other people's emergencies: random thoughts of an urban paramedic

For more than twenty years I've worked as a paramedic for the city of Boston, Massachusetts. The opinions expressed in this diary are mine alone, and do not represent the views of Boston EMS. Names, dates, locations, and physical characteristics have been changed to ensure patient confidentiality.

Friday, November 20, 2009

Thank the Spammers for This

Recently, a number of "comments" posted on this site have actually been ads placed by automated spam programs. This is now happening so frequently that I don't have time to delete them all. Since nobody really wants to read "Here's the best place to buy Viagra" in the comments section of a blog, I'm going to disable the comment function. If you feel like commenting to me directly, feel free to e-mail me at urbanparamedic@hotmail.com. I check the mail at this address only occasionally, so you might not get an immediate response, but eventually I will get back to you.

There's not much else to report. I continue to work on the evening shift, and, of course, as soon as I announced my decision to discontinue posting, we had a flurry of interesting calls. In one twenty-four-hour period, we went to two stabbings and a shooting--more penetrating trauma than I'd seen in the entire two-year period since I'd left the night shift!

Before anybody asks, no, I don't plan to resume blogging. I'm just too busy with other things. The Army, especially, has given me plenty to do, sending me on brief, two- and three-day active-duty assignments every few weeks. I've been working on the ambulance book in my free time, but progress has been slow. If it gets done, it gets done. And if not, well, I guess it wasn't meant to be.

Anyway, thanks again for reading.

Saturday, June 13, 2009

Heal Thyself

It started half a mile into my run. A sensation in the left side of my chest, a cross between pressure and squeezing. I felt somewhat out of breath, too. It was bad enough that I slowed my pace to a walk.

Gradually it subsided. I was only planning on running four miles. For me, that's a fairly short distance. Pain or not, I could surely go that far.

I started to run again. A mile later, the pain returned. Just as bad as before, in exactly the same location.

I returned home, wondering what had happened. Hopefully it was one of those annoying little aches, familiar to anyone who exercises regularly, that comes and goes with no obvious cause. I hoped that it wouldn't be there the next time I ran. But it was. Each time I went out to run, I felt it.

I should have gone to a doctor, of course, because chest pain while exercising can signal a heart problem. But there was no way that I could be suffering from angina. I'm relatively young, with normal blood pressure and good cholesterol levels. I run between four and twenty miles per day, all year round, and I bike, and do strength workouts, and play ball with the kids. I've never smoked, and I don't even drink. I couldn't possibly have a cardiac problem.

And besides, the Boston Marathon was coming up. This would be my twentieth marathon, and my fifth Boston. My training hadn't gone particularly well, but I was determined to compete anyway. I wouldn't run fast, but I knew I could finish. Forced to miss last year's marathon while in Germany with the Army, I'd been training for two years. After all those workouts, I wasn't about to withdraw just one week before the race.

I discovered over the next several days that I could forestall the pain by running at a slower pace. As long as I kept my speed to around eight minutes per mile, I felt fine. So I kept running. And I went to the marathon. I started, and despite feeling lousy, I made it to the finish line.

For three weeks afterward, the pain persisted. Whenever I tried to pick up my pace, it would return. Finally I decided that enough was enough. I picked up the phone and called my doctor.

"Given your health history, this probably isn't a heart problem," she told me, "but you should see a cardiologist anyway. We'll eliminate the most serious causes first." She scheduled me for a cardiac stress test, which involves running on a treadmill while a cardiologist monitors the EKG.

But the cardiologist had other ideas. "I've looked at your old lab results," he told me in his office, "and I see some things that concern me. I think we should skip the stress test and go straight to catheterization. That's the only way to know for sure whether any of your coronary arteries are blocked."

The idea seemed ridiculous. I was perfectly healthy. Everyone seemed to agree that I was unlikely to have a cardiac problem. Yet there I was, being scheduled for a procedure normally associated with the sick and elderly. Sure, I'd go in for the catheterization. Once it revealed clean arteries, we could begin to search for the real source of the pain.

I reported to the hospital at 7:30 in the morning. A nurse started an IV and gave me some Fentanyl. It would make me feel drowsy, she explained, but it wouldn't put me to sleep. I didn't bother to tell her that I knew how Fentanyl works because I administer it to other people all the time.

In the cath lab, I quickly nodded off. I awoke to a tremendous crushing sensation in my chest, much worse than anything I'd felt while running. Through the haze of the Fentanyl, I heard one of the nurses saying something about "ST segments." An alarm bell went off in my head. ST changes indicate one of two things: either a shortage of blood supply to the heart muscle, or, worse, damage to the cardiac muscle in the form of a heart attack.

"Did you say something about my ST segment?" I asked the nurse woozily. Then I grimaced, as another wave of pain crushed my chest.

"Yes. We're opening a balloon in your artery to open it," she said. "That's why you're feeling some pain. That'll go away in a minute."

"Oh, crap," I remember saying. Even in my drugged-up state, I understood what this meant. The young, healthy marathon runner had been suffering from angina after all.

An hour later, I awoke in the recovery room. My wife was standing over me; she looked as if she'd been crying. I was hoping to learn that it was all a dream; that I didn't have a heart problem at all. But her expression told me otherwise.

"They told you?" I asked.

"Yeah," she said. "I'm sorry." She knew I'd be disappointed.

The cardiologist came into the room. He assured me that the procedure had gone well, and that the problem had been resolved. I asked him when I'd be able to resume my regular activities, like running.

"Oh, I don't recommend that you compete in any more races," he said. "That would be too stressful. But we'll talk more about it tomorrow." At that point he left, and I was glad. In the course of a one-hour procedure, my entire life had changed, and as much as I tried to fight it, the frustration, disappointment, and fear were making it hard not to cry.

Now that several days have passed, I can view the whole thing more rationally. I had been foolish not to see a doctor sooner. In fact, I was fortunate even to be alive. The pain, I learned later, had been caused by a 95% occlusion in my left anterior descending artery--the main vessel that supplies oxygenated blood to the heart. On any of those runs--and at any point during the marathon--I could have had a heart attack and died.

But the important thing is that I didn't. In fact, my heart suffered no damage at all. I stayed in the hospital for just one night, and I'll return to work at the end of the week. I reported the incident to the appropriate Army authorities, and it's not going to disqualify me from service. Even my running shouldn't be affected too seriously. The last time I talked to the cardiologist, he said, "I didn't mean that you can never run again, or even that you can never race again. Exercise is good. I just meant that for now, while you're still recovering, you should avoid the stress of racing. Go back into it gradually."

All this week, I've been sorting out my feelings. I wish it had never happened, of course, because I've always been proud of the way I stay in shape, and nobody ever wants to admit that they have a health problem. For several days I felt embarrassed about it. I went out of my way to ensure that nobody knew what had happened, because I was afraid of being perceived as weak. "Some athlete," I imagined people saying sarcastically. "See? He does all that running, and competes in all those races, and it doesn't mean a thing. That's why I don't run."

But after giving it a great deal of thought, I realize that this kind of thinking is idiotic. Having a health problem is nothing to be embarrassed about, especially when the problem has already been resolved. And running and other forms of exercise are definitely worth the effort. Sure, a runner occasionally makes news by dropping dead in the middle of a marathon. And, yes, I was awfully young to have a problem with my heart. But if I hadn't been so fit from running, then it probably would have happened sooner, and perhaps I wouldn't have recovered so nicely. As the cardiologist told me afterward, "The fact that you were able to run a marathon with a blocked artery is quite a testament to your cardiac fitness. Think of how healthy your heart must be, to do that with the blood flow nearly cut off."

It'll be interesting to see how this affects my view of cardiac patients. Since joining the military, I've developed much greater empathy for homeless veterans. Will the same thing happen when treating patients with chest pain? Perhaps.

When I return to the ambulance next week, I'll have the opportunity to find out.

This will be my final post. I've said this once before, but this time I really mean it. As much as I enjoy writing--and reading your responses--blogging is extremely time-consuming. I'd like to accomplish other things, such as writing a book about EMS. That will never happen as long as I continue to do this. There are other reasons, but that's the biggest one.

So, once again, thank you for reading. It's been fun. And if you ever see a book in Border's or Barnes and Noble with my name on the cover, be sure to buy it.

Thursday, June 04, 2009

Not So Bad, Maybe

I went to physical therapy today. Already my back was feeling better, so I began to wonder if the nurse practitioner had been right after all. Maybe it really was a muscle strain, instead of the disc herniation diagnosed by the emergency department physician.

When I entered the PT office, I saw a familiar face. Nine years ago, I injured my shoulder in a wrestling match with a heroin addict. The damage was pretty severe. Not only were the rotator cuff and the head of my biceps torn, but the labrum--the structure that holds the top of the arm into the shoulder joint--was ripped apart as well. I needed surgery in three places.

It took at lot of work to reach the point where I could use my shoulder at all. Three times each week, for more than nine months, the physical therapist put me through my paces. Strength workouts, flexibility workouts, manual stretching, ultrasound, heat treatments, cold treatments, deep tissue massage--he used every tool imaginable.

There were times when I felt like giving up. My shoulder ached constantly, and it didn't seem to be getting any stronger. But in the end, his hard work paid off. My shoulder will never be quite as strong, or quite as flexible, as it once was, but it feels pretty good right now. I can throw a baseball, and I earned a perfect score on my most recent Army physical fitness test. Not bad for someone who couldn't turn over in bed for a long time without gasping in pain.

