticut I shared with my own girlfriend at the time. I visited him in the hospital when he got a bad infection and had to get IV antibiotics. We’d talk on the phone sometimes and get caught up on how all the people we worked with at Eastern were doing. He told me he was honored when I mentioned him in my first book. I was honored to be able to write about him. Whenever he’d call, even if we hadn’t talked to each other for a couple years I’d say “Kevin” recognizing him at the first sound of his voice.

The last time I talked to him was three years ago right around the birth of my daughter. He’d mentioned there was going to be a new get together of some of the old people we knew. I wrote his number down, but in the confusion of the time, misplaced it. I have always been somewhat of a recluse. I work all the time and I’m not the best about keeping in touch.

A month ago I talked to a woman who’d also worked ambulance up in Springfield, starting shortly after I had left the area. When I mentioned I had worked for Eastern, Kevin’s name came up. She said she knew him and that he was helping teach basic EMTs at the college where she also taught. I said to say hello. Later in a New Year’s Day phone call, she told me she had talked to him and that he had been excited to hear she had spoken with me. He told her about the good times we’d had as partners. She’d given him my cell phone number and he’d said he was going to call me. She wanted to know if he had ever gotten a hold of me. He hadn’t. And now he won’t be. The reason for the call was to tell me he had passed away suddenly. She didn’t know the details. The rest of the conversation was a fog. I kept thinking. What do you mean? He passed away?

I have always found it hard to believe people I have known are gone. I have to see the obituary in the paper. I found it and there is was in print. Kevin Andrews, 52.

I am not one who believes in heaven or an afterlife. I believe when you are dead, you are dead. There is no place where you go to sit with others or wander among the clouds. Your conciousness is no more.

But what I do believe in is memory. I can close my eyes and see Kevin sitting right next to me in the ambulance, telling me a story. I can see him standing there in his mother’s house smiling watching his brothers and sisters play, and then years later, sitting on the back deck watching his own children play in my yard. I can see the true friendship in his eyes and feel his warm handshake when he says “Keep in touch.”

And I can still see him taking care of that old woman on the church steps as clear as if I were still there. I watch his hands and I want my hands to be able to soothe someone as his do.

***

Kevin shaped me as a caregiver and as a person. He helped make me the paramedic I am today. If I am gentle toward a patient, than Kevin’s spirit is in me, Kevin’s touch is in my hands. If watching the way those of us who were influenced by Kevin treat their patients, others are now gentler with the sick and injured, then Kevin’s hands and heart are also in them. His breadth widens. This is what becomes of him. This is how Kevin is passed on, from one caregiver to the next. Let this be how he is remembered.

The great church doors open to the icy weather. Outside on the cold steps, an EMT caring for a patient.

Posted by on January 10, 2011 • Filed under: ems-topics

An ED Visit

6 comments

Thanksgiving 2010.

My little daughter Zoey is sleeping beside me on the couch, her head on her favorite green pillow and a soft blanket pulled up to her neck. I watch her closely to see that she is still breathing.

She was very fussy yesterday, then at two in the morning I heard a regurgitation sound in my sleep, a sour, acidy sound you could taste in your throat. It was followed almost immediately by the full-fledged sound of vomiting. Her mother reacted quicker than I did. She had Zoey sitting up and leaning forward, sleepily and miserably retching up most of what she had eaten yesterday- grapes, mini pizza, macaroni and cheese, and the gingerbread girl she had decorated, and then probably eaten too much of. The vomit was everywhere on her clothes, the pillow, the sheets. We washed her face and stripped the bed. We changed Zoey and laid her back down between us and went back to sleep.

Fifteen minutes later, I felt her lift her head and heard the burp, and she threw up again. This went on all night long. Not just vomiting, but multiple trips to the bathroom for diarrhea. By seven in the morning, she was exhausted and her face was ghostly pale. She could barely lift her head off the pillow she was so weak.

“Maybe we should take her to the hospital,” her mother said. (Her mother is an ED nurse).

