I have been asked by people when my new book Mortal Men will come out in paperback. The answer is if it does, it likely won’t be for awhile. The publishing industry has changed a great deal in recent years, particularly with regard to fiction, which unless you are Stephen King or Joan Collins, is a difficult market to crack, much less make a dollar. Where a certain number of books needed to be sold to make the publishing profitable, now with electronic books and Print on Demand, it is more economical to publish — even fiction, although less so than with the more traditional non-fiction.

After much discussion with my agent, she felt the best approach would be to issue my novel as an electronic book, sell it at a low price ($3.99) and then depending on how sales went, there could be a paperback later (either with the book being picked up by a major publisher or to be published under DGLM, my agent’s imprint, which is the imprint for the e-book.

Electronic books do seem to be the future. Since I bought my Kindle over a year ago, I have read far more books than in previous years. I rarely if ever buy a print copy (I did just purchase Michael Morse’s great new book Responding), but only because it was not available yet as an e-book. Over half of the sales of my first two non-fiction books in the last year have been electronic, and the percent increases with each six-month report. I would love to be able to convert my home library (including boxes of books in my garage) into e-books to declutter my house and give me easier access to books when I think of them.

So how can you read Mortal Men if you don’t have a Kindle or a Nook? It can be read on an I-PAD, a computer, or any kind of smart phone. I have a Kindle app on both my computer and my smart phone that allows me to read when I don’t have my Kindle nearby.

The site below has links to various methods of downloading Mortal Men (and printing it if you desire).

Smashwords

The site offers a free sample of the first 8% of the book. Likewise, the main Amazon site also offers a free sample. Click on the book’s cover where it says LOOK INSIDE! and you can read well into the 4th Chapter. Kindle and Nook also offer free samples before buying. For those who have enjoyed my non-fiction books, I would recommend this so you can get a sense of whether my fiction compares favorably or not for you.

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I used to get upset when the call was for an old fall or fall yesterday or fall last night. The same when I’d get called for abdominal pain and a person says they have been having the pain for two weeks or three months. I got upset because the nature of the call was not acute. When many think of EMS, they think of us responding to sudden emergencies. We think this way most of the time, as well. Not an acute emergency, why are you bothering us? So the pain is not new, why didn’t you call when it happened? Two weeks, really, never thought to go to the ED before now? But think about this: assuming their levels of pain are the same, who do you think more of? The man with pain who sucks it up for a week until he can’t take it anymore or the man who calls 911 after only 15 minutes of pain.

The question I always try to get answered is why did you call now?

The answer is usually one of two.

A. The pain kept getting worse until the point where I just could not take it anymore
B. I ran out of pain medicine, and now is a convenient time for me to get to the hospital and get some more pills

I am all for treating pain, but when it comes to nonacute pain, it gets less easy.
Here is how I handled each of these two scenarios in recent weeks.

A. Patient has had abdominal pain for three days. He is at home watching the football game. He is wearing a New York Giant hat and wearing a New York Giant t-shirt. There is a plastic waste basket by the couch side that the patient has been vomiting into. On TV the Giants are locked in a tight game with their opponent. The man lives three blocks from the ED.

B. The woman was in a car accident a week ago. They gave her Ultram at the hospital and Ultram does nothing for her. She hurts all over. She usually takes Percocet for her back pain, but she has been out for several days. She says can’t take the pain anymore. She lives three blocks from the hospital. When we arrive, she has her coat on and is locking her front door.

Both said they were 10 of 10 on the pain scale.

I gave patient A 100 mcgs of Fentanyl and 4 mg of Zofran. I treated Patient B’s pain by getting her as comfortable on the stretcher as possible, fluffing her pillow, talking courteously to her and using “distraction therapy for pain management.”

Patient A I believed was in true agony, and was only calling because he truly couldn’t take it. Patient B seemed more like getting her Percocet renewed was just another item on her list of things to do for the day.

I always wonder if I did right.

Patient A ended up in a hospital bed in a room with a TV set where he fortunately got to see his Giants come back to win the game.

Patient B ended up in the waiting room.

Sometimes I wish pain management were simpler. I wish there wasn’t so much controlled substances paperwork and the need to exchange kits after every use, and so many cautions about possible drug seekers or excess concern about side effects, and just plain judgment. I wish that other caregivers wouldn’t say, “You gave them how much!” And I wouldn’t have to always explain the patient is stable and still in pain, and likely needs more. I wish that for every patient who said they were in pain, we could just turn on pain medicine like oxygen and let it flow.

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My latest book was published today. Mortal Men is a novel about paramedics in Hartford, Connecticut in the 1990s when a gang war was raging in the city. It is a work of fiction.  Here is the official description:

Paramedic Troy Johnson battles trauma and sickness on the streets of Hartford, Connecticut. When a fellow medic is shot responding to a 911 call, a grief-stricken Troy vows to avenge his friend, while struggling to come to grips with his own mortality.

Mortal Men examines the ancient bonding between friends and partners who count on each other to make it safely home. Written by veteran paramedic Peter Canning, author of the acclaimed Paramedic: On the Front Lines of Medicine and Rescue 471: A Paramedic’s Stories, Mortal Men provides a rare view into the real-life world of street medicine and into the lives of the men and women who fight its battles.

The book is available as an electronic book for Kindle, Nook or any other e-reader.

Here is a link to some of the places to buy it. The books sells for $3.99.

Barnes and Noble

Amazon

Smashwords

Scribd

It should soon be available on all ebook platforms including Apple and Sony.

I’ll be writing more about the book next week.

Check it out!

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I am one of my own favorite comedians.  Perhaps you have seen me on the Johnny Carson show?  No, perhaps not then.  Sometimes I really crack myself up. I am easily entertained.  I don’t perform publicly, other than in small bit roles for my partner and patient while on the job.  My latest gag has to do with the power stretcher.  Once we get the patient on the stretcher and all wrapped up in blankets and strapped in, I stand at the head and dramatically levitate the patient by slowly raising my hands like a master prestidigitator, as my partner presses the up button, then just as we hit the top, I spread my hands out, like a conductor finishing a movement.  The dialysis nurses love it!  I take it that their days are generally lacking in comic diversion.

