Being a Soldier Is a Little Like Being a Paramedic

We completed our military law training today. Two and a half months of lectures on the Uniform Code of Military Justice, and rules of engagement, and Article 15 investigations. Two and a half months of tests and homework assignments. Two and half months of nine-hour days in the classroom. We'll remain here at the Judge Advocate General's School for a few more days before leaving for combat skills training at Fort Benning.

We went through an interesting exercise this afternoon. After drawing M-16s, we went on four hours of mock patrols along a Virginia river. Along the way, we encountered faculty members, dressed sometimes as farmers, sometimes as rebel militia forces, and sometimes as uniformed enemy troops. Some of them were armed with handguns and others with AK-47s. One carried a rocket launcher.

The faculty members played their roles well. They know how rebels and farmers act in foreign countries, because all of them have deployed to Bosnia, and Afghanistan, and Iraq. They know what it's like to go on patrol for real--to encounter genuine troops, armed with loaded weapons.

This made the scenes quite realistic. They shouted at us in Arabic, and they refused to follow our orders to drop their weapons. At one point, a "rebel" came a little too close, waving his AK-47. He started to walk behind us. We haven't had any training in tactics yet--we'll get that in the coming month, at Fort Benning--but even to my untrained eye, this seemed problematic. As a paramedic, you learn quickly not to let anyone get behind you during a hostile situation. That's a good way to get killed.

I ordered the "rebel" to step back. He kept coming. I lunged for his weapon, and in the struggle, he managed to get off a couple of "shots" that killed two of our people. I tackled him, though, and after he'd been subdued, we discovered a handgun and a bomb hidden in his clothing. His plan all along had been to infiltrate our line and kill us. Only my instincts as a paramedic kept him from succeeding.

After the exercise ended, one of my classmates complimented me on my quick thinking. He knows what I do in my civilian life, and he wondered if it had been my paramedic experience that had allowed me to recognize the threat. And, of course, he was right.

It was a valuable exercise. It was nothing like real combat, obviously, where 18-year-old soldiers encounter real enemies carrying real weapons. And where, if they make a mistake, people will die. But it gave us a small taste of just how stressful combat activity can be. And that was one of the major points the faculty wanted to teach us, of course.

I didn't mention my comparison of paramedic work and soldiering to anyone else in the class. Some of my classmates have already gone through the real thing, as enlisted personnel in the Middle East. Working as a paramedic can be dangerous at times, but it's nothing compared to the danger of combat, and I didn't want any of them to think I was making that comparison.

There are similarities, though. Of that I'm certain. Both jobs require you to remain vigilant; otherwise, you can get killed. Both jobs require immediate decisions in chaotic situations.

And, as I learned today after tackling a Lieutenant Colonel dressed as an Iraqi rebel, both can end with the good guy taking down the bad guy--or, if the good guy isn't careful, the other way around.

I Tried

I tried to keep the blog going while I was away on active duty. Other EMS personnel have been great about contributing material in my absence. Unfortunately, I'm discovering that I don't have enough time to blog--not even to edit other people's stories. We're just too busy.

I'm not sure what this means for the long term. I suppose it means we're right back where we began--not knowing whether this blog will continue or not. Maybe I'll have time to blog after I return home in June. Maybe not. Maybe I'll feel like it. Maybe not. Maybe those of you who have been so great about reading will check back in. Maybe not. We'll just have to wait and see.

No matter what happens, it's been a great pleasure hosting this site so far. I'm amazed at the number of you who became regular readers. The discussions spawned by your comments have been fascinating. It's certainly been an interesting experience.

Thanks again.

--TS

Interview on NPR

Shortly before I left for active duty, National Public Radio's Robin Young interviewed me for a segment on a nationally-syndicated noontime program called Here and Now. It turns out that Robin's intern has become a big fan of this blog, and thought it would make a good feature.

Anyway, it took a while, but the program was finally edited and broadcast. In it, I discuss the idea of blogging as a paramedic, as well as the good and bad aspects of the job.

If you're interested in listening, it's available online. Go to http://www.here-now.org/, click on "Archives" (a button on the left side of the page), and navigate to the air date, March 18. My segment is about 33 minutes into the show. There's a digital clock at the bottom to use as a scale. I don't think I said anything terribly foolish, but you can judge for yourself.

The Time Has Come

Those who have been reading this blog for a while know that I'm about to leave for a while. Since the beginning of December, I've been a first lieutenant in the U.S. Army's Judge Advocate General's (JAG) Corps. I've been training monthly with a local reserve unit, but now the time has come to go on a status the army calls "active duty for training." I'll be gone until mid-June, first in Virginia, and then at Fort Benning, Georgia.

Tomorrow I plan to get up early, to go skiing with my family. Then, in the late afternoon, I'll begin the thirteen-hour drive south. I don't actually have to report until Sunday, so I'll have plenty of time to get there without any stress.

I leave with a combination of sadness, excitement, and fear. Sadness, because I'll miss my family--and they'll miss me. I won't be gone for long, but this will be the longest we've ever been separated.

I'm excited because I look forward to the challenge. I'll learn a lot about military law, and about soldiering, too. I look forward to the physical challenge. I love to run, and I've worked hard to get the rest of body in shape. Hopefully, this will pay off as I train beside people much younger than me.

I don't mind admitting that I'm a little scared, too. I don't mean that I'm scared to go, or that I'm scared of what they'll do to me down there. It's not as if I'm going straight into combat, after all. But with any challenge comes a fear of failure. I want to do well. As long as this feeling remains small, I figure it's normal.

A small number of people at work wished me well this week. Most, I think, didn't even realize I was going anywhere. Perhaps because of my own strong feelings of self-consciousness, I felt a little uneasy accepting certain compliments. It was nice to hear some people say, "Good luck," or "Have fun." But when one of my coworkers asked if any kind of going-away party had been planned, I felt rather silly. I appreciated the sentiment, of course, but as I said at the time, "It's not as if I'm going to Iraq. I'm going south, to keep the Commonwealth of Virginia safe from terrorism!"

Let's save the compliments for the people being sent to Iraq and Afghanistan, and for those who must leave their families behind for assignments in Germany and Korea. Those are the people who really deserve the praise. Again, thanks for reading, and thanks for commenting. I would have quit doing this a long time ago, but I have too much fun reading your responses. Your participation has definitely been the best part of this little project.

Collision With A Twist

Whenever a car rolls over, there is a risk of serious injury. Occupants get tossed around, smashing their heads against windshields, and their chests against steering wheels and dashboards. For this reason, in Boston, paramedics are dispatched along with EMTs to all rollovers.

This one happened on Storrow Drive, the parkway that runs along the Charles River. Wreckage blocked both lanes, backing up traffic for more than a mile. It took us a while to weave through the stopped vehicles. We arrived to find two cars smashed, with two drivers standing in the breakdown lane.

Climbing down from the cab, I surveyed the damage. One car had a dent in its right rear corner. The other had been damaged on all four sides. The dents were not deep, which would have suggested severe impact, but all of the windows had blown out and the roof was dented inward. Skid marks on the asphalt led to skid marks on a concrete retaining wall. Obviously, one of the vehicles had both rolled and spun, hitting the wall and the other vehicle in the process.

Troopers were interviewing the drivers. The owner of the car with little damage denied being injured. He didn’t even want us to look at him.

The other man said his shoulder hurt.

“Your car’s pretty banged up,” I said. “How fast were you going?”

“I’m not sure,” he replied. “I stopped looking at the speedometer when it went over a hundred.”

“I’ll get the immobilization stuff,” I said to my partner. Anybody going that fast must be presumed injured until x-rays and a CT scan prove otherwise.

Soon we had him strapped to the board in the back of the ambulance. Incredibly, he didn’t have a scratch on his face. “He’s bleeding from someplace,” one of the EMTs said. “There’s blood on his pants.”

The man was cooperative but extremely hyperactive. He kept trying to sit up. As I gently pulled him back down, I saw blood on his hand. Turning it over, I saw a series of parallel slice marks on his wrist. His other wrist had similar cuts.

“Did you cut your wrists on purpose?” I asked.

“Why, yes,” he said, smiling the way some people do when they’re drunk.

“Is that why you were going so fast? Were you trying to kill yourself?”

“Yes, I was. I want to die. Will you please stick a needle in me and give me some poison?”

