Mistakes

He was sprawled across the platform of the subway station, his head resting in a pool of blood. EMTs and firefighters were performing CPR. An EMT supervisor was there, too, directing a pair of firefighters to ready a spineboard. In fact, the supervisor was the one who'd called for us. The EMTs had been prepared to write the man off as dead, until the supervisor intervened.

"He's got a big open area on the back of his head," the supervisor told us as we approached. "But no gray matter is visible, and I can't feel any depression in the skull. There's no rigor or anything like that. I didn't feel right pronouncing him."

I looked for myself. The wound was impressive. It was oval-shaped, and it looked to be about four inches in diameter, although it was difficult to see the borders with so much blood oozing out. The supervisor's assessment seemed right, however. I couldn't see or feel anything that resembled a skull fracture.

"Okay, then. Let's get things moving," I said. The man wasn't going to survive, because nobody ever survives cardiac arrest as a result of blunt head trauma. But if we were going to make the effort, we had to do it right. And since we have little to offer in the way of field brain surgery, transport would be our primary goal in this case. Transport to a trauma center. Fast.

The EMTs rolled the patient on his side. Firefighters slid the spineboard underneath him. We strapped him down, and the EMTs continued CPR as we carried him to the end of the platform and up the stairs. At the top, we encountered a problem: The station was about to close, and somebody had locked the gate while we were downstairs.

"Transit police!" I shouted down the stairwell to a cop who had been sent on the call with us. "We need some keys up here!" Seconds later, I heard jangling as the cop sprinted up the steps behind me. He released the padlock and threw the gate open.

"What happened to this guy, anyway?" I asked as we loaded the patient onto a stretcher and wheeled him to our truck. "Anybody know?"

"Looks like he got hit by a train," the supervisor said. "He was right at the edge of the platform. He must have leaned over too far and got clipped by the first car.""He's got work gloves on," one of the EMTs added. "There was a huge plastic bag full of cans nearby. He must have been there to pick up the trash."

We decided to do everything else on the way to the hospital. While the EMTs drove, we intubated him*, started an IV, and continued CPR. There was nothing else to do. The hospital's trauma team went through the motions, giving cardiac medications, taking an EKG, even looking at the chest with a portable echocardiogram to see if there was any heart movement. There wasn't. The resuscitation effort was stopped, the EKG and echocardiogram were turned off, and the police were notified that the man had been pronounced dead.

This kind of call always generates a lot of interest in the emergency department. Doctors, nurses, technicians, and students of all kinds drop whatever they are doing and flock to the treatment room to investigate for themselves. Questions are asked, and since we're the ones who were on the scene, these questions are invariably directed at us. What happened to him? Was there a lot of blood? Was this a murder? What was he doing in a subway station so late at night?

I did my best to answer. He got hit by a train, I said. Or at least we think he did, but nobody knows for sure. Yes, there was a lot of blood. The puddle was probably two feet across. No, it wasn't a murder. An accident, probably. But nobody witnessed it, so we really don't know. And as for his presence in the station, well, I'm going to guess that he was working, collecting trash. He's wearing utility gloves, and there was a bag of cans on the platform next to him.

"But he doesn't have any ID," a nurse observed. "If he's a transit employee, shouldn't he have an ID card on his shirt?"

Good point, I thought. Come to think of it, he wasn't wearing a uniform, either. In Boston's subway system, even the trash collectors wear uniforms. I revised my thinking, deciding that he was probably a vagrant, collecting cans for the recycling value. He must have been walking down the platform, from one trash can to the next, when a train approached from behind. He turned his head the wrong way, and being a little too close to the edge, he was clipped from behind. That would explain the wound on the back of his head. The wound was slightly on the left side, too--the side that would have been nearest the track. It all made sense.

I looked into the room one last time before leaving. A nurse was going through the man's pockets, searching for identification. Suddenly I saw her hesitate, a look of concern spreading across her face. "What's this?" she asked.

From the dead man's pocket she removed one syringe, then another. She also pulled out a medication bottle. "Clonopin," she said, reading from the label. "Prescribed for a patient named Theresa. Funny, he doesn't look like a Theresa."

We'd made a huge mistake. Those things never should have made their way into the emergency department. We should have looked for them, and we should have found them, not only for the safety of the hospital personnel, but for our own safety as well. Getting stuck with a dirty needle can prove deadly.