“Maybe,” I said. “Let’s let her sleep and see how she does.”

“Ten minutes later, he tries to raise her head to vomit again. We have to lift her. Nothing comes up.”

“She may need an IV,” her mother said. “What do you think?”

I call a close friend of mine who is an ED doctor and ask his advice. He says as long as her belly is soft, I should probably keep her home and have her drink Pedilyte, a little bit at a time. If I brought her to the ED and he was working, he’d probably just give her some Zofran. And if she kept the fluid down after that, just have her take in fluids. He says to call him if she keeps vomiting.

I run out to CVS and get some Pedilyte. When I come back her mother says she threw up two more times. She looks so weak. She can’t even lift her head up. What if it is food poisoning or who knows what? She really looks life she needs hydration and I don’t think she’ll hold the Pedilight down.

We would call the pediatrician, I think, but it is seven A.M. on a holiday. If we are going to take her to the ED now is probably the best time. Holiday mornings are always dead. They are probably sitting aorund with nothing to do. No way will it be a ten-hour wait sitting in a crowded waiting room with other sick kids and their families.

I don’t want to overreact, but Zoey looks so sick. And no one else has been sick in our family, certainly not like this. Its not something we can say, oh so and so had it and they got over it in a couple days. Who knows what it is? And kids can deteriorate fast. She is my daughter and she is so small. Screw it, I think. We’ll take her down. At least we are not calling an ambulance. But then I wonder what I would do if I were alone with her. Would I dare drive with her alone in her car seat. What if she started to throw up? How could I protect her airway? Would I consider calling an ambulance or just drive slow, one eye in the mirror, going side streets so I could pull over at first hint of vomit?

When we arrive at the hospital, I see I was right. The ED is empty. They are very friendly at registration — happy for business it seems — and they send us right to a room. Very encouraging. A nurse comes in and is very friendly with Zoey, even managing a smile out of her, as we tell the nurse Zoey’s sad tale. The nurse palpates Zoey’s belly and listens to her breathing, and then she leaves us with the clicker for the TV on the wall and says she isn’t certain how long it will be until the doctor comes in.

We watch Kung Fu panda and wait. This isn’t so bad. But then we wait. And wait. Slowly a stream of patients comes to join us in the ED. Most look like us, two parents and a small sick child. I hear an ambulance radio patch. A child with a broken arm. Zoey looks worse; she throws up again and has a small amount of diarrhea. We clean her up. I find myself standing in the doorway looking down the hall. I feel like all those families I see everyday in EDs, keeping watch by the door of their loved ones, waiting for word or a sign of what is happening. Finally the nurse comes back and gives Zoey some Zofran. A half hour later she brings a Popsicle.

Zoey is happy with the Popsicle, but she only eats half of it. The nurse says she is not certain which doctor will come in. I admit I am starting to think about leaving, taking Zoey and going home and managing her myself. Maybe this was a bad idea coming down here. What was I thinking?

Finally, after almost three hours we see the Doctor. She comes in and with a big smile on her face, explains that since Zoey’s vital signs are so good and since the nurses say Zoey has been smiling and chatting, she is unlikely seriously dehydrated. It is likely a virus and should be managed by drinking plenty of fluids and following up with the family pediatrician, who should always be available for consultation (even on Thanksgiving).

A nurse gives us the discharge instructions and gives Zoey a parting smile as we bundle her up. Her mom goes to work and Grandma comes over and makes chicken soup with dumplings, and spoon feeds her patiently as Grandmas do so well. It takes a couple days, but Zoey gets better.

I am always enlightened to see health care from the other side. You are so grateful when people are nice to you (and just about all of them are!). You are also ever so thankful when they let you know what is going on. Two valuable lessons learned again — and a third — smile or no smile, you can tell who is sincere and who isn’t.

I guess we didn’t need to take Zoey down. I certainly felt chastened when we left. Maybe we should have waited. Maybe we should have called the pediatrician on that holiday morning,

But my little daughter was so small and so sick.

And you can’t get Zofran over-the-counter at CVS.