And that's who I saw when I walked into the physical therapy office today. The same therapist who restored my shoulder nine years ago was going to treat my back.

He began with a complete evaluation. While he couldn't completely rule out the possibility of a disk injury--to the contrary, he said that many back injuries involve a small amount of disk herniation, even when that's not that the primary injury--he seemed to think that my injury was primarily muscular, and would respond pretty quickly to treatment. For the next hour, he used many of the same techniques on my back that he'd used on my shoulder.

At the end of the session, I was sore. That's to be expected, I suppose, since ultrasound and deep-tissue massage don't work unless you can feel them. But I feel as if some progress has already been made. I've got a feeling that recovery will occur pretty quickly, and that I'll return to work faster than I ever would have imagined.


Credit where credit is due: The physical therapy center mentioned in this post is The Boston Center for Physical Therapy and Sports Medicine, located at the Boston Athletic Center in South Boston. The therapist is Declan Fennell.

Tuesday, June 02, 2009

Injured

The man was homeless. He suffered from multiple sclerosis, and that's why he was confined to a wheelchair. He'd called us because of chest pain, although he was quick to point out that he wasn't having a heart attack. Several times he'd been treated for the same kind of pain, and each time a doctor had given him a clean bill of health.

A nurse at the shelter's clinic had called 911 on his behalf. As unlikely as a heart attack may have been, I couldn't really fault her for that. Patients who claim to know that they are definitely not suffering from heart attacks don't always know what they're talking about.

We examined the man and decided that the pain was more likely coming from some other condition. He winced as my partner applied the EKG wires. Asked if he could locate the pain by pressing on his own chest, he did so easily. While this doesn't necessarily eliminate the possibility of a heart attack, it certainly makes one less likely. His EKG was normal, as was his blood pressure. It was beginning to look as if he'd injured his chest in some way.

My partner stood behind the wheelchair. I stood in front of it, and together we lifted him onto the stretcher. As we did, I felt a twinge of pain in my lower back. As we pushed the stretcher to the ambulance, this pain shot down my right leg. It wasn't excruciating, but it was definitely noticeable. I must have been wincing--just as the patient had been wincing--because my partner asked if I was all right.

Not really, I told him. I think I did something to my back.

By the time we'd run the patient through triage, and settled him into a room, my back was feeling pretty tight. I mentioned it to a nurse, who arranged to have me examined. A short time later, a doctor declared me the victim of a herniated disk. "Nine times out of ten, these things heal on their own within a month," he told me. "Take it easy, and stay out of work for a week, and go to see Occupational Health. Surgery is an option if it doesn't get better, but I suspect that it will."

I thanked him and went home. That night, I did some Internet reading the subject of disk herniation. Sure enough, back pain coupled with pain in one leg was listed as a cardinal sign of disk rupture. Imaging tests, such as an MRI, aren't necessary to make the diagnosis, it said, because the nature of the symptoms corresponds so perfectly to the diagnosis.

The next day, I reported to Occupational Health, as ordered. The nurse practitioner performed the same tests that the doctor had done, but reached a different conclusion. "I don't understand why that doctor thought you had a disk herniation," she said. "He didn't even order an MRI. I think you have a muscle strain."

She wrote something into my chart. Then she looked up at me from across her desk. "There's no reason why you can't work with this," she said. "I mean, you're a paramedic, right? You wouldn't be lifting patients all the time, would you?"

For a moment I was speechless. How could a nurse practitioner be so clueless about the nature of a paramedic's job? It's bad enough that the public tends to have no idea what EMTs and paramedics do, but it seemed to me that a nurse practitioner should be fairly well versed in such things--especially when she was the one responsible for making decisions about whether I was physically able to perform my job.

"Actually, we have to do these kinds of lifts several times during each shift," I told her. "We frequently carry people down three or four flights of stairs. Sometimes they are very heavy people. We have to climb over things, and crawl under things, too."

"Oh," the nurse practitioner said. "I had no idea that it was such a demanding job. I thought you had people to do that for you."

At this, I practically fell off the chair. Like who exactly? A valet? A baggage handler? Oh, Jeeves, the man on the third floor appears to be suffering a heart attack. Be a good fellow and fetch him down for me, will you?

Yikes.

I wanted to tell her about the last time I was injured on the job--the time when a heroin addict woke up unexpectedly and fought with us as we carried him down three flights of stairs. Unable to let go of the chair, I supported the guy with one hand while fending him off with the other. We'd just about made it to the street when he latched onto my wrist with both hands and cranked down hard, causing a painful snap in my shoulder. The patient went to the emergency department, where he recovered from his overdose and was promptly discharged. Meanwhile, I went to the operating room, to have my damaged arm repaired in three different places.

But I didn't tell her about that. There didn't seem any point. She was already on the phone, arranging for me to get into physical therapy. "I have an EMT here who needs to work on his back strength," I heard her say. I couldn't be bothered to explain the difference between an EMT and a paramedic, or to explain just how physically demanding our job really is. I got the impression that she wouldn't have cared.

Now I don't know what to think. Two professionals, two conflicting opinions. Only time will determine which one is right, I suppose. I'll go to physical therapy, and either my back will get better, or it won't.

We'll see.

Sunday, May 31, 2009

Ironic Justice at the Airport

Most of my coworkers dislike responding to Logan International Airport. I suppose that's because so many 911 calls originate from there. The vast majority of those calls turn out to be non-emergencies, so I guess that adds to their sense of frustration. When you respond to the same place often enough, you begin to resent it.

But I've always enjoyed handling calls at the airport. For one thing, the conditions are ideal. The terminal is heated in the winter, air conditioned in the summer, and you never get rained or snowed on. Plus, there are plenty of elevators, so you never have to carry your patient up or down stairs. It certainly beats treating a patient in a cramped, third-floor North End apartment.

Recently, instead of sending us to the main entrances of the terminal, the dispatchers have been sending us to a gate that permits direct access to the taxiways. This saves a lot of time, because we don't have to go through the TSA checkpoint, and we don't have walk all the way out to the very last gate, which is where the patient always seems to be. Instead, we drive directly to the side of the plane. As a kid, my dad used to bring me to the airport to watch planes taking off and landing, and even now I find them fascinating. Driving along the taxiways, with 747s and Airbuses criss-crossing in front of us, makes for a pretty surreal experience.

I think of this now, because we just returned from an airport call. Categorized as an "unconscious," we were suspicious about its legitimacy from the start. "Twenty-one-year-old female, passed out," was how the 911 operator had described it. It sounded like someone had ordered one too many drinks while in flight.

And that's exactly what it turned out to be. We went to the gate, and drove along the taxiway to a 44-passenger commuter aircraft, where we found our patient, who was too inebriated even to stand up. The Massachusetts Port Authority firefighters had done their best to get some useful information out of her, but she'd refused to cooperate. They'd checked her blood sugar, which was normal, and they'd even tried to get one of her parents to come and claim her, but she'd refused to provide any telephone numbers.

I picked her up from one end, and an EMT picked her up from the other. We placed her on the stretcher and fastened the seat belts. "What are you doing?" she demanded. "I want to go home!"

"We tried to make that happen," a firefighter told her. "And you wouldn't work with us. Now it's too late. You're going to the hospital."

It was a fitting ending, I thought as we wheeled her to the ambulance. A night never seems to pass without somebody giving us a hard time. We elicit complaints about taking people to the hospital, not taking people to the hospital, taking people to the wrong hospital, sticking them with needles that hurt too much, taking too long to respond, giving them medicine they feel they can do without, and everything else imaginable. Sometimes it feels as if we can never please anyone.

This time, though, the patient who'd made things difficult for the firefighters and was giving us a hard time had succeeded only in hurting only herself. If she'd cooperated, she'd be on her way home right now. Instead, she gets to spend the next several hours trying to sleep in a busy, loud emergency department.

And why?

Because she refused to answer a few simple questions.

Friday, May 29, 2009

What's So Funny?

Health care workers have long enjoyed a reputation for their dark senses of humor. They are amused by situations that other people would find appalling--situations that often involve death, disease, and even mental illness.

They do this, of course, as a defensive mechanism. Subjected constantly to images of suffering, they realize that they must either make light of a particular situation or become depressed by it. Think about the old TV series, M*A*S*H. Hawkeye, Trapper John, and B.J. found humor in just about everything. They had to, or else they couldn't have done their jobs. That's how it is in the world of medicine. To avoid becoming a casualty, you have to develop a thick skin. In the process, you learn to laugh about topics that make other people uncomfortable.

This behavior is not limited to those who work in hospitals, of course. Police officers do it, too. And firefighters. And EMTs and paramedics.

Last week, a man in China threatened to commit suicide. He stood at the edge of a bridge for several hours, tying up traffic as public safety authorities negotiated with him and readied an air bag below. Finally, a retired soldier decided to take matters into his own hands. He approached the would-be jumper, reached out to shake his hand--and shoved him over the edge. Asked in a newspaper interview why he did it, the man said that it had been selfish of the jumper to keep so many people waiting, especially when it was clear that he didn't have the courage to actually kill himself.

I found this story amusing, not because I have anything against people who contemplate suicide, but because the retired soldier actually did what others surely were thinking. There have been times, while negotiating with would-be jumpers, that I've thought to myself, "This is ridiculous. You're never going to jump. So why are we even up here?" I'd never say that out loud, of course, but I couldn't help thinking it. And here was this guy in China, actually carrying out those thoughts. The story would have been better only if it had been the rescuer, instead of a passerby, who had pushed the guy over the edge.