When I was first hired by the city, the concept of self-preservation was drilled into our heads. Never trust anybody, we were told. Before you wake up a sleeping drunk, always check his pockets. Make sure he doesn't have a knife, or a gun, or a needle hidden in his pocket, or his pants, or socks. You don't want to be caught off guard and attacked once he wakes up. Always stand at the patient's side. That way, he can't strike at you directly. Remove the patient's hands from his pockets. You never can tell what kind of a weapon he might be holding in his hands. And never straddle a patient. That makes you a prime target for kicking.

These kinds of things aren't stressed any more. In today's kinder, gentler, politically-correct world of EMS, great emphasis is placed on cultural awareness. We are taught to respect language differences, religious differences, ethnic differences. But EMTs are no longer taught to protect themselves. Not to the extent that we were taught, anyway. We routinely have to remind new EMTs not to wake up a sleeping patient without first checking for weapons.

This time, though, we were the ones who dropped the ball. The patient looked like a subway employee, and he therefore posed an unlikely threat. But that was no excuse. I should have checked his pockets. I should have found the syringes and pills. It was my responsibility, and I failed.The presence of drugs raised another question. Did the man die simply of head trauma, or did overdose play some role in his death? For all we know, he may have stumbled, drowsy on heroin and Clonopin, into the path of the oncoming train. With the man now dead, it doesn't make much difference. But it might have. Had he still been alive, with a reasonable chance of survival, overlooking the possibility of an overdose could have been disastrous.

Out in the ambulance bay, my partner asked an equally important question. "Why did we work that guy?" he wanted to know. "Blunt head trauma. Cardiac arrest. He fit the criteria for pronouncing him dead in the field."

He was right. I'd forgotten entirely. In the past, a patient could be pronounced dead only when there was evidence of longstanding death. Rigor mortis had to be present, or decomposition, or the clotting of blood within the body. But those standards have changed. Studies have shown that resuscitation doesn't work in the setting of blunt head trauma. By carrying the body to the hospital, we succeed only in contaminating a potential crime scene, making it more difficult for detectives to figure out what really happened. The EMTs knew this, and that's why they balked at performing CPR. But then came the supervisor, ordering them to begin treatment, and they had no choice but to comply.

Unlike the EMTs, I did have a choice. As a paramedic, I am more highly trained than the EMT supervisor, and therefore not subject to his direction. I should have recognized that a mistake had been made. I should have corrected it. The man was dead. I should have left him on the platform where he belonged.

I don't feel particularly good right now, knowing that I made two serious errors on the same call. First I attempted resuscitation on a patient who should have been left for dead, and then I overlooked some important, potentially deadly items he'd been carrying in his pocket. The mistakes proved harmless, and this gives me some consolation, I suppose; it would have been far worse if I'd later learned that we'd destroyed evidence of a murder, or that the nurse had stuck herself with one of those needles. But still it bothers me. We do an important job, a job where people trust us with their lives. We can't afford to grow complacent, not for a moment, for this is a job where even the smallest error can have dire consequences.
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*For the non-medical reader, "intubation" refers to the practice of endotracheal intubation. Using a lighted, L-shaped instrument known as a laryngoscope, we insert a hollow plastic tube--an endotracheal tube--past the tongue, between the vocal cords, and into the trachea. Once the tube is in place, we connect a football-shaped "Ambu bag" to the exposed end and squeeze, thereby forcing oxygen directly into the patient's lungs.

Prisoners

This may come as a shock to some people, but prisoners sometimes fake illness to get of jail.
Yes, it's true. The prospect of being locked overnight in a six-foot-by-ten-foot windowless concrete box does not appeal to everyone. Especially when the bed is a steel platform, the toilet has been plugged up for years, and previous occupants have urinated on the floor.

It's not as difficult to escape from a jail as one might think. Police stations aren't prisons. Most people held in these facilities are charged with extremely minor crimes. Knowing that the police department cannot spare an officer to guard every shoplifter for a three-hour-long emergency department evaluation, they gasp for air and claim to have asthma, clutch their chests as if having a heart attack, or feign unconsciousness when there is nothing wrong with them at all. They ride to the hospital in an ambulance, and then, when nobody is looking, they wander away.