While taking a patient out to the ambulance, I realized for all the benefits of the power stretcher, we still have to load and unload it, so I wondered if perhaps the next generation power stretcher would be more robotic where we would not have to lay our hands on it to load and unload.  We can stand like foremen in a high tech warehouse and move the stretcher in and out simply by turning a knob on a remote control device,  It gets even better the more I think about it. 

 You know how soldiers living in the suburbs drive to work at their base in Las Vegas or Omaha or some Middle American city, take their desk in front of computer screens and go to war, launching missile strikes, flying predator drones, etc?  Picture EMS in a few years.  Instead of getting in our ambulances and going out on calls, risking life and limb while driving lights and sirens, and walking up three flights of wobbly stairs as cockroaches scatter at out feet, dealing with blood, vomit, decay, and unexpected violence, what if…?

 The paramedics of the future practice by remote control.  We use keyboards and joysticks.  A mechanical arm restrains the patient, while we identify the vein with a little red laser dot and fire the catheter in.  Using a stylus we tap the computer screen, checking a box for the drug we are going to give and the amount.  Zofran 4 mg SIVP over 2 minutes.  If the patient looks like they are about to vomit, no problem.  No need to quickly jump out of the way.  So they might splat on the camera, our camera will have automatic windshield wipers so our vision will only be briefly impaired.

 But I know this sounds too mechanical.  Where is the human touch, the caring?  Why we have paramedic drones.  Robots, and with time they will look less like department store mannequins and more like us.  Eventually, they will be so real people won’t even know they are not being treated by robots.  Their caregivers will look like us, complete with bad haircuts, sweating pores, occasional foul mouths, and sore backs.

And we may not be the only robots.  The nurses and doctors could be robots too.  And why not the patients?  I mean why be sick and in pain when your robot self could suffer for you.

Of course with the economy and the need to impose efficiencies, there will be mass mergers, and soon the EMS world will be all managed in one place by just a few super EMS — let’s call them — gamers.

And what fun they will have!  Since they control not only the EMTs, but the patients and the other medical staff, they can devise elaborate scenarios to mess with us.  “Hey,” one gamer says to the other.  “Let’s F— with Medic G today. ”  “Sounds like fun!”

 The ancient Greeks believed this was how their universe operated.  They were just pawns at the mercy of the gods who sat up on Mount Olympus and played with them while they drank wine and ate meat dripping with fat.  One could only hope to win favor with the gods and protection — to be given gifts of strength and speed and not be sacrificed on a whim.  Maybe today, this is how it is for us too. 

 The gods that oversee us  start hitting all the buttons – fourth floor carry downs, frequent flier with same complaint, long triage lines,  incomprehensible dispatching, irritable nurses,  traffic, spitting patients, pagers going off, sirens, swearing, screaming, conflict, insanity.   All day long they ramp up the stress until at 4:58 the medic’s head starts spinning.  The gamers try to ease the tension back, but it has gone too far.  The head starts smoking, fire comes out of the nostrils and then the head completly blows off and fireworks shoot out of the medic’s open neck and then the screen goes blank.

Meanwhile the next day you come to work.  “Anyone see G?”   “No, he didn’t come in to work today.”  And like so many others in the past, another one of us is gone with no trace, only rumor.  “Yeah, G.  I was at the Institute for the Insane yesterday and I swear I saw him walking the floor in just an untied Johnny, shuffling along with his bare butt hanging out the back of his gown and a vacant look in his eyes. ”

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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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We are called for the violent psych and told to stage for police. Years ago we would have just been called for the violent psych. Once we got there, if we needed the police we would call for them, or depending on how the call came in, they might already be there.

This morning the call is at a nursing home and when we get there the cops are not there yet. We wait a few minutes, and then just decide to go in. It is not like we are entering a house with a violent mental patient barricaded inside. At the desk, they tell us he is up on the 2nd floor. As we wait for the elevator, the policewoman walks in the door. She is a petite woman, unlikely to be able to wrestle a raging maniac, but she does have a gun and night stick.

On the 2nd floor, the nurse points out the patient, sitting in a wheel chair by the desk with his eyes closed. He is large and muscular—built like a bull – with a scar on his hard face. He looks likes the strong man in the movies who the hero punches, but the punch does not even make the man flinch. Still his body appears relaxed, and he looks up at us without menace.

I introduce myself and my partner to him, and he nods and says hello. As I help him onto the stretcher, my partner asks the nurse what happened. To get on the stretcher, the patient locks the wheels of his chair and then moves himself over with his muscular arms, as I hold the stretcher in place. I notice then his right leg is amputated above the knee.

“He threatened to kill one of the patients here,” the nurse says. “He said he was going to stab her with a knife.”

“No,” he says. “I said I would slit her throat from ear to ear with my straight razor if I had it, but I no longer carry a straight razor.”

“Say what?” the officer says, “You want to repeat that for me, honey?”

“I said I would slit her from ear to ear. The dirty bitch stole my shirt. Everyday she steals from me, and they do nothing about it.”

“Where’s your knife?” the officer says. “He has a knife?”

“No, I am without weapons. I said I no longer carry a straight razor, nor do I have a gun at my side. I gave up my violent trade. I was just saying if I had my straight razor, she would bleed for what she does to me. The dirty whore, stealing from me and they do nothing.”

“What hospital are we going to?” I ask the nurse, as the officer stands there still trying to understand if a true threat has been made.

“Hospital B,” the nurse says.

“B,” my partner says. “We almost always go to A from this facility.”

“Yes,” the nurse says, “But we have learned when we send patients to A, they send them right back. If we send them to B, we do not see them for awhile.”