I shook my head and tried not to laugh. I don’t believe suicide is a funny matter, of course. But the man was acting so happy that it was hard to take him seriously.

“I’m sorry,” I finally told him. “You know, I’d really like to help you with that, but I can’t.”

“Please? I think it would be a good idea. You can do it. Just give me a needle.”

It was the strangest situation. I’ve had conversations like this with people who were weeping, but never with people who were grinning.

“When did you cut your wrists?” I asked.

“An hour ago. I’ve been very sad lately. So I smoked some marijuana, and drank some beer, and cut myself.”

“And then you drove fast.”

“Yes. And then I drove fast.”

We started toward the hospital. On the way, I started an IV. He remained strangely cooperative, not even flinching as the needle punctured his skin. There was none of the drama of the usual suicide attempt.

He remained in the hospital’s trauma room just long enough for a cursory examination. Then it was off to the CT machine for a head-to-toe internal exam.

I was just about to leave when a trooper walked in. He gathered the usual information—the name of the patient, the name of the doctor, the names of my partner and me. Then he smiled. “I feel sorry for the poor bastard in the other car,” he said.

I asked why.

“The guy was driving along, and he saw the flash of headlights in his mirror. He looked back, and there was this car, rolling end over end, catching up to him. He’s doing sixty miles an hour, and the car actually smashes into him from behind as it rolls along. Scared the shit out of him.”

I laughed. What had begun as an ordinary collision had turned into something quite bizarre.

One of the emergency department nurses made a very astute observation, though.

“This would never happen to any of us,” she said. “Only somebody trying to kill himself could hit a wall and another car at a hundred miles an hour—then walk away without even getting hurt.”

Take a Chance

This is supposed to be a diary. There are plenty of blogs that compile the latest medical news, and in particular, EMS news. I don't intend this to become one of them. Sadly, I have to confess that I don't even follow medical news all that closely. I just do what the experts tell me to do. And then, sometimes, I write about it.

Today, though, I think I'll make an exception.

Not long ago, in response to an entry I posted about people who call ambulances when they aren't seriously ill, one reader suggested that the city staff a van to pick these people up. Apparently, somebody in Dallas had the same idea.

This morning, a coworker of mine passed along an article from yesterday's Dallas Morning News, in which the fire chief of that city, who also oversees rescue and ambulance services, announced plans to implement an "alternative transportation program." Under this system, a van would pick up multiple, non-actute patients and bring them to the hospital. Since vans can pick up several people at once, this will likely have a huge affect on ambulance availability.

I think it's a wonderful idea. Everybody gets to the hospital, the city saves money by handling more calls with less emergency vehicles, and ambulances respond more quickly to the real emergencies, where they belong. If it works, then maybe we'll follow suit and adopt a similar program here in Boston.

Of course, concerns over liability might cause this whole thing to fall apart. All it takes is one sick patient, mistakenly referred to the van instead of the ambulance, to draw criticism from the public and perhaps an enormous lawsuit.

Still, I think it's worth the effort.

In EMS, nothing is ever certain. Lacking x-rays, and CT scans, and laboratory testing, EMTs and paramedics provide treatment based on what they think is wrong with the patient. Sometimes you guess correctly, and sometimes you don't. But taking a guess is certainly better than waiting to be certain. The alternative is to deliver the patient to the hospital with no treatment at all.

The same holds true for dispatching. All an EMS dispatcher can do is ask some questions, take a guess at what's going on, and send what seems to be the most appropriate resources. You could treat every call like a life-threatening emergency, of course, and hurl all of your resources at it--fire engines, police cars, ambulances, paramedics. But that's a lousy solution. These days, in big cities especially, there are just too many 911 calls to get away with such a shortsighted plan. Before long, all of your resources are tied up, and when somebody gets really sick, there's nobody left to send.

And yet, in too many cities, that's exactly what happens. We do it right here in Boston. This isn't the fault of the dispatcher, certainly. He or she must follow orders from above. It's not even the fault of the patient. Sick people don't know anything about triage or ambulance utilization rates. Most of the time, they don't even know the difference between EMTs and paramedics. They only want to get to the hospital.

No plan will ever be perfect. But it seems to me that a certain amount of risk is necessary. Only by taking some chances can we do the most good for the most people--or, to be more accurate, the most good for the sickest people. And if that means taking a chance by dispatching a van instead of an ambulance, then so be it.

But what do I know? It's not my job on the line here. I'm not the one who'll have to answer if the city gets sued. I'm not a chief. I'm not even a supervisor.

In fact, most of the people I bring to the hospital each night think of me only as an ambulance driver.


Link to the Dallas Morning News article about proposed changes to Fire-Rescue service:
http://www.guidelive.com/sharedcontent/dws/dn/latestnews/stories/020508dnmetfireneedsfolo.33daa1d.html

Who Knows?

We found him unconscious on the sidewalk, a heavyset man in several layers of clothing. Nobody knew what had happened to him, exactly. One of the cops said something about a fight, and that was all.

With the help of some firefighters, we rolled him onto an immobilization board. We lifted him onto the stretcher and into the ambulance. Only then did I realize just how heavy he was.

Inside, I looked closely at his eyes. They were open slightly. I touched my hand to his eyelashes. Normally this will cause the patient to blink. This guy didn’t react at all. He was deeply unconscious.

I slipped a plastic tube, known as an oropharyngeal airway, into his mouth. This device keeps the tongue away from the back of the throat, helping to ensure that breathing will not be cut off. It’s easier to insert than an endotracheal tube, though it doesn’t prevent the patient from choking if he happens to throw up. Oropharyngeal airways do serve one other useful purpose, however. Patients who aren’t truly unconscious will immediately begin to gag, making it easy to detect those who only pretend to be unresponsive.

The man didn’t reach up to pull it out. He didn’t gag. He just lay there, snoring.

I strapped an oxygen mask to his face.

Meanwhile, my partner had been cutting away the man’s clothing. We checked him front and back, head to toe, but couldn’t find much evidence of injury. He had a fresh scrape on his lower lip, but that was all.

We continued to search for anything might explain his condition. In the pocket of his jacket, we found an empty syringe.

“Kind of big for a junkie, isn’t he?” I asked. My partner nodded. Heroin addicts always seem to be scrawny, because they spend all their meal money on drugs.

We kept looking. From another pocket I pulled out an empty pill bottle. The prescription for antidepressants, which should have lasted two months, had been filled just twelve days earlier. We added “prescription medication overdose” to the list of possible causes.

His odor reeked of alcohol. His pupils were big. If he was unconscious from a heroin overdose, they should have been small. Then again, with booze and antidepressants flowing through his body, anything was possible. Those might have competed with the heroin, potentially dilating his pupils. We decided to give him some Narcan, the antidote for a heroin overdose. If he woke up, we’d know his problem lay elsewhere.

As we waited for a response, a cop came to the side door of the ambulance. “Where are you going to take him?” she asked.

“To the hospital,” said.

The cop smirked. “Very funny. Which one?”

I told her a destination. She thanked me and closed the door. We drove away.

Halfway to the emergency department, the man stirred. Groaning, he reached up with his hands. I looked at his pupils. They were no bigger than they had been earlier. Maybe he was waking up from the Narcan, or maybe it was just a coincidence.

“You’re in the back of an ambulance, I told him. “Don’t try to sit up.”

He seemed to relax.

“Do you remember what happened to you?”

He grimaced. “Got hit with a pipe.”

“In the face? You have a split lip.”

“Yeah.”

“What did the guy look like? The police will want to know.”

“Didn’t see him.”

“He hit you in the face with a pipe, and you didn’t see him? How is that possible?”

“Don’t know. I just didn’t see him.”

We were almost at the hospital. The patient had lapsed back into unresponsiveness. “That’s not much of an injury for getting hit with a pipe,” my partner said as we backed up to the ambulance entrance.

“Maybe it was a little pipe. The kind you smoke.”

My partner laughed.

We wheeled the man inside. The triage nurse stared at his face. “What’s this guy’s name?” he asked. “He looks familiar.”

“Forsythe,” I told him. “Peter Forsythe.”

The nurse shook his head. “Oh, yeah. Now I remember. He was just here a couple of days ago. He was obnoxious.”

“An intoxicated, drug-addicted combatant, obnoxious? No way.”

The nurse laughed. “He’s a real beauty. When he was here the other day, he pissed on another patient.”