That's what happened tonight. The prisoner was a young woman, a greasy-looking twenty-four-year-old charged with a nickel-and-dime drug offense. She never even made it to the cell. While being booked, she dropped to the floor and held her eyes shut while the police called for us.
The drama continued even after it became obvious that she was going to be released. Her blood pressure and heart rate were fine, and she didn't have a fever, but she groaned continuously, adding an occasional "Oh, I'm so dizzy" and "I don't feel good" for extra effect.

The booking officer pulled up her record. She'd been arrested more than twenty times. Three different courts had issued warrants for her arrest after she'd skipped out on trial.

The EMTs loaded her into the ambulance. They delivered her to a hospital right up the street, where she was triaged with the not-so-specific complaint of "not feeling well." To nobody's surprise, she was gone when the doctor went in to examine her.

Talk about "revolving door" justice. This particular jailbreak didn't bother me much, because the prisoner hadn't hurt anyone but herself. She was a drug user, not a drug dealer. Sooner or later she'll be arrested for something else, and the process will start all over again. It wasted fifteen minutes of our time, but nothing more.

Sometimes, though, this scam is played by prisoners accused of assault or larceny. That does bother me. Petty as these crimes may be, they have victims--victims who have cooperated with the police and, quite reasonably, expect some sort of justice. The police officers have done their job by making an arrest. Unfortunately, police departments have a well-grounded fear of lawsuits, and the criminals, knowing this, take full advantage, literally walking away from their crimes.

Danger

The bars had all closed. The yuppies and college students had gone home in various states of intoxication. Street sweepers roamed the now-deserted financial district. The city was quiet.

On the twenty-second story of the Westin Hotel, a middle-aged man from Arkansas was having a diabetic crisis. His wife coaxed him into drinking some orange juice. She knew, as the spouse of every diabetic knows, that his blood sugar had dropped, and that she could avoid a trip to the emergency department if she could just get some glucose into him.

This episode seemed different from prior ones, however. Her husband was drowsier than usual. He wasn’t responding to the juice as quickly as he had in the past. Just to be safe, she picked up the phone and asked the desk clerk to call for an ambulance.

Ninety seconds later, the doors went up at the downtown EMS station. The EMTs’ ambulance went out first. We followed them. The streets were empty, so we made good time. With no pedestrians and very little traffic to get in the way, you can drive fast at night.

Two blocks from the hotel, a black Dodge Durango approached from the left. The traffic signals were blinking yellow for the ambulances, red for the Durango. The Durango was supposed to stop, but didn’t. It plowed into the side of the lead ambulance at close to 40 miles an hour, pushing it sideways amid a shower of metal and plastic scraps. We swerved around the wreckage, screeched to a stop, and radioed a request for a police car and fire engine.

It would have been easy to panic, but nobody did. The EMTs climbed out of the ambulance. The driver of the Durango needed help getting her crushed door open, but once she was out, she calmly apologized. There were no cuts, no bruises, no complaints of neck pain. Satisfied that no one had been injured, we continued on to the hotel. By the time we got there, the diabetic had recovered completely and was relaxing in bed. He declined a ride to the hospital, as diabetics usually do.

Everyone knows that police officers and firefighters have dangerous jobs. Ambulance work is dangerous, too, but you rarely hear anyone talk about that. Not many newspaper articles have been written about the dangers faced by EMTs and paramedics. In movies and television shows, it’s always the cop or firefighter who makes the daring rescue, never the EMT or paramedic.

Each May, EMTs and paramedics from all over the country gather at a church in Roanoke, Virginia to honor EMS personnel who have died in the line of duty. I’ve been to several of those ceremonies, and they are quite touching. It’s hard not to become teary when faces of EMTs and paramedics, now gone, flash across the giant video screen, surrounded by the faces of children and parents and spouses who loved them and now miss them. Among the personnel memorialized this year were a paramedic and flight nurse who died when their helicopter crashed. There was a paramedic shot in an ambush by a psychiatric patient. And there was a New York City EMT who died in a collision not much different from the one I witnessed just a few minutes ago.

EMTs don’t often dwell on the dangers of their job. But it certainly is dangerous. I’ve struggled with patients over knives. I’ve found guns hidden in their clothing. I’ve worked on patients in puddles of gasoline, on top of scaffolds, beneath subway cars. More than once I’ve been stuck with the needle of a junkie, but for reasons I’ll never understand, I have not yet contracted HIV or hepatitis.