“There you go,” my partner says, and the nurses all laugh.

“Did you really mean to do violence?” the officer asks the man.

“How can I slit her throat when I no longer carry my straight blade? But if I did carry it, it would always be near my hand, and she would feel its edge.” He says, “I do not like to be stolen from, to be made a fool.”

We get our paperwork and take him to hospital B. On the way out, he sees another nurse and says. “You call for them to take me to jail, you better come down and pay to get me out. I know you have money.”

The nurse just laughs and shakes her head at him.

At the hospital, the triage nurse also shakes her head at his story.

After we transfer him over to the hospital bed, we ask, as we always do if there is anything more we can do for him. “If I might have my mouth swabbed,” he says. “It has has been several days since I have had my teeth cleaned, and I do not wish my breath to be foul.”

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I watch as he slices a pear, an orange, and a banana and sets them next to the red grapes on the plate. He pours me a glass of orange juice and then lays out plates of sausage, low sodium bacon, honey glazed ham, and potatoes. From the oven he takes out French toast.

A month before a supervisor handed me an envelope at work when I came in off 12 hours on the road. I opened it up that night, and found a two page, single spaced typed letter from a patient I’d taken care of this summer asking me to call him. He said while he does not remember much about the call, a nurse had told him at the hospital that he needed to find me and thank me. He said he wanted to do it in person. He is a chef and wanted to cook for me.

When he met me at his door, I told him he looked good, and he does. He says he has lost forty pounds, has a new medicine regime, goes to cardiac rehab, and now he has a defibrillator in his chest. He says he is grateful for each day.

We sit and eat and talk about our lives in the kitchen of his home. Like me he has a young daughter born later in his life. She calls while we are eating and asks him to find a folder she forgot to bring to school. Both of us talk about how having a child has changed our lives.

I don’t know why it took me almost three weeks to call him. But I am glad I did. In our line of work, we separate ourselves from our patients. We become a tribe unto ourselves. Here this morning, as the two of us talk about growing up in the area and raising families while doing the things we love, I feel like I am part of something larger – a part of the community. We rise in the darkness, go out into the world, and at the end of the working day, come home to our families. We are surrounded by others, grocers, bankers, electricians, teachers, factory workers. I am a paramedic and he is a chef.

He tells me how the French toast is made out of artisan bread. He sliced the bread into cubes and mixed the cubes with chunks of apple, then piled them on top of uncut slices of bread and baked them with just a touch of cinnamon. The toast is rich and delicious; the kitchen warm. We talk like old friends.

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The snow started in the afternoon earlier and harder than expected. I got the kids inside with some DVD’s and pizza. I cracked the thermostats up to give us some heat in the event we lost power that evening, which was the worry with the autumn trees still being so full of leaves and the snow predicted to be wet and heavy. The kids didn’t get halfway through RIO before the lights went out. They were impatient for it to come back on, but with daylight still present, and a quick call to Grandma confirming she had power, I packed them up with a couple days clothes and some food and drove through the storm. Once I had them safe, I headed back home to wait the storm out. Getting home was crazy. Power lines and trees down, streets blocked. I was happy to make it back to my driveway unscathed. All that night you could hear the trees cracking and the wind whistling. Occasionally the sky light up green as transformers blew. Instead of four inches, we’d gotten 12.

When the storm was over 800,000 plus in the state were out of power. Many of the towns like my own were 100% out. The devastation was rare to our area, which at worse gets a blizzard or a weakened hurricane. Many roads were impassable. Trees were down in nearly every yard.

I slept at night in long johns and under every blanket in the house. On the fifth night the temperature in the house dipped down to 48, and the cold took root in my bones. I came home the next afternoon to find the power finally on, although still no phone or cable service. I was lucky as many of my neighbors were still and are still in the dark. The utility company said everyone would have their power restored by midnight of the eight night, but it hasn’t happened.

This morning we responded to a fall. The house a nicely kept middle class home, not far from a commercial center, was dark and cold when we walked in. No power here. In the bedroom we found a 89 year old man in bed, skin pale and cool and dry, shivering under a mound of blankets, wearing a winter jacket and a baseball cap that said 101st Airbourne. A first responder told me the man’s legs had given out and he’d fallen against a table and bruised his chest. It was 42 degrees in the house, and now he couldn’t stop shaking.

“He was at the Siege of Bastonge,” the responder said.

There are place names that invoke awe. Bastonge is one of them. Late in World War II, the Germans mounted a massive surprise attack against the Allied lines in Belgium under the cover of severe weather. The 101st airborne were surrounded in the Ardennes forest near the town of Bastogne. Unable to be reinforced, they dug in in foxholes, fighting subzero temperatures, while being blasted by artillery. They were critically short on food, medicine and ammo, but they repeatedly refused entreaties to surrender. Some of them froze to death. Still they held the Nazis off for a week until General Patton’s tanks could come to their rescue. More commonly known as the Battle of the Bulge (the Bulge signifying the near break in the Allied lines), it was a key turning point in the war that devastated the Germans’ hopes to hold off the Allied advance.

“If you haven’t heard it enough, thank you.” I said to the old man, and then added, “I guess this cold now must all be like a summer day to you.”

“I was a younger man then,” he said, quietly.

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Many years ago, I was a taxi cab driver. Us cabbies used to talk about cab towns. What was a good cab town and what was a bad cab town? A good cab town was always hopping. People used cabs instead of cars. There were no traffic jams. The rides were of conversation distance. You wanted at least a $7 dollar fare. You hated the take me three blocks calls. In a good cab town, cops couldn’t be bothered to hassle cabbies. And in a good town, people knew how to tip proper. At least ten percent of the fare and lots of keep the change, buddys. You could make a living in a good cab town without having to hustle all the time, and if you did hustle all the time, which is what we did, you could make a fine living. A bad cab town, on the other hand, had short rides, dime tips, parking lot traffic, cops who like to bust on cabbies and a safe and functional bus system.