“Great.”

We brought him into a treatment room and slid him, board and all, onto the gurney. He remained more or less unconscious.

Whether it was the alcohol, a head injury, the heroin, or antidepressants that had made him that way, we really didn’t know.

Conversation with a Victim

Several months ago, sometime during the summer, we responded to a stabbing in Chinatown. I used to see stabbings all the time on the night shift, but on evenings, trauma happens only rarely.

A roving citizens' patrol had found the man unconscious in the doorway of a restaurant. The patrol flagged down one of our ambulances, which just happened to be passing by. Seeing the pool of blood on the sidewalk, the EMTs requested us.

We arrived to find the victim nearly dead from a chest wound. He'd lost practically all of his blood, and was already in the ambulance, not breathing. One of the EMTs squeezed oxygen into his lungs with an Ambu bag. The other was about to tape a dressing over the hole near the man's heart, but then he decided against it, because there wasn't any point. The man had lost so much blood that there wasn't anything left to come out of the hole.

We started an IV on the way to the hospital. This brought the victim's blood pressure up, and he began to stir. He pushed away the Ambu bag. Then I noticed a bulge on the wall of his chest. The knife had punctured his lung. Air was filling the space beneath his skin, causing his lung to collapse.

I plunged a huge IV needle into his chest. The man groaned. Barbaric as this practice might sound, it was necessary. By relieving the pressure beneath the skin, we kept his lung from collapsing further.

The man was awake now. His condition had improved, but there was no guarantee of survival. Realizing that I might be the last person ever to speak to him, I asked who'd stabbed him.

"A Latino," he said.

"Do you know his name?"

The man shook his head. "Never mind. I'll take care of it myself."

I felt like telling him that he might not live that long. But of course I couldn't do that. We rode the rest of the way in silence.

At the emergency department, x-rays confirmed our suspicions. The man had suffered a collpsed lung. The knife had punctured a major artery. He went to the operating room even before we'd cleaned the blood from the back of the ambulance.

This afternoon, as I returned home from an errand, my cell phone buzzed. It was a call from EMS headquarters. The Suffolk County District Attorney's Office needed me in a courtroom immediately.

I soon discovered why. Detectives of the Boston Police Department had caught the man responsible for the stabbing. Originally he was charged with attempted murder, but since the state couldn't prove that he'd meant for the victim to die, the charge was reduced to assault and battery with a dangerous weapon. The assistant district attorney had offered a two-year sentence in exchange for a guilty plea, and the assailant had taken it. But today, at the last minute, he changed his mind. The case was going to trial after all, and I was to be the first witness.

I rushed home and threw on a uniform. Off I went to the courthouse.

Walking into the courtroom, I was surprised to find it nearly empty. The prosecutor was there, along with the detective who'd worked the case, and that was it. No judge, no defendant, no other witnesses.

The prosecutor apologized. "We might have a plea after all," she said. "We offered him a lower sentence. Take a seat. We'll know for sure in a minute."

The judge entered. He shuffled through some papers. "A year for a stabbing?" he said gruffly, glaring at the prosecutor. "And the victim almost died? I can't approve this."

The prosecutor, a young woman, looked up at him and shrugged, embarrassed. "He doesn't have any prior record, Your Honor."

The judge read some more. "No. I'm not going to approve this deal. This trivializes the amount of damage that was done. The victim spent seventeen days in the hospital. This fellow is fortunate to be alive."

He put the papers down and looked at the two attorneys before him. "I'm going to break for lunch. See if you can work out something better."

The prosecutor conferred with the lawyer for the defendant. Then she came over to me. She apologized for the delay, but said she was still optimistic about a guilty plea. I was to come back in an hour, when court would again be in session.

I went downstairs and bought a soda. I read for a while on a bench in the corridor. Always bring a book to court, I've learned. There's always a delay of one kind or another.

At the appointed time, I returned to the courtroom. This time, in addition to the detective, a young man was sitting in the gallery. I had no idea who he was.

The judge took the bench. A court officer led a man into the room in handcuffs. He was Hispanic, just as the victim had told me on the evening of the stabbing.

"So, we have a deal, then?" the judge asked.

"Yes, Your Honor," the prosecutor said. "Two-and-a-half years, one year to be served."

The judge shook his head. "I still don't know about this," he said. He looked at the prosecutor. "It still seems light. The Commonwealth is satisfied with this?"

"Yes, Your Honor."

"Okay." He turned and faced the man in handcuffs. "You've talked this over with your attorney?" he asked. "And you've agreed to the terms?"

A translator spoke to the defendant in Spanish. "Yes," the translator said.

"And you realize that if you mess up while on probation, I'll not hestitate a second before sending you back to prison for the entire term of the sentence?"

Another exchange in Spanish. "Yes," said the interpretor.

"You realize, too, that by pleading guilty, you may be subject to deportation?"

"Yes."

"Does the victim wish to make an impact statement?" the judge asked.

The prosecutor turned to the man sitting behind me. "Do you want to say anything to the judge?"

"No," the man said. "I'm good."

"The victim declines to make a statement, Your Honor."

"Very well," said the judge. He turned to the defendant. "Sir, I find you guilty of assault and battery with a dangerous weapon. I sentence you to thirty months in the house of correction, one year to be served. The rest of the sentence is suspended."

He banged his gavel and left the courtroom. The defendant was led out a side door and off to jail.

The prosecutor came back to the gallery. She thanked me for coming. Then she motioned to the man who had declined to speak. "This is Alphonse Pacheco," she said. "He's the man who was stabbed." Motioning to me, she said, "This is one of the paramedics who worked on you."

The victim shook my hand. "Thanks," he said.

"Last time I saw you, you were more or less dead," I told him.

He looked surprised. "Really?"

"Oh, yeah. I didn't think you were going to survive the ride to the hospital."

"No shit. I had no idea I was that bad."

We continued to talk as we strolled to the elevator. It was odd speaking to someone we'd treated. We often testify at trial, but rarely get to interact with the victims afterward.

"What I don't understand," he said as we left the building, "was why he got such little time. I mean, a year? He's already been in jail for eight months. That means he'll be out in just four months, right?"

"Yeah, I guess so."

"How is that possible? I almost get killed, and he's going to stay in jail for just four months after the trial? That's nuts."

"It just goes to show you how much crime we have in this country," I told him. "The prisons are so full that almost killing someone doesn't mean very much. To get a long sentence, you actually have to kill the person. But, hey, the important thing is that you're lucky to be alive. If that citizens' patrol didn't find you, you would have been dead, no question about it."

He shook his head and thought about this for a moment. "Yeah," he finally said. Then he thought some more. "The cops told me he came into this country illegally. Are they going to deport him?"

I shrugged. "I really don't know."

"Why wouldn't they deport him? He tried to kill me."

"I wish I could tell you. There are a lot of apologists out there. People who'll say, 'He needs to stay here. Conditions are tough in his home country.' They think everyone should be allowed to stay here, no matter how they act."

"You know, he stabbed two other people that night."

"Really? Nobody told me about that."

"Yeah. They refused to talk to the police. I was the only one who did."

"Well, thank you for doing that. I'm glad you changed your mind about going after him yourself."

He gave me a curious look.

"That night in the ambulace, you wouldn't tell me who stabbed you. You said you'd handle it yourself."

The man grinned. "Yeah. That sounds like something I'd say."

"Well, it's a good thing you didn't. At least he's got a record now. If something like this happens again, he'll get a much longer sentence."

The man shrugged. "Yeah. I suppose."

At this point, he stopped walking. Again he shook my hand. "I'm going to catch the subway across the street," he said. "Thanks again for helping me."

"No problem," I told him. "Take care of yourself."

"I'll try."

He jogged across the street. Continuing on, I found myself thinking about the outcome. To be honest, it didn't make me feel very safe. I mean, we're not talking about a property crime here. We're not talking about a punch in the nose. We're talking about a guy who snuck into the country illegally and plunged a knife into the chest of an American citizen, nearly killing him in the process. And yet, incredibly, he'll be back on the street even before the current school semester ends.

What does this say about the kind of people who roam our streets? Sure, the jails are crowded. And for political reasons, deportation isn't especially popular right now. But what, exactly, does it take to remove someone from the American population for a prolonged period nowadays?

Apparently, an awful lot. More than attempted murder, anyway.