When finding certain things amusing, we sometimes forget that the experience of the public is not the same as our own. Outsiders will hear us laughing about the antics of a homeless person, for example, and they'll become incensed by our callousness. But there's generally nothing mean-spirited about any of this. It has more to do with familiarity. We deal with homeless people every night of the week, and at times, they do things that happen to be funny.

The same holds true of death. For the most part, resuscitation is a serious business. You're trying to bring someone back to life, after all, and nothing can be less funny than that.

But even during a cardiac arrest, with CPR in progress and all sorts of medical procedures being frantically performed, humorous things occasionally happen. It generally begins with an observation of some kind--Why did it take so long for that woman to call 911? Didn't she notice the dead body in the middle of her kitchen?--and then additional comments are made until finally we're laughing so hard that tears are streaming down our faces. To an ordinary person, this scenario is completely unacceptable. Death is a sacred topic, and besides, the rescuers on TV and in the movies always take everything so seriously. But you have to remember that this is our workplace. We've worked hundreds, or maybe thousands, of cardiac arrests, and we can do most of the necessary procedures in our sleep. Every so often, something funny is going to happen--just as it will in any workplace--and it's going to make us laugh.

Of course, some things are never funny, not even to us. If a patient goes into cardiac arrest, and his relatives are within earshot, then of course we're not going to laugh during the resuscitation effort. That would be callous. Likewise, you'll never find an EMT or paramedic laughing about a tragedy involving a child, or about certain kinds of terminal diseases.

Because while we may be thick-skinned, we're not heartless.


The story about the would-be suicide in China was reported in several places. Here is one link: http://news.bbc.co.uk/1/hi/world/asia-pacific/8064867.stm

Thursday, May 28, 2009

You Know Your Patient is Dead When...

At shift change tonight, we found ourselves talking about dead bodies. I'm not sure what prompted this discussion, exactly, but as you can imagine, it's not a particularly unusual subject in an ambulance station.

Mostly, the conversation revolved around the locations where people had been found dead. Finally, an EMT from the evening shift told the most amusing story of all.

"We were called to this bar one time," he said. "The patient was supposed to be unconscious. As we walked in, we saw this guy on the floor. We asked what had happened, and everybody just kind of shrugged.

"As we roll the guy over, we find that he's totally stiff. He's been dead for hours, or maybe even days. So again we start asking around, trying to see if anybody knows what happened to him. Finally somebody tells us that he'd been sitting there all day, on a stool at the bar. At some point he'd passed away, but he was perfectly balanced, and he remained upright, so nobody even noticed."

"Who called the ambulance?" another EMT asked.

"He stayed there for such a long time that someone finally decided he was asleep. This other guy taps him on the arm, and the guy tips over. He falls on the floor, with his arms sticking up in the air, totally dead, like a dead pet in a cartoon, or something.

"We couldn't believe it. It was totally Weekend at Bernie's."

Tuesday, May 26, 2009

Memorial Day

The man on the ground was supposed to be unconscious. But we knew he'd be drunk. He was sprawled across the concrete plaza near the Park Street MBTA station, where every patient we treat seems to be homeless and intoxicated.

I tapped him on his shoulder. He opened his eyes. "Don't fuck with me," he growled.

"Whoa," my partner said calmly. "Let's not start that."

"C'mon," I said to the man. "We're going to help you sit up."

The man seemed to sense that we hadn't come to give him a hard time. With our assistance, he sat up on the sidewalk. "Let's move to that bench over there," I said.

Unsteadily, and with one of us on each side, he took a seat on a nearby park bench. By this time a pair of EMTs--one male and one female--had arrived. "You in the military?" the man asked the male EMT. Even now, I have no idea what made him pose this question.

The EMT held out his arm, exposing a long tattoo based on the Army Airborne insignia. "I think this says it all," he told the man.

He turned to me. "How about you? Did you do any military service?"

"I'm a JAG guy," I said.

"What branch?"

"Army Reserve."

"And you?" he asked, looking at my partner.

"Aviation medic," he said. "National Guard."

The male EMT sat beside him on the bench. I sat on his other side. It was a glorious spring afternoon, and the tourists swarmed around us in full force. It struck me as odd that just a few minutes earlier he'd been a passed-out drunk awakened by us on a sidewalk. Now, because of a common connection, we were sitting in the sun, chatting like old friends.

"So, how about you?" I asked. "You must have been in the military. Otherwise, you wouldn't have asked all those questions."

"I was in Vietnam," he said. "Nineteen seventeen-one to nineteen-seventy-three. A grunt."

He talked a bit longer. We were genuinely interested in his experiences, but there came a time when we had to move on to the next call.

"You want something to eat?" one of the EMTs asked.

"Sure," he said.

"We'll, come with me. We'll take you to the hospital. They'll keep an eye on you, and you can have a sandwich or something."

As we escorted him to the ambulance, I found myself wondering why, with so many resources available to veterans, this guy wound up living on the streets. The government gives veterans all sorts of loans, and educational benefits, and housing assistance, and health care. There's a shelter, exclusively for veterans, right up the street. Yet this guy wound up homeless, drunk, and asleep on the sidewalk.

The answer, of course, is that veterans' assistance, extensive as it may be, does not come close to meeting the needs of every veteran. Some have too many psychological problems to blend in with society. Others have such terrible substance abuse problems that they can't hold a job or even seek out the necessary services. And this is a shame, because of all the people who need public assistance in this country, veterans deserve it the most. They stood up when the nation needed them, and now that they need help, they should get it, whatever the cost.

We helped the man into the ambulance. "Thanks a lot," he said.

"You're welcome," I told him. "And happy Memorial Day."

Monday, May 25, 2009

If You Can't Do the Time...

Often you can tell what's happening at the scene of an emergency even before you begin your response. When someone reports an "unconscious man in an ATM machine," for example, you know that you will arrive to find a homeless man taking a nap. That's what it aways turns out to be.

So, when we saw on the ambulance's computer screen that we were responding to a "thirty-five-year-old male, unconscious after shoplifting," we knew that he wasn't unconscious at all. He was hoping to land in a hospital instead of in jail.

We weren't the only ones to pick up on this. We arrived at the department store to find a bunch of firefighters and a trio of security guards staring at a man on the floor. None of them seemed to be particularly concerned, because they all knew what was really happening.

"He stole a bunch of sunglasses," the fire lieutenant reported to me. "The security guard grabbed him as he was going out the door, and he started to have this kind of seizure thing."

The man was awake, but when I asked how he was feeling, he made only a groaning sound. I could have assessed him further, but there wasn't any point. He would continue the charade as long as necessary to avoid being arrested.

Instead, we lifted him onto the stretcher and wheeled him to the ambulance. "Is he under arrest?" I asked the security guards. "Does anybody want to accompany him to the hospital?"

The guards shook their heads. It wasn't worth their while to guard him over twenty dollars' worth of merchandise. We put him inside the truck and closed the doors.

I knew how this call would turn out. We'd bring him to the hospital, and when nobody was looking, he'd run away. This kind of thing happens all the time. I saw it first when I was still working as an EMT. We picked up a woman who'd been arrested on a similar charge, and who, like this man, was pretending to have a seizure. We brought her to the Massachusetts General Hospital, and as I opened the ambulance door, she shoved her way past me and ran up the street. I wasn't going to chase her, because there wasn't any point. What would I do if I caught her? Force her to stay in the hospital, to be treated for a condition she didn't have?

I wasn't going to go through that again. Instead, It made sense to get right to the point. "Here's the situation," I said to the man, who was still groaning. "The store doesn't want to press charges. The security guards are gone. You're free to leave if that's what you want to do."

The man lifted his head. He looked around the ambulance. "My God," he moaned. "Where am I?" He knew perfectly well where he was. It wasn't exactly an Oscar-winning performance.

"Listen to me," I said. "You're free to leave. Nobody's going to stop you."

Hearing this, he jumped up from the stretcher. He looked out the back window, and then out the side window. "I can't leave!" he said in a panic-stricken voice. "The police will get me!"

"There are no police," I told him. "Only security guards. And they're all gone. You can leave. Nobody's going to stop you."

"My bike!" the man shouted, looking out the window with greater urgency now. "Where's my bike? I left it right there by that streetlight!"

That would have been a bit of ironic justice, I thought--for the thief to have his bike stolen while committing his crime. But then the man sighed with relief. He'd spotted his bike. It was right where he'd left it.

Slowly he opened the ambulance door. He stepped out cautiously, obviously concerned that we'd set some kind of trap for him. When he saw that there really weren't any police officers out there, he straightened up, hopped on his bike, and pedaled furiously away to freedom.

I don't like the way this call ended. As trivial as the theft may have been, it's wrong to let shoplifters get away with their crimes. Retailers lose millions of dollars to petty criminals each year, and we certainly don't want to send the message to shoplifters that they can evade prosecution simply by faking an illness.

But what choice is there? Denying care to a patient who appears to be faking could prove disastrous. Those are the calls that turn into lawsuits.

At the same time, though, it makes no sense to tie up the ambulance with an unnecessary transport, when everyone knows that the guy will flee the moment he lands at the emergency department.

The least bad option, as I see it, is simply to play the game.

Saturday, May 23, 2009

Haste Makes Waste

I returned to the classroom last night, for another evening of mandatory continuing education. First a pediatrician talked to us about childhood pulmonary diseases. Then we heard from a surgeon about chest trauma. Finally, at the end of the night, a trio of Boston Police detectives talked about the status of various street gangs.