Having worked in more than a few towns in EMS, I can tell you there are good EMS towns and bad EMS towns. A good EMS town has single floor homes, not too many nursing homes, a populace educated enough not to call 911 for a genital wart, and enough highways, industrial buildings and driveways that need shoveling to ensure that when EMS is called, the people likely really do need a paramedic. A bad EMS town has three and four floor walkups, apartment buildings with broken elevators, nursing homes as a their cottage industry, a populace without cars and a dsyfunctional transportation system. A bad EMS town isn’t necessarily a poor city. Sometimes architecture alone can be a drawback. Some of these nice two story homes in upper class towns are such that the patient is always bedbound up on the second floor and there is little room to maneuver at the top of the stairs, and the staircases are narrow and steep, and there is artwork on the stairwell walls, and antiques on the landings. In bad EMS towns, they don’t like bad weather boots on their carpets. I will take a town of humble single story homes any day over most anything.

It is hard to find a town with all the elements of a good EMS town. And of course, it varies with what you like to respond to. Don’t like trauma? You don’t want an interstate or windy back roads in your town, nor do you want hip hop clubs and crack houses. Don’t like sick old vomiting people? You don’t want an elderly population. If you like crazy people, the city is for you. If you don’t like crazy people, I have news for you, crazy people are in every town! Tired of taking people two blocks to the hospital for a finger lac? Find a town without a hospital in it.

Me, I like variety, which I get now. I respond in several different towns during the day depending where system status management has me posted. Variety is good, but I also like decent calls. By decent I mean if someone is going to call 911; I like them to really need us. I like to have my skills and knowledge challenged. Although sometimes, I am content to not have to do more than be a taxi driver again. I don’t get tips anymore, but my paycheck has always been good at the bank.

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Your patient is unresponsive. They are also cool, and diaphoretic. You are thinking they are diabetic. You have pricked their finger to get a capillary blood glucose. This is the moment of truth. You are actually hoping for the reading to come back LO or at least less than 50. If it does, you relax, you believe the issue is simply low blood sugar and some IV dextrose will have the person back to normal and maybe even signing a refusal in no time. But if the blood glucose comes back normal, that’s bad. That means something else is causing the patient to be unresponsive and cool and clammy, something far more sinister and less responsive to treatment than hypoglycemia. You wait as the meter counts down. 5, 4, 3, 2, 1.

If it is LO – You give IV Dextrose. If it is normal – you start thinking maybe this is a stroke or cardiac (what does the monitor say?) or it is hypovolemia (You would likely already know this by an absent or weak thready pulse).

If they are hypoglycemic, there can be a second moment of truth. In most cases, they respond and wake up and swear that they knew they should have eaten and damn, where are they? And no, absolutely, no, they don’t want to go to the hospital. But sometimes, they don’t respond and you check the sugar again, and it is now normal or even high, and they are just like they were – cool, clammy, unresponsive. The low blood sugar either wasn’t the cause of this episode and is just a symptom of it, or they have been with low blood sugar so long some damage has been done.

I have had several patients over the years who I encountered with low blood sugar, who ended up going into cardiac arrest on me. One was a man with very poor IV access. I couldn’t get a line, so I took out the glucagon. Unfortunately, I dropped one of the vials, and had to get down on all fours and reach under the stretcher for it. When I finally reached it and came back up, now eye level to eye level with the supine patient, he looked different to me. Different like his eyes were open and lifeless and he was not breathing. I know one medic who encountered a patient with low blood sugar, loaded him into the back of his ambulance, told the family their loved one would be fine, and when they met him again at the hospital, the ambulance doors open, the embarrassed medic was doing CPR.

The other day I had a woman found unresponsive in a car and vomiting. She was cool and diaphoretic. Her husband said she was a diabetic. Something didn’t strike me right about the call. As the first medic there checked the sugar, the number came back – 129. Normal. All right, let’s get moving, we both agreed. The woman was hypotensive. BP of 80/40, then 70/36. The heart rate was 60. We didn’t have knowledge of her meds other than she took insulin. The woman groaned and was alert enough now to complain of severe abdominal pain, as well as pain in the back. We popped in two IVs and called in a medical alert. Her belly was hard and distended. We were both thinking maybe a GI bleed or a AAA. The 12-lead was normal – no STEMI. The lady was so clammy and hypotensive, I thought she was going to code on us.

They met us at the hospital with a full team. They did an emergency ultrasound that was inconclusive. When I checked back on the patient later, she was looking much better. Still in her ED room – not in the OR or up in ICU. Her skin warm and dry, her BP in 118/78. Pulse of 60. Sat – 98% on a cannula. Yesterday, I saw a nurse who take of her and asked for the bottom line. Likely constipation. It seems the patient hadn’t had a bowel movement in 5 days. Maybe she vagaled, the nurse said. She was disimpacted and went home that night.

Twenty years of this, and you never really know what you have. Diabetic, Triple AAA, GI bleed, or a vagaled constipation?

5,4,3,2,1…the answer isn’t always the answer.

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I think EMS is a lot like baseball. It can be fairly slow-paced (boring, if you prefer), but it has its moments of excitement. You have your days when you don’t even remember the calls you did they were so routine. Like in baseball, you can stand around all game in the outfield waiting for them to hit you a ball, and maybe on a typical day, you get a couple easy flys you can catch, or maybe a couple singles come out your way that you retrieve, and return to the infield with a crisp throw. Every so often you get a chance to make a spectacular play, and even rarer, you get a chance to make a spectacular play with the game and the season on the line. Same with at the plate, you bat your average for the season, and every now and then you get a chance to win the game in the last of the ninth, but that chance is rare. It’s a long season, and, just like in EMS, the trick is to stay ready on every play, never knowing when you will be truly tested.