I Didn't Bash the Diversity Program

In responding to comments left by readers of this blog, I normally add my responses to the "comments" section, along with the readers' observations. I'm making an exception this time, though, because I want to be sure that a couple of readers see this response.

Specifically, I would like to respond to two of my coworkers, who didn't seem to think very much of my most recent post. I'd like to bring to their attention a couple of subtle, yet important points--points you seem to have missed.

First, I agree that since I did not personally attend the diversity workshop, I cannot be certain about what happened there. But I never pretended that I could. To the contrary, I made it clear that I was describing the incident as it was described to me.

Both of you seem to think that I was bashing this project. At least one of you thinks I acted like a gossipmonger. And you're entitled to your opinion. But I don't believe I did either of those things.

I direct your attention to the third paragraph from the end, where I say, "Don't get me wrong. I'm not saying that participation in diversity-awareness training by EMS personnel is a bad idea." I draw your attention, also, to the paragraph in italics, where I admit that I'm no expert in this area, and where I ask people whether they think this program might do any good.

Does this really sound like someone who's bashing a project maliciously? I don't think it does. I think it sounds like somebody who is questioning the methods employed, and is anxious to learn more about them. In fact, if you look at the very last sentence of this post, you'll see that I went out of my way to solicit the opinions of experts in this field--people who obviously know more about this than I do.

Did I discourage anyone who participated in this program from commenting? No, not in the least. Maybe somebody can provide a glowing report about how much was accomplished. I'll gladly post it right here.

I'm sorry, but I disagree with your contention that I bashed this program just for the sake of complaining. That wasn't my intent, and that's not what I did.

Please, read that post again, and read it carefully this time. I did not say that that the program was a bad idea. I only questioned its timing. Let's not forget: This program was funded with overtime money at a time when Boston EMS is terribly shorthanded. We can justify it only if the program is likely to produce some results. And that's exactly what I asked about. I asked whether people familiar with diversity training thought this kind of approach, which strikes me as somewhat unorthodox, might actually produce some results.

If it will, then I'm completely in favor of it.

In any event, I was questioning a program, not bashing it, and there's nothing wrong with that.

One Potato, Two Potato

As much as anyone, the EMTs and paramedics of Boston recognize the connection between racism and violence. We respond to a fair number of shootings, stabbings, and brawls—events that commonly arise from racially motivated anger.

And that is why, when the Boston Public Health Commission earlier this week sought volunteers from among our ranks to participate in a diversity-awareness program for school kids, several Boston EMS personnel agreed to participate.

The program would work like this: Students from several Boston middle schools would be bussed to a ski area north of the city. There they would watch a film about tolerance. Afterward, they would take part in discussions and exercises with EMTs and paramedics who had been removed from ambulances for the day. The EMS personnel would serve as mentors, or at least as positive role models. And when they were done, they’d all go skiing and snowboarding together.

It sounded like a pretty good idea. Who knows? Maybe it would change the way some of these kids thought, and perhaps even prevent some violence in the future.

But at least one of our EMTs wasn’t so sure.

“Did you hear what they did at that diversity program?” he asked me after the group had returned from the ski area.

I told him that I hadn’t.

“They watched a movie. It was called Blue Eyes, Brown Eyes, or something like that. It was about a classroom where the teacher tells her students that all the kids with brown eyes are dumb. Then, the next day, she tells them she made a mistake. It’s the blue-eyed kids who are dumb. This is supposed to get them thinking about the way we perceive other people on the basis of physical appearance.”

He went on. “So, they get up to this ski area, and everybody sits in a circle, the EMTs along with the students. Everybody is handed a potato. They are told to name their potatoes, and to give them a personality.” He paused for a moment. “Now, these are middle-school students, mind you. Kids thirteen, fourteen years old.

“Next they were supposed to introduce their potatoes to other people in the group. They were supposed to learn about other kids’ potatoes, too. The potatoes were supposed to interact. Get to know one another. After that, they had to introduce their potatoes to the group, telling everyone how their potatoes act, and what they look like, and how they dress.

“Then somebody gives them a big sack. They put all the potatoes into it. The leader shakes up the potatoes and dumps them out all over the floor. Everybody was supposed to find his own potato.”

“That’s it?” I asked. “They travelled all the way to New Hampshire to throw a bunch of potatoes on the floor and see if they could identify the one they’d been given?”

“Yeah. And then they went skiing and boarding for the rest of the day. I heard about this from somebody who'd participated in it. He was talking all seriously about the course. But me, I was covering my face because I was laughing so hard. I mean, introducing potatoes to one another? And this is going to stop one gangbanger from shooting another one? Come on. Let’s be serious.”

We have to start somewhere, I suppose. I’m sure there are plenty of experts who will swear that this potato-matchmaking exercise improves interpersonal communication and reduces the likelihood of violence by instilling a sense of diversity awareness in the young participants. Personally, I don’t see it, but then again, I’m not a sociologist.

If this program gets even one kid to think twice before pulling a trigger, then I guess the whole day was worth it. If nothing else, a handful of soon-to-be high schoolers had a chance to go skiing with EMTs and paramedics. Hopefully, they learned that these men and women aren’t such bad people after all, and they’ll remember this the next time a couple of them come to their neighborhood in the aftermath of a shooting, or a stabbing, or a domestic abuse situation.

Still, there are realities to consider. Boston EMS has been hemorrhaging personnel of late, with EMTs and paramedics quitting every week to become firefighters, and police officers, or to get out of emergency work altogether. There are many reasons for this: the ever-growing call volume, the constant implementation of new regulations that have made the job more difficult, the lack of promotional opportunities, and the lack of respect we receive from the public.

As a result, we have a massive shortage of field personnel right now. Many shifts, EMTs and paramedics are being forced to remain on duty because we don’t have enough bodies to keep the ambulances running. Twenty new EMTs have just been hired. Forty more will soon begin training, and we’ve begun to hear rumors that ten paramedics will soon be selected. Clearly we need more help.

And in the middle of all of this, we’re reassigning field personnel to New Hampshire to play with potatoes and go skiing.

Don’t get me wrong. I’m not saying that participation in diversity-awareness training by EMS personnel is a bad idea. I appreciate the fact that diversity training may eventually have an effect on the level of violence in this city. That, in the long run, that will make our city safer and our jobs easier. We have to start someplace. In theory, it’s a great idea.

But this whole thing seemed a little bizarre to me. Simply put, at a time when we don’t have nearly enough people to respond to potentially life threatening emergencies, we’re diverting some of our resources to give names to potatoes at a ski area in the North Country.

The EMT who initiated this discussion left the station shaking his head at the priorities of this place. And I'm not really sure that I disagree with him.


As I said, I'm not a sociologist. Nor do I have a teaching certificate, or any training in psychology or violence prevention. But I'd be interested in knowing what you think. Does this program seem worthwhile? Will it do any good? Feel free to express your opinion, especially if you have expertise in one of these areas.

A Train Wreck of the Medical Variety

Every so often, in between ordinary calls, we’ll see a patient with a truly mysterious problem.

That happened tonight.

Earlier in the day, the woman had gone by taxi to an East Boston health center. That probably was a mistake. She should have gone to a hospital.

She complained of pain in her back. It hurt so much, she said, that she was having trouble catching her breath. This had begun at 10:00 in the morning, gradually worsening through the day. By the time she arrived at the health center, she was screaming in pain.

This type of pain has many causes. It could have been a heart attack. Or pancreatitis. Gallbladder inflammation. A kidney stone. The list goes on forever.

The doctor at the health center immediately diagnosed pulmonary embolism, a blood clot that forms in the blood vessel leading to the lung that prevents oxygen from reaching the body. Untreated, this condition can prove fatal.

It wasn’t necessarily a bad thing to consider. The woman happened to be pregnant, and pregnancy increases the likelihood that such clots will form. Also, as a female, she had an increased risk of pulmonary embolism. Women develop this problem more often than men do.

But as we examined the patient, some pieces of the puzzle didn’t seem to fit. For one thing, she wasn’t gasping for air. Since a blood clot in the lung keeps oxygen from reaching the body, patients typically will have a sense that they are suffocating, even though plenty of air is moving in and out of their lungs.

Also, a useful device known as a pulse oximeter, which clips to the finger and scans the blood as it passes through the capillaries, indicated that 99% of her blood cells had oxygen molecules attached to them. Her body could barely hold any more oxygen, no matter how quickly she breathed. Since she was absorbing oxygen so well, a clot in her lung didn’t seem likely.