I enjoyed the gang lecture the most, because the topic was so unusual. The information will probably come in handy at some point. If nothing else, it'll help us to avoid transporting rival gang members in the same ambulance.

Of all the speakers, the trauma surgeon appeared the most comfortable. For some reason, surgeons always make good lecturers. Naturally confident, they appear poised, no matter how large the audience.

The surgeon who spoke to us tonight kept us amused. He opened his talk with a series of videos that demonstrated all sorts of ridiculous injuries. Then he got down to business, describing the proper ways to diagnose chest injuries and perform tracheotomies.

During his talk, he told a story. "These days, we don't waste time opening chests in the emergency department," he said. "Thirty percent of all trauma patients have either HIV or hepatitis. It doesn't make sense to reach into a thoracic cavity and risk getting exposed, especially when hardly any of those patients will survive. If a patient arrives at our hospital within eight minutes of getting shot or stabbed, we'll open him up. Otherwise, we just pronounce them dead."

He paused for a moment to let this information sink in, then continued.

"It wasn't always that way, though. Doctor Hirsch, the great trauma surgeon, told me about an incident he witnessed back in the seventies, shortly after he became an attending physician. Back then, they opened the chest of every shooting and stabbing victim. Whenever a trauma victim arrived, the residents would run to the emergency department, because they all wanted to open the chest. Whoever got there first would have the opportunity to do it.

"One night he gets a call from the hospital operator, who says that a shooting victim has come in by ambulance. He runs to the emergency department, and there he finds a resident with the patient. The patient has been shot, but he doesn't seem to be bleeding. Yet for some reason, there's a giant puddle of blood on the floor. That's when Doctor Hirsch notices that the resident is holding a couple of fingers in his hand. The resident had been in such a hurry to open the chest that, well, you get the idea.

"Anyway, that's why we're not in such a hurry to open chests anymore."

Thursday, May 21, 2009

Death on a Motorcycle

He came up the street like a rocket, witnesses said. According to the police, he was riding his motorcycle through downtown streets at more than one hundred miles per hour.

And now he was dead.

We were in the emergency department at the Massachusetts General Hospital when the call went out over the air. A few minutes earlier, we'd transported a pleasant, middle-aged man who seemed to be having his first angina attack. The dispatcher asked if we could handle a call for a motorcycle accident, and at the same time, several police officers sprinted out the door.

I wondered if it was a motorcycle officer who'd been injured.

My partner had put away the equipment we'd used on the previous call. I could write the report later. Sure, I told the dispatcher. We could handle the call.

A few minutes later, we turned onto the street where the collision had happened. The motorcycle lay on its side in the middle of the intersection. It was a big, powerful Japanese bike, the kind used in road racing. Two cars and an SUV had stopped nearby. Each had damage along its side.

According to the 911 caller, the motorcyclist had been trapped beneath the SUV. The EMTs who arrived before us had pulled him out and were strapping him onto an immobilization board. We lifted him straight into the ambulance.

He wasn't breathing. He had no pulses. While my partner prepared to intubate him, I set up the IV equipment. Meanwhile, one of the EMTs started to pump on his chest, while the other cut off the man's clothing. This took a while, since he was dressed entirely in leather. When his torso was finally exposed, I saw scrapes and bruising all over his chest and abdomen. The impact must have been extraordinary.

"There's blood coming out his ears," one of the EMTs said. This was a sign of a skull fracture.

"Did he have a helmet on when you got here?" my partner asked.

"We didn't see one," the EMT said. "I don't know whether he lost it during the collision or not."

"His pupils are fixed and dilated," my partner observed. He didn't have to say anything else, because we knew what this meant. He was already brain dead. We were trying to resuscitate him for nothing.

But we'd already begun, and so we'd continue. We started for the nearest trauma center. My partner talked to a nurse by radio, to let them know we were coming. They were ready for us. A dozen nurses, doctors, and technicians greeted us inside.

"Why would anybody do that?" one of the EMTs asked as the trauma team continued the resuscitation effort. "I mean, going that fast downtown is like suicide."

I didn't have any answer for him. Neither did anyone else. A police officer passed us in the doorway. He looked at me, as if he was about to ask a question, and I already knew what it was, because police officers at hospitals always ask the same question.

"He's not going to live," I told him. "He's dead right now, and he's going to stay dead."

"I'll call Homicide," the officer said.

Wednesday, May 20, 2009

Even Simple Calls Can Be Rewarding

We met the most delightful woman tonight.

Her name was Jane, and she was ninety-nine years old. A neighbor had come over to visit, and Jane had stumbled while getting up to answer the doorbell, striking her her on the linoleum floor and raising an enormous lump on her forehead.

I asked if she felt pain anywhere. She said no. I pressed on her ribs, arms, hips, and legs. "Any pain here?" Again she said no.

We rolled her gently onto an immobilization board. The lump on her head, coupled with the age of her bones, made it impossible for us to ignore the possibility of an undetected spinal fracture. Looking up at us from the board, she said, "Three heads. I see three heads." In her own way, she was trying to express surprise that so many people had come to care for her.

Jane lived alone. At such an advanced age, this seemed an impressive achievement all by itself. We'd been called because the neighbor at the door had heard a shout of "Oh, God!" followed by a crash. She'd called Jane's daughter, who had rushed right over. Now, as we lifted Jane onto the stretcher, the daughter snapped a photo of the head wound on her cell phone. "I want to show it to her later," she told us, "when she tries to tell me that she wasn't really hurt too badly."

Smart woman.

We were just about to wheel Jane to the ambulance when the daughter mentioned something about diabetes. On a hunch, we checked Jane's blood sugar, and found it to be 39, roughly half of what it should have been. This amazed us. For a ninety-nine-year-old woman to hold lucid conversations was remarkable by itself, but for her to speak coherently with a blood sugar that would have left most people unconscious was simply amazing.

Rather than torturing her with an IV, we fed her some oral glucose paste and took her to the hospital. Her blood sugar gradually returned to normal. Later, as we brought another patient into the same emergency department, the daughter told us with a smile that her mother wouldn't even have to be admitted. The head injury was superficial, and she would get to go home.

Nobody goes into EMS hoping to care for old ladies who have fallen. There's nothing challenging or prestigious about those kinds of calls.

Sometimes, though, these can be the most rewarding calls of all. While the situation amounted only to a minor emergency, the family truly needed our assistance, and we gave it to them. The family was grateful, and we left the hospital feeling as if we'd genuinely made a difference.

Monday, May 18, 2009

Follow Up: The Cardiac Arrest

Some of you wondered what became of a cardiac-arrest patient we recently resuscitated. (Winning the Battle; Losing the War, May 1, 2009.)

Well, I learned some details last night, and the news is surprisingly good. He didn't have a ruptured aneurysm at all, as we'd feared. In fact, it was a straight-up cardiac arrest, a so-called "primary arrest" that did not involve any medical conditions beyond the cardiac event itself.

The patient will survive. He suffered some brain damage after being deprived of oxygen, but he is awake, able to talk, and remains an inpatient at the hospital where we transported him. Soon he'll be transferred to a rehabilitation facility, where he'll receive physical and occupational therapy. Unfortunately, some of the brain damage is likely to be permanent. But the hospital staff expects him to make a good deal of progress, and hopefully, to return almost to normal.

Saturday, May 16, 2009

To Some People, When You're Right, You're Still Wrong

Tonight we responded to the Aquarium MBTA station, where a woman was supposed to be having an allergic reaction to gluten. We could see her on a bench, surrounded by concerned-looking commuters and MBTA workers. From a distance, she didn't appear to be in any great distress. People in anaphylactic shock tend to pass out, after all, or to gasp for air, or at least to lay down.

As we got closer, though, I could see that her face was covered with hives. In fact, her entire body was covered with hives. Her breathing didn't seem too bad, but when I took hold of her wrist to check her heart rate, I couldn't find a pulse.

"Do you feel lightheaded?" I asked.

The woman looked at me, opened her mouth to reply, and promptly passed out.

Grabbing her arms and legs, we lowered her to the platform. My partner filled a syringe with epinephrine and injected it into the skin over her forearm. A few seconds later, she groaned and began to stir.

One of the EMTs tried to take her blood pressure, but he couldn't hear anything. The woman was awake now, as long as she didn't try to sit up.

My partner gave her an injection of Benadryl. We started an IV. Every few minutes, the EMT took her blood pressure again. After a liter of saline solution had run into her body, she still didn't have much of a pulse.

My partner suggested an injection of 1:10,000 epinephrine. Normally this course of treatment is reserved for patients in cardiac arrest. By this time, though, I didn't see any other choice. After two doses of medication and a huge bag of IV fluid, the woman still didn't have any blood pressure. being down in the subway, we were a long way from the ambulance, and an even longer way from the hospital.

He injected the medication into the IV. We lifted her onto the stretcher and wheeled her to the elevator at the far end of the station. As we rode up to street level, the EMT took yet another blood pressure, and reported it to be 70. That wasn't much, but at least it was something.

The woman's eighteen-year-old son wanted us to bring her to the Beth Israel Hospital, all the way across town. I looked at the rush-hour traffic, and told him, sorry, that it just wasn't possible. At least three other hospitals were closer, and with such a low blood pressure, a cross-town trek wouldn't really be safe.

"Her sister is in that hospital," the son said. "She's dying. That's why we're here. We came all the way from San Diego to be with her."