When I tell my ED doctor friend the next day that we ended up going down to the ED, he is upset with me for not calling him back. He would have been happy to come over and examine her and give us a script for Zofran. He is sorry we had to go to the ED. I do know he would have come over, but I didn’t want to take him from his own family on Thanksgiving and I didn’t want to bother the pediatrician either. I thought the Ed could see her quick and fix her. They were at least on the clock. And if it was more than just a simple virus we would have gotten a head start on it.

I think when it comes down to it, parents are more concerned with their children’s immediate health than with looking stupid for using the health care system inappropriately. At least that’s the way I leaned when it was my decision time.

I need to remember that when I’m the one wearing the stethoscope.

***

Postscript: Zoey was better in a couple days. In the meantime, the virus ran amuck through the tribe of sisters and cousins, uncles and aunts, and even whacked yours truly pretty hard. I lost nine pounds in one day. (It took me a week to gain it back). At least I can tolerate Pedilyte.

***

On The Night You Were Born

Happy Birthday, sweetheart!

Posted by on January 4, 2011 • Filed under: ems-topics • Tagged: , ,

My Hollywood Adventure

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On my previous post about the pilot for the Hartford based police drama, The Second District, mcffp asked, “Didn’t I hear you might have been working on producing an EMS based drama?”

In 2006, I was asked to be a advisor/possible writer on the TNT show SAVED when the show was green-lighted for 13 episodes. Unfortunately, the money they offered me was less than I was making in 40 hours much less the 80 hours I was working. Had I been younger and less attached, I likely would have still jumped at the opportunity. Instead, I had to pass and they turned to someone else. Here then, reposted, is my account at that time of “My Hollywood Adventure.”

***

March 4, 2006

About a month ago I come home one night and see the message light blinking on my answering machine. I hit the play button. It is a message from an assistant at a television production company in Southern California, telling me that the Executive Producer of a new TV series about paramedics has read my books and is interested in talking to me.

***

Background:

Many years ago when I was on an author tour following the publication of my first book I appeared on a show called “Home Team with Terry Bradshaw” a very short-lived talk show (much like Oprah, except with Terry Bradshaw and some lady, whose name I don’t remember, as hosts). It was filmed on a studio lot in Hollywood. In my segment I was already sitting in a chair next to Terry Bradshaw when the cameras came on. How I had wanted to be introduced and with music playing, walk out on stage doing a little funky semi-pimp walk, pointing fingers at my boys in the crowd. I guess since I was taller than Bradshaw they didn’t want me to stand next to him. Anyway, it was a fun experience. I had a dressing room with a paper sign with my name on it posted on the door. I swiped it when I left. I remember Bradshaw being very nice, but constantly having to wipe the sweat off his brow. He flubbed his lines and they had to reshoot my segment. They were holding big cue cards while he interviewed me. Anyway, the producer who had pre-interviewed me in preparation for the segment told me she liked my book and asked if any Hollywood producers had called yet. No, I said. She assured me they would.

Eight years later, the call has finally come.

***

I stand there in the silence after hearing the message, and am both thrilled that my long awaited moment had arrived, but also a little disturbed that my life that I have so carefully put together (a house, a job I love (great work assignment, seniority, 401K), exciting writing projects, a regular poker game that I am beating, a girlfriend with two children I am quite fond of and who are fond of me) is now at threat. I will admit that a part of me wishes the message isn’t there. But Hollywood…Hollywood is the American dream. How do you say no to Hollywood?