But the doctor ignored these facts. Instead, he relied on a single laboratory test, something called a “D-dimer” test, which detects inappropriate coagulation of the blood. This woman’s D-dimer was elevated, and for the doctor, that was enough. He panicked, ordering the nurse to call 911 to have the woman rushed immediately by ambulance to a hospital.

There was just one problem with this decision. The D-dimer level rises not only when the patient has a pulmonary embolism, but also when she has been subjected to trauma, or infection, or pregnancy.

Being thirty weeks pregnant, it was entirely possible that her D-dimer had been elevated all along.

And pregnancy wasn’t the only condition that might have skewed her results. The woman was a medical train wreck. Looking at the records prepared by the health center staff, I learned that she was a longtime heroin addict. And a diabetic. She’d suffered nerve damage after failing to take her diabetes medications.

But that wasn’t all. She had venereal disease, too. And an enlarged heart. And liver failure. And depression. About the only disease she didn’t have was AIDS.

She had the medical record of a ninety-year-old. Yet she was only thirty-nine.

The doctor wanted her out of his health center. To the EMTs who’d arrived before us, he said, “Here’s the chart. Take her to the hospital. Go.” To expedite things, he’d already called the hospital and told the doctor in the emergency department to expect her. We pulled up to the health center just as the EMTs were wheeling her outside.

The woman was jumping around on the stretcher, shrieking in pain. “Good God! Make it stop! Oh my God! It hurts so much!”

“Have you ever had this pain before?” I asked.

“Yeah, once!” she bellowed. “When I had pneumonia. Owww! Make it stop!”

“Is there any chance you're in labor?”

“No! God, it hurts!”

“You’re not bleeding or anything like that?”

“No. It just hurts!”

The health center nurse had already started an IV. All we had to do was drive her to the hospital.

“How many times have you been pregnant?” I asked as we started downtown. I wondered if she would recognize labor pains when she felt them.

“Eight times,” she gasped. “I have four children.”

Eight pregnancies. If anyone knew what contractions felt like, it was this woman.

Going through the tunnel, I had time to review the woman’s charts. The doctor, it seemed, hadn’t called the emergency department, as he'd told us. There was a notation that he’d talked to Labor and Delivery, and that she was supposed to go up there. This made no sense at all. Labor and Delivery was no place for a woman with a pulmonary embolism. And if the doctor didn’t really think it was an embolism, then why the big rush to get her into the hospital?

I kept reading. The woman was unemployed. She was on welfare. Eight times she’d been pregnant. She’d retained custody of all four of her children despite being a drug addict. I couldn’t help wondering if she was a prostitute. That would explain the venereal disease and repeated pregnancies.

Under “Elective Procedures,” there appeared an entry that read, “Saline breast inserts.” This amazed me. The woman was an unemployed junkie who had remained pregnant during most of her adult life. She and her children were on welfare. But somehow she’d come up with the money for a boob job.

I decided to call the hospital myself, to see what they wanted us to do with her. The nurse who answered the radio consulted with a doctor. Together they decided to treat the woman in an emergency department trauma room.

The woman continued to scream as we wheeled her inside. She quickly became a curiosity. Doctors and nurses and medical students streamed into the room until finally some had to be shooed out.

“Maybe she’s abrupting,” one resident said, referring to the painful, premature separation of a placenta from the uterus.

An echocardiogram machine was wheeled in. Two dozen doctors and medical students gawked as an obstetrics resident scanned the woman’s huge belly. Everyone wondered what it would show. The resident searched and searched, but couldn’t seem to find anything amiss. “Um, well…there’s a baby in there,” she said tentatively.

I couldn’t resist. “Four years of medical school taught you that?” I asked. Several of the other doctors snickered. The resident shot me a nasty look.

“I can’t find anything wrong,” she finally said, turning off the machine. “Normal fetus. Normal fetal heartbeat. Looks like an ordinary pregnancy. Has anybody checked to see if she’s actually in labor?”

“I just did a pelvic exam,” an emergency medicine resident said. “She’s one centimeter dilated. She’s certainly not far enough into labor to explain all that pain.”

Finally we had to leave. We moved on to other calls, but I kept wondering what was really going on with that woman. In the closing minutes of the shift, I did something I haven’t done in years. I called the hospital to ask about the diagnosis.

It wasn’t a pulmonary embolism. It wasn’t an abruption. She didn’t have a kidney stone, and she wasn’t in active labor. The hospital had admitted her to the Labor and Delivery floor, but nobody had the slightest idea what was wrong with her. Ten hours after seeking help, she still hadn’t been diagnosed.

Some patients are just mysterious that way.

He Broke His Parents' Hearts

The man on the floor was dead, and he wasn't coming back. Because he was young, though, and because his body was still warm, we had to make the effort.

I knelt on the floor and looked into his throat with a laryngoscope. Watery vomit spilled out of his mouth. Rather than wasting my time with the suction machine, I tilted his head to the side and absorbed the fluid with the man's t-shirt. He wasn't going to need the shirt anymore.

The intubation went smoothly. My partner, meanwhile, was having difficulty starting an IV. Years of heroin abuse had left the man's veins badly scarred.

The only promising vein lay on the side of his neck. Since I was closest to the head, I plunged a needle into the skin. I always wince involuntarily as I do this. For some reason, the process of starting an IV seems more barbaric when it happens on the neck.

We gave him the usual medications. No response. We gave him the antidote for heroin. Nothing happened. The line on the cardiac monitor remained flat. It was time to quit.

I went downstairs to inform the patient's father. He knew what I was coming to tell him. Tears streamed down his cheeks even as I descended the stairs.

"I'm sorry," I said. "We did everything the hospital would have done. He was just too far gone."

The man burst into a fit of sobbing. He wrapped his arms around me. I was a stranger--the same stranger who had just announced that his son was dead--but he so desperately needed consolation that I hugged him back.

"I knew this was going to happen," he said, sniffing and catching his breath. "He went to rehab twice, but it didn't work. We threatened to kick him out of the house, but of course we couldn't do it. He went to Nevada to live with his brother, who's in the army. But then his brother got sent to Iraq, and he came back here. The minute he got back, he started using again."

I explained what would happen next. We'd call the medical examiner. The medical examiner would decide whether to conduct an autopsy. After that, we would leave, but a police officer would remain on the scene until the body was taken away.

He said he understood.

As we finished talking, the boy's mother came home. She and the father embraced. Immediately she fell to pieces. "Why?" she bawled, over and over again. "Why did this have to happen to my baby?"

I excused myself and went into another room to call the medical examiner. He agreed to accept the case, meaning that the body would be brought to the morgue for an autopsy. The dead boy's mother took this news badly.

"Why do they want an autopsy?" she asked. I could tell what she was thinking. She worried that there was more to the situation than an accidental overdose.

"It's standard procedure," I assured her. "Your son was young. Drugs were involved. The autopsy doesn't mean anything more than what it seems to mean. He didn't die of natural causes, and the medical examiner wants to make sure nothing is overlooked. Please don't worry about it."

The shook her head, indicating that she understood. She didn't like it, but she accepted it.

It was time to gather the information for my report. Most of the details were readily available from documents such as the boy's driver's license and welfare card. I asked the father when he had last seen his son alive. "Just after noon," he told me. "He came home from a job interview."

"And you were the one to find him dead?"

"Yes. I noticed that the light was on in his bedroom. I went upstairs and turned it off. And, you know, as I was doing it, I was getting angry at him. I must have asked him a million times to turn off the light when he goes out. I thought to myself, 'He's done it again. He's left the house without turning that stupid light off.'"

Suddenly he paused. A panicked expression came over his face. He started to sob again.

"Oh my God!" he said in a voice louder than before. "He must have been right there on the floor behind the door. I walked into his room, and I turned off his stupid light, and the whole time he was right around the corner, behind the door, dead. Oh, God!"

I told the father that it wasn't his fault. He couldn't possibly have known that his son was there. And even if he had known, there was no guarantee that it would have made any difference. It's just not possible to watch a grown man all the time, every day. They had been powerless to prevent their son's death.

They thanked me. They said they realized I was right, that it wasn't their fault. But I'm not sure they believed me. I'm pretty sure they'll continue to feel guilty about it.