I felt terrible, but this really didn't change anything. It would take us at least twenty-five minutes to get over there. With little or no blood pressure, that would be a risky proposition.

The son understood. He didn't debate the point. We took her to a closer hospital, though I felt lousy about it.

The woman looked better as we wheeled her into the emergency department. Her blood pressure still hadn't gone above 70, but she remained awake, and the hives had cleared somewhat. She didn't seem to mind that we'd gone to the closer hospital. I was grateful for that.

In the treatment room, a nurse started a second IV. A doctor went in to examine her. A moment later, he came out to the front desk, where I was writing the report on the call.

Whatever he was going to say to me, I knew it would be confrontational. We've always enjoyed a fantastic relationship with the nurses and clerks at this particular hospital, and with nearly all of the other physicians, too. But for some reason, this doctor never has a pleasant word for us. When he's not ignoring EMTs and paramedics, he's criticizing them for something.

The last time I dealt with him, he accused us of letting a heroin addict leave without treatment. If he'd checked his facts first, he would have learned that we were the ones who'd brought the addict back from respiratory arrest, and that we were the ones who'd convinced him to go to the hospital. In fact, we were the ones who'd caught the patient escaping, long after we'd transferred responsibility for care over to the emergency department staff. But the doctor assumed that we were incompetent, and so he laid into us, right there in front of the patients and hospital staff, barking at us about our responsibility to safeguard our patients, and threatening to report us to the state EMS authority. And when he learned that it had been his staff that had slipped up, and not us, he refused to back down, never once offering an apology. Since then, several other EMS personnel have told me that they, too, have had run-ins with him. My partner tonight summarized the whole thing by saying, "He's a real asshole."

Tonight's interaction didn't improve our relationship. He walked over to me and said, "Did you give that patient epinephrine?" It sounded more like an accusation than a question.

I told him about the epinephrine, the Benadryl, and the IV fluid. I felt confident in what we'd done, because we'd followed state EMS protocols to the letter. And, more importantly, the patient's condition had improved. We'd delivered the woman to the emergency department awake, with a blood pressure, and in no respiratory distress.

"How much epinephrine did you say you gave her?" He'd heard me the first time. As usual, he felt the need to challenge our care.

I repeated the dosages. "Oh, that explains it," he said. "No wonder she's shivering." Then he turned around and marched away.

Of course the patient was shivering. The temperature downstairs had been about forty degrees, and she'd been laying on the concrete floor of a subway station. Plus, we'd given her substantial doses of epinephrine, a substance that stimulates the nervous system. That would make anyone shiver.

But the shivering, apparently, was the biggest thing the doctor could blame us for. Ignoring the fact that we'd reacted to a life-threatening situation quickly and reasonably, and ignoring the fact that shivering was a normal side effect of a necessary treatment, he chose this as the basis upon which to criticize us.

I didn't expect him to thank us. I didn't expect him to congratulate us. But I didn't appreciate being criticized for something that wasn't even wrong.

For a moment I thought about responding in kind, by telling him what I really thought about him and his opinions. But then I decided against it. No matter what he says, I know that we treated that patient well.

If he wants to be a jerk, that's his business. I'm not going to follow suit.

Thursday, May 14, 2009

Almost Back

I meant to post a couple of times while away, but I simply haven't had the time. I'll return to Boston tomorrow, and I'll be back on the ambulance Saturday. I'll post again soon. Promise.

Thanks for your patience.

Sunday, May 10, 2009

Here We Go Again

I'll be away from the ambulance for another week, for more military duty. This time I'm off to Fort Gillem, Georgia, just outside Atlanta. I fly out in a couple of hours.

This will be a busy week, with only a couple of hours of free time each day. I've written a couple of new entries, but I don't know whether I'll have the time or facilities to post them. We'll see.

In any event, I'll return to the ambulance--and to posting--next weekend.

More Than One Patient is No Fun

It just figures.

I've been complaining recently about the lack of variety on the evening shift. The only calls we handle, it seems, are cardiac ones. I can't wait for the end of the year, when I'll have an opportunity to go back to the night shift, so I can deal with drunks, and brawls, and car crashes, and shootings.

A couple of weeks ago, a woman was shot to death in the Back Bay. This was the so-called Craigslist Killer case, the one in which a BU medical student allegedly shot a prostitute who'd advertised her services via the Internet. Since it happened shortly after 10 p.m., I probably would have responded. But I didn't, because it happened on my night off.

And then, last evening--also on my shift--a pair of Green Line trolleys collided between Government Center and Park Street stations, sending some forty-six people to various hospitals. I would have responded to that call, too, and since the accident location isn't far from my EMS station, I would have been among the first to arrive.

But I didn't go to that call, either. I'd been given the night off, for military duty.

Truth is, I wish I'd responded to both of those calls. Not because I have any great desire to jump into newsworthy stories, because I really don't care about any of that. Work for a big-city EMS agency for a while, and you'll see yourself on television and in the newspapers. It comes with the job. But after a while, you find yourself ducking away from the reporters and photographers, because you no longer feel like being involved.

I regret not being there for a much simpler reason: it would have been something different. A call that for once didn't involve chest pain or difficulty breathing.

There would have been a downside, of course. Calls involving multiple patients are a lot of work. Chaos is inevitable. Some EMS personnel would take this a step farther, referring to such incidents as "circuses"--or worse.

We responded to Logan Airport once, where a man had suffered a head injury. It was an international flight, and we had to wait for a while as the plane taxied to the gate. When we finally got on board, we discovered that our patient had indeed injured his head. It had been split wide open, all the way down to the bone, from one ear, across the top of his head, to the other ear.

The plane, we soon learned, had flown into a severe downdraft, plummeting 5,000 feet in a matter of seconds. The patient had been standing up in an aisle at the time. When the plane went down, he went up, slamming the top of his head into the ceiling.

As we treated him, a flight attendant called our attention to another patient, at the opposite end of the same row. He'd suffered an identical injury. His head, too, had been split wide open.

Somebody tapped me on the my back. It was a third passenger, also with a head injury. Then a fourth came forward, and a fifth, and a sixth. Finally I announced, "Everybody injured, raise your hand!"

Eighteen hands went up. My partner and I would need some assistance.

In caring for patients on airliners, we sometimes ask the flight attendants to keep the other passengers in their seats while we evacuate the patient. Other times, we let the healthy passengers leave first, to give us more room to work. It all depends on circumstances.

This time, we asked the crew to "deplane" (in airline parlance) the uninjured passengers. We didn't have much choice. Alone with my partner and a handful of airport firefighters, we couldn't possibly remove eighteen patients.

At a scene like this, triage tags are used. They look a bit like baggage tags, with a string for attaching it to the patient. Each one has a series of color-coded strips--red, yellow, and green to indicate severity; black to identify patients with no chance of survival. You rip off three of the strips, leaving the one that applies, and you attach it to the patient, giving everyone an idea of just how urgently that patient needs to be transported.

Someone had the wise idea to use a catering truck to evacuate the patients from the plane. Normally these trucks are used to lift hundreds of dinners to the plane's galley. On this day, though, they carried a different cargo--injured passengers.

In the end, everyone seemed to make out all right. It took a while, but eventually everyone went to a hospital. Fortunately, the patients seemed to understand that we were working as quickly as we could. Nobody panicked, and nobody became unreasonable.

These kinds of calls generally go much worse. On the plane, everyone needed to be immobilized for neck injuries. But only the men with the split-open heads were bleeding severely. Imagine walking into a mass-casualty incident where eighteen people are bleeding to death. Where would you begin?

My colleagues who responded to the MBTA subway crash last night went through this same process. They triaged the injured, tagged them by priority, called in reinforcements to help with immobilization, carried the injured to ambulances, and shipped them all off to hospitals. Meanwhile, other colleagues of ours--the EMTs who work in the EMS communications center at Boston police headquarters--worked the radios and telephones, determining which patients should go to which hospitals.

So, in a sense, I'm glad that I didn't have to deal with the chaos.

But I still wish I'd been there.

Saturday, May 09, 2009

Another Veterans' Resource

A reader recently asked if I knew of any counseling or legal services that could help a wounded soldier, recently returned from Iraq, to get benefits after being denied assistance by the VA.

I've been in Maine for the past two days, helping a Transportation Company prepare for its Middle East deployment. While there, I posed this question to a VA administrator. She told me that some soldiers are indeed denied certain benefits. A soldier who leaves the Army after just two or three years of service, for example, will not qualify for benefits that go only to retirees--despite having suffered injuries in combat--because leaving the service at the end of an enlistment obligation is not the same thing as retiring. Of course, personnel who are forced to leave the service because of injuries may qualify for "medical retirement" because of their injuries, but that's a discussion that goes beyond the scope of this blog.

Anyway, the VA representative went on to say that at a minimum, every soldier who continues to suffer health consequences of a combat-related injury qualifies for VA treatment of that condition, even if he qualifies for no other benefits. If, as EMS personnel, you come across a soldier suffering from PTSD or some other traumatic or health consequence of military service, have him contact the Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Program Manager at their local VA office. I'm told that every VA office--or at least every VA medical facility--has one, and that they are eager to help veterans get the benefits they need, especially medical ones.

Thursday, May 07, 2009

One More Thing...

In response to my previous post, a reader mentioned an organization called "Homes for Our Troops," which builds specially adapted homes for our severely injured veterans. Given how much these troops have sacrificed, this is an an extremely worthy cause, and certainly worth a mention here. Please consider helping them at www.homesforourtroops.org. Thanks!