***

More background:

When I was in college I took a year off. I hitchhiked out to California where I was going write the Great American novel. I ended up in Hollywood, living a few blocks off Hollywood Boulevard in a seedy apartment building at Wilcox and Yucca where my neighbors where drug dealers, transvestites, and illegal immigrants. A few weeks before I moved in, there was a fatal shooting in the lobby. The manager, who I ended up drinking beer and smoking pot with when I showed up to see the room advertised in the paper, told me he hadn’t cleaned up all the blood yet as a warning to people to keep it clean in his building. “You can do anything you want in the street,” he said, sucking on a giant reefer, “but don’t fuck with me in my building. You fuck with me you better kill me dead, because otherwise I’m putting my combat boots on and I’m going to hunt your sorry ass down.” Just then a girl, probably a runaway, who was dancing by herself to Edgar Winter’s Free Ride, danced over to him, and he started making out with her in a very physical way. His assistant, a fourteen year old Mexican kid, who never smiled, glared at me and said, “He’s serious dude. Don’t fuck with him.” His glare seemed to add the words, “or me.”

Wanting to be as far away from them as possible, I took a job out in Santa Monica as a telephone solicitor. I’d take a two hour bus ride out there early every morning, work the morning shift, spend the afternoon on the beach by the pier, work the night shift, then come back to Hollywood and sneak into the building. At night, the police helicopter would shine its spotlight into my room as it searched for wanted men. I could hear the cops on the loud speaker telling the desperados to give up and come out. It seemed to happen every night. I lasted in that building a month. The runaway smiled at me on the stairs one day when she was walking by with the Mexican kid, and I caught the glare in his eye, and after that I was convinced the Mexican kid was going to get high one night, and carve me up with his knife just for fun.

As soon as my first month rent was used up, I left town and went to San Francisco, which was another story altogether.

***

I get on the internet and research the producer and find a news clip about the show. The production company is located in Santa Monica. I believe in the circular nature of life. I never got into Harvard, and then years later I returned in my own triumphant way. The Governor of Connecticut was the featured speaker at the Harvard JFK School for government. As his speechwriter, I sat in the back row and listened to the power of his voice as he gave song to my words. The standing ovation…I was redeemed. (Now how pathetic am I? Harvard does not want speech writers; Harvard wants the person who gives the speech. Still, I felt a measure of I told you so.) Now it is time to return to Hollywood/Santa Monica. It seems predestined.

***

I talk to the producer the next day and he says he read my books to prepare the pilot episode and now that it has been green lighted by the network (TNT) for thirteen episodes he would love to have me come out and serve as a technical consultant and story developer, and maybe eventually working with another writer, try my hand a doing a script for the series. He needs someone who can combine story-telling with the technical know how to make certain they get it right. And they need me right away. I tell him I am interested, but am not certain I can get off work to come out. We leave it that I will look into getting a leave of absence, and he will look into finding a way to work me into the budget. In the meantime he will send me a copy of the pilot and the first script.

***

The operations head is excited for me and agrees to let me take a leave of absence. The head of the suburban volunteer service where I am based as a contract medic agrees to let me return to my post provided the company can find a regular replacement for me while I am gone. I like my suburban post so much that if I were to lose the post, I would not go.

While I wait for news I take my girl friend’s kids swimming. The five-year old jumps into the water and swims to me. We gradually go deeper and deeper until she is jumping in over her head. She jumps in and pops up and dog paddles to me with a big smile of success. She wraps her arms around my neck. When we leave the pool, her ten-year old sister says, “This was the best day ever!” I feel pangs about leaving them.

I hear nothing for two days, and then get an email from the producer telling me they have not forgotten me, but are working through the bureaucracy. I check the mail — no script or pilot. I get another email from another producer saying they are hoping to work something out and I should call if I have any questions. I talk to him, and he apologizes for the delay in making an offer. I ask again for the pilot. Nothing comes.

I am beginning to think they are blowing me off. I think I should have just said no, up front. My life here is more important than any stupid Hollywood red carpet dream.

I am out in the street playing football with the girls and their two cousins. We huddle up. I tell the five-year old boy to do a buttonhook and then go deep. I tell the ten-year old girl to go straight, and then cut sharply to the mailbox.

“Car! Car!” the defenders shout.