As we were leaving, the parents again embraced. Together they sobbed, their hearts having been shattered by the person they loved most.

I wonder if the boy would have kicked his habit if he'd known how badly it would affect his parents.

Somehow, I doubt it.

"Other People's Emergencies" Wins Its First Award

Somebody nominated this blog for an award. And it won.

We're not talking Pulitzer Prize here. Not even close. The award is called "Blog of the Day," and as the name implies, a new award is given daily. Other winners this week include a blog about chicken recipes, and another about interesting t-shirts.

Then again, one of these awards went to "My Mommy Needs a Life," a blog by a single mother with a disabled child and an abusive ex. I suppose this means that not all of the award-winning blogs are silly.

The Blog of the Day judges don't take themselves too seriously. Winning a Blog of the Day, they say, "can be the crowning achievement of a lifetime of work or it can be the beginning of a new chapter in the life of a blogger. Presentation of these awards can bring acclaim and notoriety beyond their wildest imaginings. The accolades and praise heaped upon winners of these prestigious awards can be best described as fabulous and the stuff of legends."

We'll see. Meanwhile, like Darren McGavin's character in A Christmas Story, I can boast of winning a Major Award.

(Thanks to the person who nominated this blog, whoever you are!)

A Crazy Job Sometimes

It should have been a simple call.

The EMTs had been told that their patient passed out. One of them had been to the address before. He recalled that the patient’s relatives hadn’t particularly appreciated their efforts the last time they were there.

It began just as the last episode had begun. Someone met them at the front door. They were led into a bedroom, where a young man appeared to be sleeping. They could see him blinking, though. For some reason, he wanted them to believe he was unconscious, when clearly he wasn’t. One of the EMTs recalled that the patient had been diagnosed with a panic disorder, and frequently took refuge in bed, refusing to acknowledge anyone around him.

Standard procedure in a situation like this is to rub your knuckles across the patient’s sternum. This doesn’t do any damage, but it generates just enough discomfort to wake all but the most deeply comatose patients. It worked well on this call. One of the EMTs rubbed the man’s sternum, causing him to shoot bolt upright and register a loud objection.

“Hey, that hurts!” he shouted.

“What are you doing to him?” shouted one of the family members.

“You’re killing him!” another one yelled.

It was starting all over again, just like the last time.

“Let’s get out of here,” one of the EMTs whispered to the other. Quietly they began to pick up their defibrillator, oxygen tank, and other equipment.

But they were detected. “Oh, no!” one of the relatives barked. “You’re not going anyplace. You tried to kill him! We’re not letting you leave!”

One of the EMTs keyed his microphone and asked for police assistance. In the background, we could hear shouting and banging.

The dispatcher asked what the problem was. Again the microphone was keyed. More shouting. The sounds of a scuffle went out over the air.

“Where are they?” another ambulance crew asked the dispatcher. First rule in the EMS business: Protect your own.

The dispatcher recited the call location. One ambulance crew announced that they were responding. Then another. We flipped on our lights and siren, and raced that way, too. We didn’t have an opportunity to announce this over the radio, because there was too much emergency chatter already.

Meanwhile, at the house, the relatives blocked the door. And with more relatives coming to join the fray, the situation would quickly grow more dangerous.

The EMTs weren’t about to wait until they were outnumbered. Dropping the equipment, they shoved the two relatives away from the door. The relatives shouted death threats as the EMTs jumped into the ambulance and drove out of sight around the corner.

The police arrived. The equipment was recovered. The enraged family was held at bay while the now-awake patient--who insisted on going to the hospital--was brought to the ambulance. One of the relatives who had threatened the EMTs started to climb into the ambulance, too, to accompany the patient to the hospital. “Absolutely not,” one of the EMTs said. They departed for the hospital, leaving the relative behind.

At the hospital, a decision was made to seek a criminal complaint against the combative family members. The EMTs did so reluctantly, reasoning that a certain amount of danger comes with the job. You don’t go to the police or the courts every time you have an angry encounter on a call. Before the shift had even ended, the people who’d blocked the door had been charged with two counts each of assault on a public employee.

In fact, one of the EMTs called me to ask if he was doing the right thing. Absolutely, I told him. Especially since they’ve bullied EMS personnel before. They need to get the message that you can’t get away with that. Otherwise, who knows what they’ll feel free to do next time?

“What would have happened,” I asked the EMT, “if this altercation had taken place between two people living in the same house?”

“They would have been locked up," the EMT said. "That would be domestic violence.”

“Exactly,” I said. “One person threatens another, and they go to jail, at least for the night. And those are people who live together. Now, look at you. You’re a complete stranger. You went to their house because they asked for help. It wasn’t your idea to respond there. Why are you entitled to any less protection than the people who actually live in that house?”

This made him feel better about pressing the issue, I think. Even if the assailants aren’t actually punished, at least it’s on the record now. The next time they pull a stunt like this, it won’t be a first offense. Eventually, they’ll learn that EMS personnel don’t have to tolerate such nonsense.

People think of firefighting as a dangerous job. Police work, too. And they’re right. Those are indeed dangerous occupations. But ambulance work is dangerous, too—often when you least expect it to be.

This is also a job that tries your patience. I mean, think about the position those EMTs found themselves in. They risked their lives responding to the call. Then, as they tried to examine the patient, they had their lives threatened. The entire family ganged up on them, attempting physically to keep them from leaving. A scary situation, to say the least.

But then, on top of everything else, the patient still demanded help. And did the EMTs abandon him? Nope.

Even after being threatened, they took him to the hospital, because that's their job.

Peter Goes to the Movies

I’m not sure what’s going on, a cop said over the radio, but there’s a guy in a hospital johnny walking into the movie theater here. He’s got wires hanging out and stuff. He must’ve escaped from a hospital somewhere.

We were right around the corner. “You like dealing with crazy people,” my partner said. “Want to go and check it out?”

I thought about it for a moment. “Sure,” I finally said. “Why not?”

We drove up to the theater. Even with a crowd exiting, we didn’t have any trouble locating them. The police officer was standing on the sidewalk, talking to a man in a gown.

“This is Peter,” the cop said. “He was in a hospital, obviously, but he won’t tell me which one.”

I examined the band on the man’s wrist. It contained his name, date of birth and medical records number. But it didn’t say which hospital had issued it.

“You came from a hospital just now, Peter?”

He grinned broadly. “I don’t know. Did I?”

“Well, it’s ten degrees outside, and you’re wearing a gown. You have a monitor wire dangling from your finger. And a hospital bracelet. Yeah, I think you were in a hospital.”

“Ay carumba,” Peter said. He started to giggle. His breath reeked of booze.

“Think hard, Peter. Which hospital were you in?”

“Yup.”

“What do you mean, ‘Yup’? Which hospital were you in?”

“I was in a hospital.” He giggled some more.

We were getting nowhere. I don't know what else was wrong with him, but he was certainly drunk. “What do you say we get in the ambulance?” my partner asked Peter. "We'll go and get warmed up.”

“Why?”

“Because it’s cold out.”

“And you’re only wearing a gown,” I added.

“Ay carumba,” Peter said again. Then he laughed some more. At least he was a happy drunk.

He stumbled clumsily inside and sat on the bench.

I called the communications center on my cell phone and explained the situation. I asked the operator to call the nearest hospital and ask if Peter has escaped from there. She called me back a few minutes later and said the emergency department had no record of treating him. I asked her to call the next closest hospital. At that point, the communications supervisor intervened. “Just take him to the closest hospital,” she said.

So we did. During the one-minute ride, Peter fell sound asleep. As we wheeled him into the emergency department, a resident seated at a computer terminal moaned, “Oh, no. Him again!”

The rest of the staff stood and gawked at Peter.

“Oh, Jesus,” said one nurse.

“He just left!” said another.

“So, you did treat him,” I replied. “We were told he’d never been here.”

“Who told you that?”

“One of our communications people. We had her call from the scene. Somebody from this emergency department said he’d never been here before.”

This annoyed the nurse. “Well, I don't know who your person talked to," she said. "Of course he’s been here. He’s been here three times today. We just discharged him fifteen minutes ago!”

“You discharged him like this?”

“He was fine when he left.”

My partner and I exchanged curious glances. Was she serious?

“Do you always discharge patients in hospital gowns?” I finally asked.

“When they’re drunk?” my partner added.