Wednesday, May 06, 2009

Lesson Learned

I took today off from the ambulance to go on a military assignment. With two other JAG officers, I went to a Wounded Warrior Transition Unit to address the legal concerns of injured soldiers recently back from combat zones.

I felt sorry for many of those soldiers, not only because of the physical challenges they face, but because several of them have run into enormously frustrating administrative problems. It's hard to believe that an employer would refuse to rehire a returning veteran in violation of federal law, but that's what happened to some of these soldiers. It's hard to believe, too, that even as a soldier lay in a hospital bed, his wife would abandon him, and move with his children into the home of a convicted drug dealer. I heard that story today, too.

Despite these problems, I found the soldiers to have remarkably good attitudes. They talked openly about their service and their injuries--most without any hint of anger or bitterness. They were proud to have served their country, despite the personal sacrifices they had made.

I found one story to be especially touching. It didn't come from any of the wounded soldiers, but rather, from a sergeant who learned a valuable lesson. He told this story to a group of officers who were training to work with injured soldiers, and one of them repeated it to me. And while it doesn't have anything to do with EMS, it has everything to do with the relationship between patients and those who care for them.

I was a drill sergeant for six years, the sergeant said. I enjoyed doing that, but after six years, I was ready to do something else. I wanted to get back to the fight. I wanted to go to an infantry unit, to do the things I was trained to do.

So I put in my request. After a while, I get a letter in the mail, with my new assignment. I opened it up, and I couldn't believe it. I was like, 'Walter Reed? They're sending me to work at Walter Reed Army Hospital? What the fuck is this? I don't want to work in no fucking hospital! I want to fight!'

I did everything I could to get out of that assignment. I made phones, sent e-mails. Nothing worked. And it's the Army, so what could I do? I've got to go on the assignment, right? I packed up and moved to D.C., and reported for work.

I was furious when I got there. I'm going to be the NCO in charge of a hospital. What a stupid assignment! They don't even do PT at the hospital! I couldn't believe it. I'd been assigned to a facility where the soldiers don't even have to exercise!

On my first day, the commander gives me a clipboard and a bunch of concert tickets. They were donated by some guy named Kid Rock. The commander wants me to pass out the tickets to solders, and write their names on the clipboard. I was so disappointed. I thought to myself, 'Is this what my career has come to? Giving out tickets? What a waste of time.'

But an order's an order. So I go to the first room, to the first soldier, and I don't even pay any attention to him. I just walk in and ask him, 'You want a ticket? It's for a concert by some guy named Kid Rock.'

The soldier tells me, 'Yeah! Sure!' He sounds all excited. I give him the ticket, and I start to walk out, and I hear the soldier call to me, 'Hey, Drill Sergeant! How have you been?'

I turn around and look at him, and I see that he's one of my soldiers, a young private I'd taught in Basic. He'd gone to Iraq. I looked down, and I saw that his legs were gone. They'd been blown off by an IED.

And that's when it hit me: My assignment was not a waste of time. That soldier was who I'd be working for. There's nothing more honorable than helping someone who needs it.

And who was I to complain about that? There I was, complaining about not getting the assignment I wanted, and about having to give out concert tickets, while one of my soldiers was sitting there on a hospital bed with with his legs blown off.

I realized at that moment that I was fortunate to be able to help him, in any way I could.

That seemed like a good sentiment for all health care providers--including me--to remember.

Monday, May 04, 2009

Questions at the Walk for Hunger

Yesterday was supposed to be my day off. Instead, I worked a detail, staffing a medical tent at the finish line of the Walk for Hunger.

A detail, in EMS parlance, is an assignment at a fixed location, usually to provide medical support for a large event of some kind. Depending on the nature of the event, this may involve working in an ambulance, patrolling a race course, riding through a crowd on a bike, or manning a first aid tent.

Yesterday's event, the Walk for Hunger, is an annual fundraiser where some 30,000 people walk 20 miles through Boston, Brookline, Newton, Watertown, Cambridge, and back to Boston again. Along the way, walkers sometimes trip and fall, get hit by cars, have heart attacks, or get blisters. To be prepared, we have ambulances, bike units, and medical tents all along the route.

We started work at 8:00 am. We caught a ride to the Common in a Special Operations vehicle, met the first-aid volunteers affiliated with the event, set up our equipment, and waited for the walk to begin. A couple of hours later, as the first walkers began to stream across the finish line, people began to request Band-Aids. Since our job was to treat and transport patients serious enough to need hospitalization, we stayed out of the way and let the volunteers handle these requests. Someone occasionally came into our tent with an abrasion after taking a fall, but otherwise, the walkers needed only Band-Aids.

Meanwhile, I was only too happy to provide directions to anyone who needed them. Maybe it's because I worked on the night shift for so many years, but I really enjoy fielding such questions, because it's refreshing to deal with a sober public for a change. And besides, since I was getting paid to be there, and I didn't have any work to do, it only made sense to be as helpful as possible.

The most common question I fielded was, "Where can I catch the subway?" But not all of the questions involved directions. Some involved other kinds of problems--lost property, lost children, a stolen backpack. I have to admit that some of these questions left me shaking my head.

Here, then, are the three conversations I found most amusing at the 2009 Walk for Hunger:

Number 3:

Walker (at 2:00 pm): Where's registration?

Me: Registration? That's the registration tent over there, but there's nobody around. Why? What do you need?

Walker: I want to sign up for the walk.

Me: You're a little bit late. The walk started six hours ago. Most of the walkers have already finished.

Walker: Can I still do it?

Me: Well, sure. I guess so. I mean, nobody's going to say that you can't take a walk. But I think it's too late to sign up for it.

Walker: Okay. That's fine. I'm going to do it anyway.

Me: Have a good time.


Number 2:

Walker: I need some advice for my brother. Some first aid advice.

Me: Okay. What's wrong with him?

Walker: His legs are sore.

Me: Really? After walking twenty miles, his legs are sore? You don't say.

Walker: What should I tell him?

Me: Tell him to stretch really well, and then take a rest. Tell him that walking twenty miles is tiring.

Walker: Okay. I'll tell him. Thanks.


Number 1:

Walker: Excuse me, but has anyone turned in a walker?

Volunteer: A walker?

Walker: Yeah, you know, one of the square metal things that old people use to help them walk? My uncle thinks he left it at the Three Mile checkpoint. Do you know whether anyone has turned it in?

Volunteer: Your uncle left his walker at the Three Mile Checkpoint, and walked the remaining seventeen miles without it? Are you sure he really needs a walker?

Friday, May 01, 2009

Winning the Battle, Losing the War

The inhaler said it all.

It lay there on the carpet, just a couple of inches from the patient's outstretched hand, right where it had fallen when he collapsed during his asthma attack. It was supposed to keep him alive, to open the bronchial passages and allow him to breathe. But it was too late. First he'd stopped breathing, and then his heart had stopped, and now a firefighter was pumping on his chest, while an EMT forced oxygen into his mouth and nose.

My partner hooked him to a cardiac monitor. The EKG looked surprisingly good. "Somebody check for a pulse," my partner said. Hands reached for the man's neck and arms. "I've got one," said one of the EMTs. "It's fast, but I can definitely feel it."

As if on cue, the patient took a deep breath. Then another. Soon he was breathing deeply and regularly. One moment he'd been dead, and the next he'd come back to life.

This doesn't happen often. Producers of movies and television shows would have you believe that CPR can save almost anyone. A character collapses, a hero performs CPR, and a few minutes later, the victim comes back to life, good as new.

But in real life, it doesn't work that way. Not without medications, anyway. CPR doesn't often bring people back from the dead. Its purpose, really, is to keep oxygen flowing through to the brain, to prevent neurological damage until the heart can be started again.

Sometimes that requires defibrillation. Sometimes, medications. But CPR alone almost never causes a silent heart to start beating again.

When the heart stops beating because of an oxygen shortage, however, and not because of a blood-clot-induced heart attack, CPR can make all the difference in the world. This is one of the few circumstances in which CPR can restore a heartbeat without any other intervention. And that's what seemed to happen this time. The patient had suffered an asthma attack, and when his heart ran out of oxygen, it stopped beating. Once the flow of oxygen was restored, the heart started beating again, giving him blood pressure and a pulse.

We lifted him to the stretcher and wheeled him out to the ambulance. He was breathing quite well by this time, though his eyes remained closed and he made no attempt to move. This troubled us. The problem had been corrected, and he hadn't been in cardiac arrest for more than a few minutes. Why wasn't he waking up?

His condition didn't change on the way to the hospital. Every so often I'd squeeze his fingertip, hoping to elicit a response to the pain. But the man never flinched. His heart was alive, but we couldn't be too sure about his brain.

"Maybe he's got a bleed," my partner said as we brought him into the emergency department. "The way he's breathing, he looks like somebody bleeding into his head. There's something about his breathing that looks like a neurological problem. If they do a CT on him, I'll bet they find a bunch of blood in his brain."

I had to admit that he was breathing like patients I've seen with ruptured aneurisms. It's funny, but after you treat enough critically sick and injured patients, you begin to identify certain conditions more through hunches than anything else. And most of the time, those hunches prove correct.

This time, though, it really didn't matter. The man had died, and we'd brought him back to life. Maybe it was a ruptured aneurism that was preventing him from waking up, or maybe he'd suffered permanent brain damage during the brief period of cardiac arrest.

But who really cares? Nobody's going to care about the cause if he spends the next forty years in a nursing home somewhere, existing in a vegetative state. His family won't care, and the patient certainly won't care. It's not the heartbeat that matters, but the brain function.