The above, translated, means, its been pretty slow and non-exiting lately at the ambulance ballpark. Some days it is more like a six year old girl’s softball game than the major leagues. (In girl’s youth softball everyone bats and there are a lot of walks). (Today I’ve transported three kids from a school bus accident who had no injuries, a two day old fall and I did a dialysis transfer). The highlight of my days has been finding good things to eat. While I love a Fenway Frank as well as the next guy, after awhile regular ballpark food can taste pretty bland. One good thing about the city I work in is the food is varied, multiethnic and generally awesome. Instead of writing about calls, I have been collecting notes on restaurants. I found an excellent plantain porridge at Mr. Snapper’s on Albany Avenue last week for $2.50, some great crispy roast duck from the A Dong Supermarket on Shield Street, and later had the best jerk pork I’ve had outside of Jamaica at the Jerk Pit Café out north on Main Street just past where Windsor Street hooks back up with Main. Today, I ate the Bem Brasil Buffett on South Whitney for lunch where you pay $4.99 a pound for food. I had chicken simmered with potatoes, short ribs, rice with vegetables, and a fried stuffed green pepper. It was great. As soon as I’d finished, I wanted to go back for me, but by then we had been moved to area 16. I’m hoping later to get posted to area 10 where on the way there I can get a pizza empanada at Aqui Me Quedo on Park Street.

Oh, yeah, and I’m listening to the Red Sox on the radio right now. Unfortunately, they are down 4-1 early in the game and unless they get their act together in the next couple games, they are in jeopardy of missing the playoffs.

Heroics may be needed.

***

Postscript: The Sox lost the first game of their double-header 6-5. They rallied to win the nightcap 18-9, and they remain two games in the wildcard lead. I did another transfer, a crash with leg deformity, and a shooting to the arm. The MVA and the GSW were stable enough to get pain management (Fentanyl) from me. I didn’t get to Aqui Me Quedo, but did get a most excellent Jamaican chicken patty (chicken in a light pastry) for $1.80 at the Golden Crust Bakery at the corner of Woodland and Albany.

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The call is for an unresponsive in a wheelchair on a street corner in front of a social services agency.

A woman who works at the agency flags us down. She says she has a man in a wheelchair who is unresponsive. She does not know him. He is not a client there. She says a stranger wheeled him up in the chair, said he was on some heavy duty drugs, and then bolted.

The man in the wheelchair’s eyes are closed, his head is tilted all the way back and his mouth is wide open. He is about forty years old with long dirty hair to his shoulders. He is wearing an army jacket. He is breathing, but you have to watch him for several moments to see that he is his rate is so slow. His pupils are pinpoint. I give him a shake. He opens his eyes, mutters, and then he falls back asleep.

This appears to be a narcotic overdose. We lift him out of the wheelchair and place him on our stretcher, and then get him in the back of the ambulance. While I assess him further, my partner opens the ambulance’s side door, and puts his wheelchair in.

When I started in EMS we always gave narcan to heroin overdoses. You had pinpoint pupils, you got narcan. Nowadays narcan is limited to suspected opiate overdoses who are hypoventilating — low respiratory rate and/or high ETCO2.

I debate what to do about this guy. If I stimulate him enough I can keep his respiratory rate up, but he can’t talk to me. I don’t know his name or anything about him. And I have to keep stimulating him or else he’ll drop back off to hardly breathing at all. I put him on the capnography and I get an ETCO2 of 57, which is high, and suggests he is not effectively ventilating. If I stimulate him, I can get him to breathe more and the number drops down. I leave him alone, and it goes back up. His respiratory rate is 4. The end tidal climbs back up into the 50s. I finally decide to just give him a tiny dose of Narcan — 0.4 mg to wake him up just enough that I won’t have to keep shaking him every two minutes.

No sooner do I give the 0.4 mg, then he opens his eyes, looks right at me and curses. “Shit, you just gave me that narcan shit, motherfucker.” He tries to undo his straps. “Now I have to go out and start all the fuck over again.”

“Whoa, Whoa,” I say. “You were barely breathing. I had to give it to you.”

“No, if you left me alone, I would have been fine.”

“Left you alone? I didn’t go looking for you. You want to get high and not have anyone bother you, lock yourself in a room and put a do not disturb sign on your door. You OD in public, someone is bound to call us, and if you are not breathing effectively, I hate to break it to you, but you will get narcan.”

“Where am I?”

“You were out and barely breathing. So you are in the ambulance now, headed to the hospital.”

“Where’s my money? Did you take my money?”

He frantically reaches for his pockets and is relieved when he pulls out some crumpled bills including at least a twenty.

“And we have your wheelchair with us, so don’t worry about that.”

“Wheelchair?” he says.

“Yeah, your wheelchair. Your buddy wheeled you over to the agency and they called 911. We put your wheelchair in the side. It’s right here, behind you. Safe and sound.”

“I don’t have a wheelchair.”

“Huh?”

“I don’t have a wheelchair.”

“You can walk?”

“Fuck, yeah.”

“Well, you were in a wheelchair.”

He looks puzzled, and then he says, “Wait a minute, does it say, “Property of Sam Thorpe’ on it?”

“I don’t know. Maybe.”

“My roommate has a wheelchair.”

I slide over and look at the wheelchair. “Property of Sam Thorpe,” I say.

“That’s it. It’s my roommate’s wheelchair.”

“What’s wrong with your roommate?”

“He doesn’t have any legs.”

***

At the hospital, the patient continues to bitch that I gave him narcan. We put him on a bed in the hallway and tuck the wheelchair in next to the bed. No sooner have I started down the hall when a nurse takes the wheelchair and starts wheeling it away.

“Whooa, whoa,” I say. “That’s his roommate’s wheelchair?”

“Where’s his roommate?” she says.

I hold my hands out. “If only I had a crystal ball.”

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So how did my day (Tomorrow) turn out?