“He wasn’t drunk when he left,” the nurse said.

“How can you say that?” my partner asked. “Look at him! He’s smashed! What was his blood-alcohol when he was here?”

“Five hundred,” one of the doctors said.

“Five hundred?” my partner asked incredulously. “You discharge patients with an alcohol level that's six times the legal limit from driving? That’s crazy!”

“But he wasn’t that drunk when he left. Really. We drew that level, like, three hours ago.”

“Well, I don’t know what happened between then and now, but he’s drunk all over again.”

“I’m sorry,” the nurse said. “We have no beds open. We don’t have anyplace to put him.”

My partner shrugged. “Well, he certainly can't go back outside like this. You'll need to find a place.”

By this time, the nurse looked very flustered. “Fine,” she said. “Put him on a bed in the hallway over there. I’ll keep an eye on him until a room opens up.”

Peter kept snoring as we dragged him across to the hospital bed.

Eventually, though, he'll have to wake up. And when he does, I doubt he'll remember that he ever left.


The comments left in response to this post made me feel as if I'd inadvertantly generated some hard feelings between EMS personnel and people who work in emergency departments. That wasn't my intent. My goal was to tell a story about a bizarre encounter with a strange character, not to accuse the hospital staff of wrongdoing. One reader, who happens to work in the hospital where Peter was treated, left a very fair comment pointing out that Peter always has a blood-alcohol content that would kill most of us, and that, even if he had a considerable amount of alcohol in his bloodstream upon discharge, he was able to function quite normally, because that is his normal state.

I wrote a follow-up post, in which I provided some additional information and asked readers not to judge the emergency department staff too harshly, because I admit that I do not know all the circumstances of this patient's discharge. Now that some time has passed, that post seems redundant, and new readers to this site may find it confusing. I've therefore removed it. Unfortunately, there was no way to save the comments that were posted there. Sorry about that. But it's time to move on, and I thank you for your understanding.

Making the Problem Worse

I frequently complain about the improper utilization of emergency services. I'm not the only one who complains, of course. Everyone who has ever worked in an ambulance resents this practice at one time or another.

As the saying goes, things are the same all over. It doesn't happen just here, but in other parts of the world, too. Not long ago, The London Ambulance Service launched a public awareness campaign meant to educate people about the danger of tying up ambulances unnecessarily.

Featuring two photographs--one of a hackney driver leaning against a traditional black London cab, and another of a pair of EMTs leaning against an ambulance--the ad, which appeared in the form of a poster on London's buses and in subway stations, reads, "Only one of these is a taxi service."



It goes on to say, in smaller print, that people needing medical advice should talk to a pharmacist, call the National Health Service hotline, or, if the matter is urgent, take an actual taxicab to a hospital.

People who are having trouble breathing, bleeding heavily, experiencing chest pain, or unconscious, on the other hand, are instructed to call 999, the U.K. equivalent of 911.

This campaign, which also featured radio advertisements, began in 2001, after an independent commission uncovered facts that would not surprise anyone who has ever worked in EMS. The commission's study revealed that one out of every 10 Londoners would call an ambulance if they came down with flu-like symptoms; that 40% of the people living in that city would take an ambulance to an emergency department if they had difficulty in reaching their primary physician; and, worst of all, that 30% of these people would call an ambulance if they couldn't get an appointment right away.

The radio advertisements featured re-enactments of actual calls for ambulance service, including a man with the hiccoughs and a woman who wanted to track down her son at a pub.

According to the London Ambulance Service, the goal of this campaign was to "urge sensible use of the service" and to "advise listeners on where to get help in a non-emergency situation." The campaign even won some awards--one from the prestigious magazine PR Week, and another from the Health Service Management Journal.

This all sounds like a good idea, doesn't it? An idea that might free ambulances to handle true emergencies--situations where someone's life hangs in the balance?

Not everyone thought so. According to my friend John, a worker with the London Ambulance Service, the campaign has been abruptly shut down after so-called "patient rights advocates" complained. Their concern? The ads might discourage people from calling for help.

Well, that's the whole point, isn't it? To teach people not to request help if they don't really need it?

In an ideal world, everyone would have an ambulance at their immediate disposal. It would come right away, as soon as you called, no matter what your problem was, or how many other people needed ambulances at the same time. That would be wonderful.

But that's impossible, of course. There aren't enough ambulances in the world to make that happen. And so, we must pick and choose. We must triage, just like hospital emergency departments do. The sickest people get ambulances first. The healthier ones just have to wait.

Eventually, though, everybody must get an ambulance. And when an ambulance crew is tied up examining a man with hiccoughs, or a talking to the woman who can't find her son at the pub, it can't respond to any other calls. Calls that might really be emergencies.

The patient rights activists think they have done a good thing by dismantling the London Ambulance Service's public awareness campaign. They think they have protected the public by giving people the kind of access to ambulances they deserve.

But they've done nothing of the sort.

All they've managed to do is make dying people wait even longer to get help, thereby putting the public at even greater risk.

Last to Know

He was proud of the fact that he hadn’t seen a doctor in a long time. Not for thirty years, in fact. But now he was gasping for air, and he couldn’t understand why. So he’d called for an ambulance.

“When did this start?” I asked.

“What? The trouble breathing?” he panted. “That’s been going on for a good six months.”

“What made you call tonight?”

“It got worse. I was sitting in my chair, watching television, and I was fine. But then I went to get up, and I couldn’t even stand. It was too hard to breathe. I had to sit back down.”

“And that’s never happened before?”

“No. Not like this. I’ve had trouble catching my breath for a while now. For two weeks, maybe. I’ve been using my wife’s inhaler, but it hasn’t helped.”

I listened to the man’s lungs. He wasn’t wheezing. No wonder the inhaler hadn’t worked. He didn’t have asthma or emphysema—the two conditions that respond well to such medicine.

We gave him some oxygen. It helped a little, but not much. We strapped him into a chair and carried him down the stairs.

“Do you smoke?” I asked in the back of the ambulance.

“Oh, yeah,” he said, sounding proud again. “Two packs a day for thirty-five years.”

“You cough much?” We were rolling now, on our way to the hospital.

“Yeah. When you smoke like I do, you always cough a lot.”

“What color is the stuff you cough up?”

“Black, mostly. Sometimes brown.”

I recoiled at the thought. Smoker or not, I didn’t see how coughing up black phlegm could be normal. It sounded disgusting.

“Have you noticed any changes in your weight lately?”

The man chuckled, then went into a coughing spasm. “I don’t exactly take care of myself," he finally gasped, "so I wouldn’t really notice. But sometimes I don’t feel like eating. So I don’t.”

“Is that a new thing?”

He thought about it for a moment. “Yeah. The last few months.”

We arrived at the hospital. I recognized the attending physician on duty in the emergency department. “What did you bring us?” she asked.

“Lung cancer,” I said.

An intern standing beside the attending grinned. He thought I was kidding. His smile disappeared when he saw that I wasn't smiling with him.

“Does he have a history of cancer?” the attending asked.

“No. But he’s smoked for more than thirty years, and in all that time, he’s never seen a doctor. He’s had trouble breathing for six months, and now he’s coughing up black and brown phlegm. He’s been losing his appetite, too. Seems to me it’s time for a chest x-ray.”

“I think you’re right,” the attending said.

The diagnosis was by no means certain. But the man had all the symptoms. It was cancer. I’d bet anything on it.

The patient seemed to think the whole thing was a joke. And why not? He’d avoided doctors for most of his life, and he’d been healthy this long, so how serious could it be? Whatever it was, the hospital would take care of it. That was his philosophy.

It made me feel sad to watch him acting this way. If I was right, and he really did have cancer, then he was in for a shock, because he might very well be dying. And how would that feel, to know that you were the last one to learn you had a terminal disease?

In this case, I would take no pleasure from being correct.

An Odd Death

The man in the condo didn’t appear the least bit upset. That was the first thing I noticed. His girlfriend lay on the floor, dead, and he didn’t seem to mind.

“How old is she?” my partner asked, kneeling on the floor to intubate her.

“Twenty-nine,” he said. “I called her on my way home from work, and she sounded short of breath. She has asthma. I stopped at the pharmacy and bought her a new inhaler. When I got here, I couldn’t wake her up.”