Because if we bring him back to life, but he never wakes up again, then we've won the battle, but lost the war.

Wednesday, April 29, 2009

No Sale

Someone tried to use us for propaganda just now.

We were standing outside Quincy Market, enjoying the first warm, sunny day of the year, and relishing the fact that two hours had passed without a single call coming our way. I'd parked the ambulance in front of a McDonald's. Every so often, someone would ask us for directions to the Aquarium or to Boston Garden, and that was about the only work we were doing.

A young man came out of the McDonald's. He appeared to be of college age. With his long hair, bell bottom jeans, and sandals, he looked as if he'd stepped right out of the 1960s.

"Are you here for a heart attack?" he asked in a British-sounding accent.

"No," my partner told him. "Why? Did you call to report one?"

"I just figured that you might have come here for a heart attack victim, because so many Americans are obese," he said. "And McDonald's is the reason for that obesity." He pointed to a logo on his t-shirt, which seemed to be an advertisement for a movie of some kind. "I work with these folks," he said. "We're trying to spread the word about McDonald's, and about the American public and their unhealthy ways."

I looked closely at the logo on his shirt. I didn't quite catch the name of the movie, but it looked a lot like Supersize Me. I wanted to tell him that someone had already made a movie exposing the connection between McDonald's and obesity, but I didn't. It had been a pleasant day so far, and there was no point in ruining it with an argument.

What this man didn't know was that I'd eaten in that very same McDonald's just fifteen minutes earlier. I do this four or five times a week. And yet, incredibly, I'm not obese. I'm not even heavy. I've never had a problem with high cholesterol, and I've never had a heart attack. McDonald's cheeseburgers may not be the most nutritious food in the world, but by running long distances every day, walking and biking regularly, and paying attention to the number of calories I consume, I've managed to remain healthy in spite of my frequent McDonald's excursions.

Could it be that unhealthy choices have caused Americans to become obese, rather than McDonald's? Perhaps if people exercised more, and took responsibility for the amount and types of food they ate, then they wouldn't gain weight--even if they occasionally ate fast food.

Not according to our friend. This guy had his own Gospel to spread. McDonald's is deadly. Fast food will destroy the world.

"Sorry to disappoint you," my partner said, "but we've had no heart attacks here today. Say, where are you from, anyway?"

"Australia."

"Really? What part?"

"Sydney."

"Are you here for long?"

"Yeah. For a couple of years, at least."

"Well, enjoy your stay."

"Thanks. You should check out our movie some time. When you watch it, you'll see for yourself how McDonald's is killing America with obesity." Confident that he'd helped us to see the light, he turned and strutted away.

I didn't tell him that I plan to eat there again tomorrow.

Tuesday, April 28, 2009

A Call That Went Right

At first, it didn't sound like much of an emergency. Someone had passed out, the dispatcher told us. She was awake now, but because of her age, the call had been classified as a cardiac problem.

We arrived to find the woman on the floor, right where she'd collapsed. According to another woman present, she'd been unconscious for about three minutes. When I asked if she felt any pain, she replied with a grin. "Why, no. In fact, I feel pretty good."

She hadn't been injured in the fall, but something still wasn't right. Her face was quite pale, and her clothing felt moist. As every health care provider knows, these can be ominous signs, indicating shock of some kind.

An EMT took her blood pressure. It was normal at first, but when he took it again a couple of minutes later, it had dropped to just seventy. My partner connected her to a cardiac monitor, and that's when we discovered the problem. She was indeed having a heart attack, without even feeling it. The evidence was right there on the paper.

We carried her out the door to the ambulance. I gave her some aspirin while my partner started an IV. We would have liked to given her some nitroglycerine, to open up her coronary arteries, but her blood pressure was too low for that.

On the way to the hospital, my partner started a second IV. A patient needs two IVs before undergoing cardiac catheterization. If our diagnosis was correct, and the woman was having a heart attack, the second IV would reduce the delay in going up to the cath lab.

Meanwhile, I was talking by radio to the emergency department. We wanted the staff to be ready when we arrived.

And so they were. The triage nurse looked up from her desk as we wheeled the woman into the emergency department. She didn't bother with any paperwork. "Go right in," she said. 'They're waiting for you."

Another nurse welcomed us into the treatment room. A moment later, we were joined by a pair of doctors. Having heard my report on the radio, they asked no questions. Instead, they asked to see the EKG we'd taken.

Taking it from my pocket, I handed it to one of the physicians. He was a cardiologist, I noticed. "Inferior MI," he said. "We'll go upstairs as soon as she has two IVs."

"She's already got two IVs," my partner said.

The cardiologist looked over at the patient and saw the twin plastic bags hanging from the ceiling. "Oh, good," he said. "I'll call them, to let them know we're coming, and we'll go right up."

Many things could have gone wrong on this call. Triaging the situation as a cardiac emergency was more a matter of luck than anything else, but it worked to the patient's benefit, because paramedics were dispatched immediately. We diagnosed the heart attack immediately. Both IVs went in on the first try, and the patient was totally cooperative. Triage nurses sometimes insist on taking vital signs at the door, even when the patient is dying, but this nurse had the good sense to dispense with such formalities. And the doctors actually believed us. That doesn't always happen. It's frustrating to watch the seconds tick by, as a doctor repeats all the questions and procedures we've already performed in the field. This time, though, that didn't happen. The patient went upstairs for her catheterization within thirty minutes of being wheeled into the ED.

While the cardiologist was on the phone to the cath lab, I stepped back into the patient's room to say goodbye. She was partially upright in her bed, looking perfectly healthy, and again she smiled when I wished her well.

"This is the most remarkable thing," she told me in a cheerful voice. "They tell me I'm having a heart attack. But to be honest, I feel just fine."

"This wasn't what you had in mind when you woke up today," I said.

"No," she replied, laughing a little bit. "Not at all."

Saturday, April 25, 2009

A Little Variety, Please

I want a shooting.

That sounds pretty bizarre, I know. It's not that I want anyone in particular to get shot. Or even that I want a shooting to occur. But if one Bostonian does decide to shoot another one, I'd like to respond to it.

EMTs and paramedics know what I mean by this. EMS personnel are occasionally quoted in the media as saying, "I don't want bad things to happen to people. I just want to be there when they do."

Serious emergencies are the focal point of this business. These are the things that attract people to EMS in the first place. We thrive on trauma and on critical medical conditions like myocardial infarction and cardiac arrest. Nobody becomes an EMT or paramedic to treat headaches or upset stomachs. We want to handle serious problems. Like shootings.

When you first become an EMT, every call is fascinating. Suddenly you're racing through the streets with sirens yelping and strobe lights blazing. Everyone watches as you speed past, wondering what kind of emergency you're going to. It makes no difference that your patient turns out to be an old lady who's had a toothache for the past six months. You're not a bystander anymore. You're the one who takes care of the problems.

But after a while, that's not enough. Racing through traffic becomes more stressful than exciting. You get sick of hearing the sirens. And when you get called to the same apartment for the third time in a single week, where the same old woman once again tells you she has indigestion, you begin to wish for something a little more challenging.

You begin to wish that just for once, someone would get shot.

A long time ago, before I became a paramedic for the City of Boston, I took a part-time job as a paramedic with a commercial ambulance company. Working with an equally-inexperienced partner, I would respond to 911 calls in the City of Cambridge, Massachusetts, each Saturday night.

I couldn't wait for that first call. I wanted it to be a collision. Or a stabbing. Something messy, complicated, and challenging. I couldn't wait to start my first IV and perform my first intubation. I couldn't wait to save lives.

But the hours ticked by, and nobody called 911. There were no collisions, no stabbings, no emergencies of any any kind. Nothing happened.

The following Saturday, it happened again. Eight hours--no calls. It happened again the Saturday after that, and the Saturday after that. For twelve weeks in a row, we spent eight hours driving aimlessly around the city without so much as applying a Band-Aid.

Finally, on the thirteenth Saturday, we were dispatched to a car accident. The vehicles were barely damaged, but one of the drivers wanted to be evaluated in an emergency department for shoulder pain. We stuck an IV into her during the ride--not so much because she needed any fluid, but because we needed the practice.

I'd never do that today, of course. I've started so many IVs that I'll be happy never to start another one. Thirteen weeks in a row without a call sounds pretty good right about now. But that's the difference between a rookie paramedic and an experienced one. The rookie can't wait for calls to come in. The experienced paramedic hopes for a quiet shift.

I spent my first twenty years as a City of Boston paramedic entirely on the overnight shift. Then, roughly a year ago, I switched to the evening shift. I was tired of living on such a bizarre schedule. I thought I would benefit from being awake in the daytime and sleeping in the dark, the way normal people do.

At first, I enjoyed this new routine. For the first time, I encountered patients who weren't drunk. On the night shift, everyone you treat seems to be drunk, or high, or both.

But soon I detected a pattern. Every call fell into one of three categories. We responded to cardiac calls, difficulty breathing calls, and heroin overdoses. Over and over again. Nothing else.

I realize now that I made a mistake in changing shifts. Though I'd never really thought about it before, one of the things I like best about this job is the variety of the calls we handle. You never know what you'll see next. That's what makes a paramedic's job interesting. That's what keeps it challenging.

Nowhere is that variety greater than on the overnight shift. That's when the strangest things happen. People get drunk at night, with with that drunkenness comes some bizarre behavior and bizarre situations. The night shift is by far the most interesting shift of all.