Too busy to get the netbook out. We did 9 transports. An asthma, a heroin OD, an ETOH, a lethargic 90 year old with leg edema, a woman feeling dizzy at work, a woman with hypertension from her doctor’s office, two neck and back pains from a motor vehicle accident, and an out of town transfer for a hospice patient. 5 ALS calls. I gave the asthmatic 2 breathing treatments and solumedrol. The heroin OD got 0.4 mg Narcan, the lethargy, dizzy and HTN patients got the routine IV, monitor. (The heroin OD and the double MVA had some humorous elements which I hope to write up this week.)

I was assigned the tiniest EMT in the company as a partner, which made for much joking, but she handled her lifts like a pro, and we had a great day together, the Mutt and Jeff jokes asides. It was funny the constant repositioning of the driver’s seat from as close to the wheel as possible to as far from the wheel as possible.

I didn’t get to my Brazilian Buffet, but I got to try a new Indian Buffet downtown. Unfortunately, no sooner had I loaded my Styrofoam carton with tandoori chicken, curry goat and some other delicacies that I couldn’t tell you what kind of food they were much less the names, my pager went off and I had to hustle to pay and get out the door. Fortunately it was for the ETOH who was just a few blocks from the hospital. My partner teched the call, so as soon as I changed the stretcher and secured it in the back of the ambulance, I was able to get back in the front seat and chow down on the food that was still hot. I plan to visit that restaurant again, and then include it in my still in planning Paramedic Zagats.

I did manage about an hour’s worth of reading during the shift. As I mentioned before, I am trying to read only books that make Best of Lists. I figure if book reviewers who read so many books can highly recommend these books, then they may be worth reading. I have been so impressed with so many of the books I have read lately. Reading good writing makes me want to write so much better, although I tell you, some of these are so good, I find it hard to imagine I could ever accomplish what these authors are doing. But then I remind myself, the trick is to write honestly and fully about what you know, and rewrite until you have it the way you want it. Blog writing isn’t quite like that. For me, it is more one draft and then a quick rewrite and edit, although sometimes I labor longer on a particular piece. I do need to orient my time so I can start writing seriously again.

We got off an hour late due to a late call. I got a text that the family wanted Chinese food for dinner, so I stopped at an Asian Buffet on the way home and got $15 worth of assorted chicken, shrimp, pork, fish, vegetables, which everyone was happy with aside from the cheese baked fake crab.

Saturday I am off, doing a mile and half open water swim in a spring-fed lake and possibly taking the family to an amusement park. Back to work on Sunday.

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I am excited to go to work tomorrow on the ambulance. No, there is nothing special going on tomorrow that isn’t going on any other day. I am just looking forward to going to work. The last three days I have been at work on my clinic coordinator job reading other responders’s run forms, reading research papers, and putting together CMEs (which included getting to hear an awesome lecture by one our cardiologists about ECG interpretation). Tomorrow is my turn to play paramedic again, and I love being a paramedic.

My last “tour” or week of work was last Friday, Saturday and Monday. This week I am working Friday, Sunday and Monday. My last two days at work I did three transfers each day in addition to about the same number of 911s. Three is a high number of transfers for a medic to do in a shift. I usually do at least one, sometimes none. I don’t know what it was those two days. I weigh the reasons. The dispatchers didn’t know we were a medic car (which sometimes happens if we get entered in the system wrong), we were heavy medic cars (the most likely possibility), the dispatchers were boning either me or my partner or both of us, or we just happened to be in the wrong place at the wrong time. In other words when the transfers came in, we were the closest cars to the transfer’s location. As I have written before, I don’t mind doing transfers, I only mind when I am doing a transfer and a basic car is sent on a 911 and calls for a medic and there are none available because the medics are doing transfers. Sometimes, it can’t be helped, other times it can. At its worst, I feel demeaned like what is the worth to being a paramedic if it doesn’t matter if a medic does a wait and return while a BLS car stays online and does the cardiac arrest or bad CHF. I guess the way I feel about it now is: it is what it is. I don’t want get too aggravated complaining about it. If it is a wait and return, I get to pull my Kindle out and read. If it is pouring rain, I don’t have to be out there getting drenched doing a minor motor vehicle. If the Red Sox game is on, I get to listen to it while I drive.

But enough about transfers, I did get to one awesome call last week. 25 year-old female ate a cookie that had a peanut in it. Two minutes later she felt her throat closing up, was wheezing and then was unresponsive. By the time we got there, she had no palpable pulse and was so out of it the first responder was getting out an oral airway to drop. She was cold, diaphoretic, responded only to deep pain, and while her torso was red, when I touched her with my hand and then moved my hand, her skin was white where I had touched her, a perfect hand print.

I wrote a while back about the various drugs we carry and I rated epinephrine 1:1000 as my number one essential drug. This call only confirmed it. I cracked open a vial, drew up 0.3 mg and injected it deep IM in her deltoid. Another medic had arrived by then and we lifted her up onto the stretcher (she had collapsed on the sidewalk in front of her house) and got her in the back of the ambulance, where we still at first couldn’t get a blood pressure, but we did get two large bore IVs (a 14 and a 16). I did the 16, the other medic who I had once precepted and who to this day remains one of my favorite preceptees, grabbed a 14, smiled at me and sunk it cleanly in the patient’s opposite AC. The patient got 50 mg of Benadryl IV, 500 cc of saline, an albuterol treatment via mask and 125 mg of Solumedrol. By the time we hit the hospital she had a decent blood pressure, her skin was dry, and while she still had considerable redness and some distal mottling, she was alert and talking and breathing without wheezes.

“Would I have died if you hadn’t gotten there?” she asked. “Ah, yes,” we both said. And that was the truth. There aren’t many calls where you can say that, but anaphylaxis is one of them.