I looked at the woman. She was thin and attractive. She did not have any clothes on. There were no cuts or bruises on her, no sign of injury. Air moved freely into her lungs with every squeeze of the Ambu bag, so it wasn't asthma that had killed her. In fact, her death made no sense.

I squatted and started an IV. One of the EMTs pumped rhythmically on the woman’s chest. The other one opened our drug box and handed me a pair of syringes, one containing epinephrine, the other, atropine.

The line scrolling across the cardiac monitor was flat. I injected the epinephrine into the IV tubing. Nothing happened. I injected the atropine. Still nothing.

The EMT handed me two more syringes. His partner kept pushing on the chest. I looked around the room. There was no drug paraphernalia, nothing to suggest that she had overdosed.

I injected the next two syringes. The line on the monitor jumped, forming quick regular waves. “Somebody check for a pulse,” I said. The drugs had stimulated some heart activity.

My partner felt at the woman’s neck. “I’ve got nothing,” he said. He motioned to the EMT, who started pumping again.

“She has asthma?” my partner asked the man on the other side of the bedroom. The man nodded. “Any other health problems?”

“No.”

“Has she been sick recently?”

“No, not at all.”

“Any chance she might be pregnant?” Given the patient’s age and gender, this was an important thing to know. The attachment of a fetus to the wrong part of the womb, known as an “ectopic pregnancy,” sometimes causes death by rupturing the fallopian tube.

“No.”

“How do you know?” the EMT asked.

“She’s on birth control. And she just had her period last week.”

“I’m going to ask you a couple of personal questions,” I said delicately. “Please understand that we’re not accusing you of anything wrong.”

The man shook his head.

“How long have you known each other? I’m only asking because I want to know if it’s possible that she has medical problems she never told you about.”

“No problem,” the man said calmly. “We’ve been going out for about a year. She told me about her asthma, and that’s all. If she had any other health problems, I think she would have told me.”

“Good. Thank you. Now, the other question. Does she ever use any drugs? If so, we need to know about it, because we need to know how to treat her. We're not accusing her of anything.”

“No. She never uses drugs. If she did, I’d know about it.”

“Great. Thanks.”

I injected a third syringe of epinephrine and atropine. Still no change. The waves continued to march across the screen, but she still didn’t have any pulses. The hospital wasn't going to get her back, but she didn't meet the criteria for pronouncement in the field.

“Let’s go to the hospital,” I said.

We lifted her onto the stretcher. The EMT kept pumping on her chest as we wheeled her out to the ambulance. The boyfriend tagged along. He still didn’t look upset.

The emergency department staff kept the resuscitation going for a good twenty minutes, not because her condition improved, but because she was so young. Everyone feels an increased sense of urgency when the patient is young. The death of an old person is expected. The death of a young person isn’t.

With CPR continuing, a surgeon used an ultrasonic device to examine the woman’s abdomen. There was no fetus inside. She was not pregnant.

The woman had not responded to the medications we’d given her, and now she was not responding to medications given in the hospital. “Well, I think that’s it,” the senior resident finally said. “It’s not an ectopic, and there’s no sign of trauma, so I think it’s time to call it.” he looked at the clock. “Time of death is five-fifteen p.m.”

“Did any family come with her?” he asked me.

“The boyfriend is out in the hallway,” I said.

“I’ll find an empty room so you can talk to him in private,” a nurse said.

I passed the boyfriend on my way outside. He was sitting in a chair with his head in his hands. I couldn’t decide whether he looked sad or bored.

Outside, my partner shook his head. “I wonder what happened to her,” he said. “I mean, the whole thing is weird. Twenty-nine years old, and dead for no reason. It makes no sense.”

I shrugged. It made no sense to me, either.

“And why was she naked?”

I’d wondered about that myself. At first I didn’t think much about it. Having worked on the night shift for so long, I’ve grown accustomed to seeing people die in their sleep, and I’d assumed she’d been in bed with her clothes off. But then it occurred to me that it was five o’clock in the afternoon. There was no good reason for the woman to be in bed. If she was naked, it wasn’t because she’d been sleeping.

Maybe the woman had died of natural causes. Maybe the boyfriend was grieving in his own quiet way. But EMS personnel are naturally suspicious, I think—myself included. It’s not unusual for people to lie to us, even as we’re trying to save their lives. It was impossible to look at a naked woman, alone in a bedroom with a calm, collected boyfriend, without considering the possibility of foul play. And while this might reflect some unhealthy skepticism, it’s actually a good thing, I think. If we don’t suspect foul play, then we won’t look for it. And often, we’re the only ones in a position to find it.

“To be honest,” I said to my partner, “I looked at the woman and immediately assumed she was a prostitute. She’s young, naked, and alone with a guy. We can’t understand why she's dead. On the night shift, the answer to questions like this always seemed to be, ‘because she’s a prostitute.’”

An Admirable Patient

Dealing with so many sick people, we develop immunity to suffering. This is inevitable, and it’s not necessarily a bad thing. Health care providers lose their ability to provide effective treatment if they identify too closely with those they treat. This is especially true in the setting of emergency medicine, where rapid intervention is essential. You can’t be a good EMT or paramedic if you cry every time you see a person in pain, or wince at the site of a disfiguring injury.

Occasionally, though, we encounter patients who touch us. Maybe it’s a child, injured in an accident or victimized by abuse, who reminds us of our own children. Or perhaps it’s an elderly person who sets a marvelous example for the rest of us by approaching death with courage and dignity. That’s one of the greatest aspects of this job—every so often, we interact with inspirational people.

We met one such patient tonight, an eighteen-year-old woman with cystic fibrosis, a horrible, frustrating disease that causes a lifetime of pain. Those who are fortunate get lung transplants, adding valuable time to their lives. But most are not so lucky. Instead, they gradually suffocate until they die.

What makes this disease especially unfair is that it strikes in childhood. Cystic fibrosis patients do not become sick after a lifetime of happy memories. They are sick from the start, never knowing anything but misery and fear.

Our patient tonight was fighting to breathe. Her name had been added to a lung-transplant list, but with demand for healthy lungs far greater than supply, the odds of getting the operation in time were slim. She leaned forward on her couch, gasping for air. She whimpered with pain, too. Unlike people with asthma or emphysema, cystic fibrosis patients rarely enjoy a respite. They fight to breathe all day, every day, and after a while it really begins to hurt.

That is why I was so impressed with this young woman’s attitude. Not being able to breathe is perhaps the scariest feeling there is, yet she never once complained to us about it. When the time came to start an IV, she suggested the best location. “The nurses always have trouble, because I have such small veins,” she said. “But I think you’ll find one in my hand.”

I looked, but the only one I could find was on the top of her thumb. That’s a very sensitive part of the body, and the thought of having it penetrated with a needle would scare even the most stoic patient. But this young woman didn’t hesitate. “Go ahead,” she told me. “That’s probably the only place you’ll get it in.”

Most people are babies when it comes to IVs. There’s nothing more pathetic that a street gangster who whines and screams, “Get it out! It hurts!” when we stick him for an IV while treating him for a gunshot wound. Yet it happens all the time. And there’s nothing more difficult than trying to get an IV into an adult who constantly wiggles and yanks his arm away, moaning and groaning as if we’re intentionally torturing him. I expect this from toddlers, but not from grownups.

This woman had plenty of reason to complain. She’s suffered through an awful lot. I felt terrible having to stick a needle into her, because the agony of breathing was enough of a burden. Unfortunately, we had no choice. Her blood pressure was low, and to relieve her pain with morphine—which in turn would allow her to breathe better and more deeply--we would first have to give her some IV fluid.

I selected an extremely small IV needle. I cleaned her thumb with alcohol and plunged the needle into her skin. I tensed, expecting her to shout, or pull her arm away, or complain the way so many older, healthier people do. But she didn’t do any of these things. She sat motionless, continuing to gasp for air, never once uttering a word of complaint. The needle went into the vein, and we were able to give her the morphine.

The patient’s father impressed me, too. Unshaven, with wrinkled clothing, he didn’t make a very good first impression. But he knew everything about his daughter’s illness. He had memorized every medication, and every date of every procedure she’d undergone, and we could tell by their interaction that he cared deeply for her. He was, by all indications, a poor, uneducated, welfare parent who lived in a housing project, but from what we could see, he was an ideal father.

As we wheeled the young woman out to our ambulance, the father mentioned her other medical problems. She had chronic back pain from bulging disks—a side effect of the steroids