I look down the street and see a big yellow DHX truck. This is it, I think. This is my future coming to snatch me away from my life. The pilot. They haven’t forgotten about me. I feel a bittersweet pain. The truck slows, but slows a little late. It passes us, and stops at the next house down. I know it wi
ll back up, but it doesn’t. The driver gets out and delivers a big thin envelope to my neighbor. We go back to our game. I hit the ten-year with a perfect spiral, which she catches with outstretched arms right by the mail box. As the defenders converge on her, she tosses the ball back to me, and then I lob it to the five-year old who catches it, does a Neon Sanders end zone dance and spikes the ball. We slap high fives all around. The five-year old girl asks if we can go in and have brownies now. F- Hollywood, I think.

***

“They blew me off,” I tell people.

***

Then on Saturday, I hear a knock on the door.

Federal Express: The pilot and the script.

***

The show is called SAVED. I read the script first. I admit it is riveting. Some of it strikes a sense of deja veu in me. I can see they did read my books. More than that, the paramedic is a poker player, who dropped out of medical school to the disappointment of his father for not pursing the more traditional work. In the opening scene, he is dealt a pair of 3s, and goes all-in on a bluff. He wins the pot. I have a long-standing poker blog. It’s called A Pair of 3s: That’s All I Got.” Except in the title story, I go all-in on a bluff and lose all my chips. I guess that’s the difference between real life and Hollywood.

I watch the pilot. It’s hard not to like a show where paramedics race across town to a soundtrack of Jimi Hendrix “Crosstown Traffic.” I watch with great interest. There is some good writing, snappy dialogue, and some very familiar scenes: The street person who thinks he is a Biblical figure, the heroin OD waking up with narcan to yank his IV and blame the caller for seeking help, the pit bull, the worry about the big national company buying up the small company they work for, some lines of dialogue…

The show seems to me a cross between MASH and ER, but not as good as either(although not a bad show). It is not Emergency. There are some medical errors that make me cringe. At least one paramedic should have her license yanked if her medical director is watching, in addition to being fired for treating her fellow employees like crap (maybe not unrealistic). There are the requisite wrinkled uninflated nonrebreathers every time you look, plenty of negative comments about doctors, and one very major medical error in the big scene at the end. (In a life and death situation, the hero debates what to do between a neccessary action and a ridiculous action, while getting some very earnest, but ignorant advice from his fellow medics.) If I am hired as a technical consultant and they do not reshoot the scene, I work on my explanation to my fellow medics. “That was before they hired me, honest, I swear.”

Still, I like the show. I am willing to suspend my disbelief at certain things. It is after all, just TV. And as I said, Great soundtrack!

My mind is racing with ideas on what to do with the characters. I already have the episode I will write sketched out (What the heck — Field Caesarian!) I am psyched!

***

The next week they make an offer to my agent. She calls me and tells me not to take it. They want me for two months (the length of time it will take them to do the scripts for the 13 episodes) and are offering me $2 less a week than I make as a paramedic working 40 hours a week, plus I have to pay my way out there. I need to work overtime just to make ends meet now, plus I’d have all the expenses of finding a place to live and a way to get around, while still having to maintain my home here. We make a counter offer. They come back with their original offer.

That won’t work for me.

As much as I would love to go to Hollywood, and as much as I recognize there is a certain non-monetary value in the experience, I don’t like being taken advantage of. I will not pay to go to the prom with a pretty girl.

My agent sends them an email telling them they do not have permission to use any material from my books or journals.

***

And so the dream is dead.

I drive to work in the morning through the darkness, thinking I should be in Hollywood, cruising the Boulevard in one of those bouncy Cadillacs with “Dr. Dre’s “Let Me Ride” blaring from the radio, a backseat full of MTV dancers.

The show should be on the air in May.

I don’t know when the Emmys are on, but I imagine watching seeing myself not on there, Cameron Diaz not on my arm, as others wave their Emmys and thank America. I’ll be at home, my girlfriend and two girls nestled up with me on the couch, eating buttered popcorn, my work clothes laid out on the table for me to slip into early the next morning when I rise in the darkness for another working day.

***
Later I posted my thoughts about the show, which can be found here:

Saved on TNT

Posted by on January 2, 2011 • Filed under: ems-topics • Tagged: ,