I am not expecting to save a life this week, although I would love to do some interesting calls. I just think of all the possibilities the roulette wheel of EMS can spin our way. I know somewhere in the week, I will get some chances to be test my medic abilities, get some good stories to tell, have some good laughs, and in general, get to hang out and shoot the breeze with my co-workers who I consider my friends, many who I have known for almost twenty years.

I also hope to have some down time to type away on my netbook, some time to take my Kindle out and read – I am reading a great book now – Just Kids—a memoir by poet and early punker Patti Smith. I have also discovered a new restaurant – a Brazilian Buffet– where I hope to grab some quick and delicious food when posted in area 9, and possibly write a review. I am considering doing A Paramedic’s Guide to Good, Fast Eats in the Hartford Area.

Life as a medic is good.

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A month ago, I swapped out of my Sunday shift for Saturday. Of course I had no idea then that a hurricane would be forecast to strike our state on Sunday. (My reason for swapping was so I could enter a mile open water swim in Boston Harbor called “Sharkfest.”) I will admit like most in EMS to being somewhat of an action junkie, but instead of being upset that I might be missing out on the hurricane action, now that I am older and have a family to protect, I was quite glad that I could spend the day at home instead of out on the road battling the elements. (Sharkfest was cancelled).

The weather media machine was in full hype for storm Irene, and having witnessed first-hand the damage done by Hurricane Katrina, I have learned to respect weather, regardless of the possibility of any storm turning out to be less than advertised. I dutifully joined others in the grocery stores, buying bottled water, canned goods, charcoal for the grille, and other provisions to tide us over through what we were warned was the possibility of being without power for up to a week. On Friday (while at work on the ambulance) the day before the storm, I even managed to secure batteries, a flashlight, candles, a lighter, and a precious manual can opener – all items I had either forgotten to get or that were sold out from the larger Home Depot stores. Through searching all the little gas station convenience stores, I managed to get what I needed. I then bought 2 bags of ice at the 7-11 right before we were sent in for the day, and thus had my emergency provision list fully completed.

That night I gave the three girls the game plan for the storm. Eat the perishable food first, don’t use the flashlights unless necessary, etc. I had them help me finish the laundry and get all the dishes done so we would be in a good state of preparedness. Their mom was working late that night and since she had to work again the next morning, she had plans if the storm was bad enough to stay at the hospital. Little Zoey got in bed with me and I gave her a heart to heart about what the storm might bring. The howling wind, driving rain, sound of trees crashing. I told her not to be afraid, that I would protect her.

“Daddy, I’m scared,” she said.

“Don’t be, it’ll be all right.”

“I think I’m going to sleep with my sisters.”

So with that, she got up and scurried down the hall.

“You can come back if the storm gets too bad,” I called after her.

I slept through the night, rising with the first sunlight. It was raining hard, but nothing truly torrential. The power was still on. I saw no damage in the yard, no water in our basement, which is usually dry after storms. I had my Diet Coke and watched some of the news. The full brunt of the storm hadn’t quite reached New York yet, still to our south. The next six hours were forecast to be our worst. I was glad to be on guard at home. I didn’t even think how if I hadn’t switched, I’d be out there in the rain, battling to get to patients through flooded streets and downed limbs.

Zoey and I made pancakes and read books while watching the news in the background. There were the traditional shots of weathermen standing in knee deep water with trying to keep their rain hoods on as the wind buffeted them.

By two in the afternoon the rain had stopped and the now Tropical Storm had passed. I put Zoey in the running stroller and Lauren rode her bike alongside us as we ran throughout our local neighborhoods, inspecting the damage. A lot of leaves and small branches down. A low-laying bridge on the golf course over a stream was now underwater. No big deal at all.

For dinner we made meat balls and spaghetti, adding our secret ingredient – whipped cream – to the meat balls. We watched the nightly news and saw all the storms highlights, washed out roads in North Carolina, demolished houses along the Connecticut shore, torrential flooding in Vermont. We also learned scattered lives had been lost and millions were without power. We were grateful we had been spared the worst of it. Zoey fell asleep watching her favorite TV show – King of the Hill (I think this is why she often greets me “Hey Dude!” — and I carried her to her room and set her head on the pillow, and pulled up the covers.

This morning I got up, showered and dressed, turned on my pager and saw the previous night’s pages asking for additional crews to come in and help out a division of ours on the shoreline and later a page for crews to help evacuate a hospital whose generators had failed. Finally there was a page thanking everyone for working so hard during the storm. Making us all proud.

My family still asleep, I walked out the front door into a beautiful late August morning. The air was fresh with ozone. I drove in for my scheduled 12-hour shift.

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When I was doing my paramedic ride time, we did a stabbing in a crowded second floor apartment over a bar. It was a hot humid summer night. Music was pounding and we had to fight out way through the crowd to get to the patient. A woman had slashed a man, there was a lot of blood, the patient was barely conscious and we had to carry him down the stairs on a backboard. I took the end of the board, and started down the stairs. An EMT on the scene advised me to lean against the wall as I went down the stairs for balance. “Just watch out for cockroaches,” he said. Leaning against the wall was a great tip, and now whenever I carry anyone down the stairs, I lean against the wall with my shoulder as I go to brace myself. It has saved me from stumbling on many occasions. As far as the cockroaches, I have seen a few, and while they are legendarily hard to kill, they are smart enough to scatter when my big shoulder approaches.

I am again carrying a patient down the stairs, but today my shoulder is not against the wall. I am not in a second floor walkup above a bar, but on the second floor of a west end mansion. My patient is not stabbed, he has a vertigo. Instead of hip-hop, classical music plays lightly in the background. The carpet is probably worth more than I make in a year and on the wall all the way down, is enough artwork to fill a small museum. You can’t lean your shoulder against a wall when a Matisse is hanging on the wall. Instead a firefighter has his hand against my back and calls out the steps as I descend. My partner and I have the patient, the firefighter has me. The Matisse looks on with approval.