On the evening shift, we deal with the same problems, call after call, shift after shift. Chest pain, chest pain, chest pain. Asthma, asthma, asthma. Every once in a while, a heroin overdose. That's about as weird as the job gets in the evening.

It's been nearly two years since I've responded to a shooting. On the night shift, we used to see a couple of shootings every week. I'm tired of treating cardiac problems. As the old saying goes, it's not that I want anyone to get shot...

But just once, I'd like to be there when they do.

Wednesday, April 22, 2009

Emergency Departments Calling Ambulances for Emergencies

I'm on vacation this week, which means that I don't have any observations to report from the ambulance. In the meantime, an anonymous reader has suggested a topic of discussion. According to a story in the Vancouver Sun, the emergency department staff at a Vancouver hospital refused to assist a man who'd collapsed just ten feet outside the emergency department's doors. Instead, they called for an ambulance.

In the United States, this incident would have fallen within the scope of a federal law, the Emergency Medical Treatment and Active Labor Act (EMTALA). Among other things, this law requires hospitals with emergency departments to screen and stabilize patients who come to their facilities seeking help for medical conditions. Under EMTALA, a patient "comes to" an emergency department once he gets within 250 yards of it, even if he doesn't explicitly request assistance. As long as the patient appears to need treatment, the emergency department must respond.

I don't know much about Canadian health care law. I don't know whether that country has any statutes equivalent to EMTALA. It's possible, then, that a Canadian hospital may have no legal duty whatsoever to help an unconscious man right outside its door.

So, here's the question: What should hospital staff do when it learns of a medical emergency just outside of its facility? Officials at the Vancouver hospital say that these matters are best left to EMS personnel, because they are trained to deal with out-of-hospital emergencies, and hospital personnel are not. But if this is true, then why do doctors and nurses regularly intervene when encountering an emergency on the street, sometimes to the point of wresting control from more experienced EMTs and paramedics? I'm not trying to say that doctors and nurses should not get involved; it's just that both perspectives cannot be true.

EMTs and paramedics: Have you ever dealt with this issue personally? Foreign EMS personnel: How does this work where you live? Doctors, nurses, and other hospital staff: How would you handle this situation? And non-medical readers: Do you have any thoughts about this?

Here's the link:
http://www.vancouversun.com/Health/Hospital+staff+call+ambulance+outside/1517456/story.html

As always, thanks for reading.

Tuesday, April 21, 2009

Random Thoughts from the Marathon

Author's note: This post uncharacteristically has almost nothing to do with EMS.


I decided to run the Boston Marathon yesterday after all.

It went better than I'd expected it to. I trained less for this one than any previous one, so I was running simply to finish, rather than with any specific time goal in mind. I finish most marathons in a little over three hours, and this one took me just over four. It was not the slowest marathon of my life, however, and I'm glad that I did it.

As everyone who spectated knows, the weather cooperated. Well, except for the strong headwind, anyway. It didn't rain, and it was cool, but not cold. No complaints there.

In watching a recorded version of the race coverage, I got the impression that my EMS colleagues had an average day. I stopped by the finish-line tent, and it didn't look as if they were overwhelmed with patients. I'm glad about that.

Not that this has anything to do with EMS, but here are some random thoughts from along the course:

- There is nothing more inspiring than a low-altitude flyover of US Air Force fighters. I actually felt shivers when they roared over the starting line with afterburners engaged. The public address announcer said, "There goes your flyover, ladies and gentlemen. They'll cross the finish line about two minutes from now. It'll take all of you much longer than that."

- The stupidest sign along the course: Obama Says Yes We Can, But Kenya Win?" The play on words is a stretch; politics have nothing to do with the race; and given that an American man and women both had a legitimate chance at winning for the first time in fifteen years, it was terribly kind of the sign's owner to call that ability into question. How about some support for the Americans instead?

- The greatest supporters: As always, the women at Wellesley College. They are truly amazing. They turn out in huge numbers, three and four deep, regardless of the weather, and their cheering--which is not just loud, but deafening--never lets up. It's true what runners say about this--you can actually hear them from about a half-mile up the road. And then there's the tradition of enticing runners to kiss them. At least half the women held up signs that said, "Free kisses for runners"--many of which had been personalized with slogans like, "Kiss me because I'm a senior," Kiss me because I'm a first-year," and "Kiss me because I'm Japanese." My favorite, of course, was the one that read, "Kiss me because I'm sexually frustrated." Slightly apart from the main body of students were a pair of women with a slightly different angle: Their sign read, "Free kisses for lesbians." After we'd passed the students, the runner next to me--a complete stranger--said, "That almost makes me want to end my race right here. If only they'd cheer for us at about mile twenty-four!"

- Most obvious sign of an educational apocalypse: I ran for a time next to a couple in costume. The woman wore a three-corner hat, a vest, a ruffled shirt, and running shorts. She carried a brown furry hobby horse--the kind of horse-on-a-stick that kids used to pretend to ride in the old days. Her boyfriend was dressed as a British Redcoat. Every quarter-mile or so, someone--grown-ups and children alike--would shout, "I like your pirate costume!" Finally the boyfriend said to his girlfriend the patriot, "That's a sad comment on the state of education in Massachusetts today. People can't tell a patriot from a pirate!"

- I decided to run in my Army PT (physical training) uniform, consisting of a gray long-sleeved t-shirt marked "Army" on the front, and black shorts that read "Army" in white. I've worn EMS-related running clothes in marathons before, and Harvard running clothes, and even US-themed clothing at a marathon in London, but I've never received a fraction of the encouragement that people gave me yesterday. From little kids, to old people, to entire groups of semi-intoxicated college students, virtually everyone who spotted me yelled, "Go Army!" While it's true that I'm "only" a reservist, I was glad to remind people that our troops need support, and it was incredibly heartening to see just how well the spectators along the Boston Marathon responded.

That'll be my last full marathon for a while--or perhaps forever. After twenty of them, I just don't have the motivation to prepare for such a long distance any more. Instead, I'm going to keep running half marathons and shorter races--which, to be honest, I've always been much better at doing. The half marathon is my favorite event of all. I generally run at a around a seven-minute-per-mile pace, which generally puts me into the top 2-5% of all finishers.

By the way, if any of you happen to be runners, please consider running Boston's Run to Remember on May 24. You can run a half marathon or five-mile course, both of which are almost pancake-flat. Both routes provide a fantastic running tour of the city, and best of all, the proceeds benefit not only a foundation for slain Massachusetts law enforcement officers, but also a "kids at risk" program operated by Boston police officers. For more info, go to http://www.bostonsruntoremember.com/. I've run the half marathon several times, and I plan to run one or the other this year, depending on how fully I've recovered by then. Who know? Maybe I'll see some of you there!

I'm sorry that this post has strayed so far from the usual topics. I'm on vacation from EMS for the next several days, but I already have a couple of good posts in the queue. Look for them later in the week.

Monday, April 20, 2009

Marathon

Today brings the 113th running of the Boston Marathon. As of this moment, I'm still trying to decide whether to run.

No, I'm not joking. I've run the Boston Marathon four times already, and I've run nineteen marathons in all. I qualified for Boston a couple of years ago, at the Chicago Marathon. I couldn't run Boston last year because of my military duty, and so my entry was deferred to this year. I have my number, and all I need to do is show up at the start.

But I don't know whether I will.

Training this year has been difficult. Between the winter weather, military duty, and other obligations, I haven't run long distances as often as usual. Part of me wants to run today, but part of me worries that it will be a mistake to try. I'm going to wait until the last minute to make my decision.

Meanwhile, my Boston EMS colleagues will be out on the course, providing medical support to the runners and spectators. This is a massive undertaking, involving hundreds of EMS personnel, dozens of ambulances, bikes, "gators" (six-wheeled ATVs that carry a stretcher), and fully staffed medical tents. The medical tent at the finish line is always a zoo. Runners come in by wheelchair, with everything from calf cramps to heart attacks, and somehow they all receive treatment.

Even so, whenever I'm not running the marathon, I like to work at it. The last several years I've had the same assignment, patrolling the course by bike between the top of Heartbreak Hill and Cleveland Circle, about five miles from the finish. Not only does this give me a front-row seat when the leaders go by, but it allows me to people-watch while getting paid.

Of course, it's not all fun and sitting around. Sometimes there's plenty of work to do. When the race day is warm, runners get into trouble, and the number of ambulances can't possibly keep up with the demand. On a particularly warm day several years ago, I was working on the Bike Unit, and I was directed to a spot, ironically, near the Boston College Cemetery, where a runner had collapsed. He'd lapsed into unconsciousness, but with every ambulance tied up, I was on my own for a while. I started an IV, checked the runner's blood sugar (which was normal), and then just monitored his condition, since I certainly couldn't transport him on a bike. While I waited, another runner collpased right in front of me. He, too, was unconscious, so I started another IV and checked that runner's sugar as well. Forty minutes went by, but there was no good solution--despite all of the planning and all of the resources that had been dedicated to the event, there was simply too many runners getting sick, and not enough ambulances to attend to them. Fortunately, they both started to come around, and they were wide awake by the time an ambulance came to take them away.

So, for those of you running the race today, I wish you the best of luck. Hopefully, you won't have any need for the EMTs and paramedics stationed along the route, but you can take heart in the fact that they will be there if you do require their assistance.

And for those of you who come out to watch, maybe I'll pass by you, and maybe I won't.

I'm still trying to decide.

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