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I’m sitting in a new Sprinter ambulance — one of those tall thin ambulances that have been popping up in the last couple years. We have just one in our Fleet and this is the first time I’ve been in it. This morning when my partner and I checked under the hood as part of our checklist, we found the radiator was bone dry. Hooray for checklists! Unfortunately, the city was going nuts and we needed to get out on the road so the supervisor tossed us the keys to the Sprinter and I grabbed my gear out of the now off-line regular ambulance and put it in the open side door of the Sprinter, shut it and then we took off for the priority one call that turned out to be a routine sick call.

When we pulled up, we both jumped out and did near identical tumbles as the Sprinter is much higher up than a regular ambulance and you need to account for that when disembarking. We were lucky it was just a routine call as neither of us could immediately figure out how to get the side and back doors open. You learn something new everyday. I know now that the best way to mount the new beast is to step up with your right foot, grab hold of the hook above the door and pull yourself up and across into your seat.

There are some nice things about the Sprinter – I love the panoramic vista of the large windows. And standing up in the back was a great experience, very easy to get the controlled substances out of the lock boxes in the cabinet as well. I have also heard they are safer than the standard ambulance.

The leg room was great, but still by the end of the day, my lower back was hurting from not being able to get the seat at the right angle. The last challenge for the day was finding the gas cap, which I finally found in the doorway behind the diver’s seat through a process of simple deduction.

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Doing calls in doctor’s offices can be tricky. “Do you start working the patient in the office or wait till you get out to the ambulance?”

Here are the assumptions. You are a transport medic so you have the stretcher with you. The patient is not in cardiac arrest or so sick that they will crash if you don’t do something right away. At the same time, they are sick enough that you will likely have to give them an IV and medicine once you get into the ambulance. Here is a scenario I have had three times — a patient with an PSVT in the 180-220 range who has come to the doctor’s office for an emergency visit because he is feeling uncomfortable. Here is how it played out each time.

1. I am a relatively new medic. After getting a report from the doctor, I say, “Do you want me to give him some adenosine?” He says “No, wait for the ED staff to do it.” Deflated, I wait for the ED staff and the ED Doc gets mad at me for not having given it.

2. I am a more experienced medic, I keep my mouth quiet. I nod, put the patient on the stretcher, get them down in the ambulance, where I do my thing, give them the adenosine — the rhythm breaks and converts to a sinus in the 80 range, the patient feels much better, and all is good.

3. Just recently, the doctor tells me the patient is in an SVT. He already has an IV line, and has done a 12-lead. This time, it is a little different. The doctor asks “Do you have adenosine?” I say, “I do. I can give it here or out in the ambulance.” “Your choice,” he says. I think a moment, and then say, “Let’s do it here.” I give it, and it all works out great.

Let’s analyze all three situations.

Situation 1. You have a doctor who doesn’t appreciate EMS. The problem with these doctors is if you ask them in front of their patient about treatment, you run the risk of a clash of wishes. I once had a 35-year-old patient having a severe allergic reaction– hives from head to toe with crazy itching. I asked the doctor what he had done for the patient. He had given Benadryl PO. “What about epi?” I asked. “No, it is contraindicated,” he said. “She is hypertensive.” “What is her pressure?” “140/90.” Okay, so now I have boxed myself in. Once I get out in the ambulance I have to convince my patient to let me give her epi against her doctor’s wishes.* Another time I had a patient having an asthma attack, I gave the patient a breathing treatment in the doctor’s office – no issue here – but then I tried to also get an IV in the doctor’s office. When I missed my first attempt, the doctor began yelling at me for wasting time and to get the patient to the ED now. Not a comfortable situation.

It has never happened to me, but I have heard many stories of medics starting care in a doctor’s office and getting into huge fights over the direction of the care. Sometimes the medic was right and sometimes the medic was wrong. Conflict like that doesn’t serve anyone well. One of the worst cases I heard of and this one sounds unavoidable, was a cardiac arrest in a foot doctor’s office in which the doctor insisted on running the code, using his own algorithms. The medic was new and wasn’t able to seize control back. I am always uncomfortable when calls become territorial, which is why I like to get on my ground.

These experiences have all led me to the general approach of situation 2. Get the history and get into your office – the back of your ambulance. This doesn’t mean that there aren’t situations where you have to stand your ground and do what you have to do. It is just that there are some cases where it might be easier for all to just vacate the doctor’s space. Some doctors do it for you. They leave the patient in the waiting room with only the receptionist or family member to give a report. They don’t want the patient taking up an exam room. I have taken care of patients unresponsive with head bleeds slumped in their waiting room seats clutching their CAT SCAN photos.

Situation 3 is relatively rare – a doctor both knowledgeable of prehospital care, engaged in the patient’s care, and respectful of prehospital’s domain. This situation, when it presents, should be seized upon. I have only had this happen one other time in a doctor’s office – where I was encouraged to work the patient right there before the doctor. That was for a semiresponsive hypoglycemic patient. The doctor was fascinated and very complimentary as we put in an IV and gave the patient D50. He had treated diabetics in his office for years, but this was the first time he had actually witnessed a patient crash in front of him and then seen the effects of D50.

None of all of this is to say that the majority of EMS interactions are not professional and courteous. Most of the cases involve getting a report, putting the patient on the stretcher and getting on the way. I have seen doctors who did not seem competent to me and I have had doctors pick up subtle ST elevation that I might have missed that turned out to be STEMIs.

As anything in EMS, whether to start working a patient in a doctor’s office (beyond 02 and a monitor) all comes down to the great saying, “It depends.” The point of this post is just to say to newer medics to beware of some of the drawbacks to doing your thing on the doctor’s turf, and unless necessary, it may be best to just get the report, ask any pertinent history questions you might have, thank the doctor, and get on your way.

* At the time epi was in our protocols as standing orders for this, now we would withhold epi and just treat with Benadryl unless the patient developed wheezing or become unstable.

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