And then there are the collisions. Every night, we race through the city, sometimes at ridiculous speeds, always with a feeling of invincibility. We drive fast because it’s part of the job. People are sick and hurt and dying out there, and we get paid to reach them quickly.Tonight, after the diabetic refused treatment, we returned to the scene of the ambulance crash. The Durango was being towed away. The ambulance, while heavily damaged, was drivable. The Durango’s driver was talking on her cellular phone, telling a friend what had happened. To her credit, she was honest. “I don’t know what I was thinking,” I heard her say. “The light was blinking red, and I know I was supposed to stop, but for some reason I went right through.”

This time, everyone was lucky. There were no injuries. But the collision reminded me that we are forever one misstep away from serious injury or even death. The next time we fly through an intersection, the impact might be more powerful. The next time I get stuck with a needle, it just might contain a lethal virus. The next time I walk through a door in the projects, there might be a lunatic waiting for me on the other side with a handgun or a knife.

I’m not going to dwell on any of this. You can’t do the job if you’re afraid of each call. In fact, if the job were safer, we probably wouldn't enjoy it as much. The dangerous calls are the exciting ones, the ones that get your adrenaline flowing. This is part of the reason people go into EMS, just as it’s part of the reason people become cops or firefighters. If we want absolute safety, we should find another line of work. But it’s certainly worth thinking about. If nothing else, calls like this one remind us to be cautious.

Let's Make 911 More Difficult to Use

Not everyone should be allowed to call 911. Some people are just too stupid.

Shortly after three o'clock this morning, we were sent to a downtown intersection, where an elderly man had collapsed--or so the caller to 911 reported. We arrived to find the entire neighborhood deserted. There was an entrance to an upscale shopping mall on one corner, a commuter rail station across the street, and high-rise office towers on the remaining two sides. There wasn't a soul around. We returned to the station.

Ten minutes later, the same person called again. He insisted that an elderly male was still unconscious at the same intersection. We responded again. And again we found the intersection deserted.

This time, before we returned to the station, we asked the dispatcher to call the person who'd reported the emergency and ask for more specific directions. Why the dispatcher hadn't done this after the first call, I really can't say.

We waited in the intersection for a few minutes, with the flashing lights drawing curious stares from the few drivers who passed through the area, until the dispatcher told us that the caller would come outside, identify himself, and point out the victim.We waited some more. Finally a middle-aged man approached. He led us inside the mall, up an escalator, across a pedestrian footbridge, and into an atrium, where, instead of a collapsed elderly gentleman, we found a drunk taking a nap. He was curled in a fetal position in a corner, snoring loudly, with a tattered gray blanket pulled over his head. We woke him up, told him to find a better place to sleep, and watched as he tottered away.

The caller, too, left. And that was too bad, because I really wanted to ask him a couple of questions. First, I wanted to know what had possessed him to think that the information he'd provided was sufficient. How, exactly, were we supposed to spot someone indoors, on a second floor, the equivalent of two blocks away from the location he'd given?

And second, I wanted to know how he'd managed to confuse a sleeping drunk with a collapsed elderly gentleman. It wasn't as if the unconscious man was sprawled dramatically across the floor. He looked perfectly comfortable. He was snoring. And people who collapse generally don't cover themselves with blankets.So here's what I propose: Let's change 911. Let's make it a more complex number, a regular seven-digit number that requires a modicum of thought before utilizing it. Or better yet, a ten-digit number with a unique area code. That way, only people with the ability to think rationally will be able to report their emergencies.And we'll be spared a lot of unnecessary driving around.

Follow-up: Suicide

One of the EMTs who responded with us to last night's suicide-by-detergent call sent me a message over the ambulance computer just now. He thought I'd be interested to know that the college student was going to be fine after all.

Her actions had an interesting side effect, however. As she settled into an emergency department bed, she coughed up bubbles. Great big masses of frothy bubbles. A nurse gave her an emesis basin, and for the next thirty minutes or so, she half-coughed, half-vomited a gallon of foam.

I doubt this was what she had in mind when she decided to commit suicide by ingesting detergent. All I can think about right now is the Three Stooges episode in which Curley eats a cake made from the stuffing of a pillow and coughs up a roomful of feathers.

I'm sure that medical ethicists frown on laughing at the misfortune of patients, but sometimes you just can't help it.

Suicide

The woman on the floor wanted me to believe she was unconscious. But she wasn’t. I knew this because she flinched whenever I brushed my fingertips across her eyelashes.She was eighteen years old, a freshman at a downtown college. Her roommates had called 911 after she tried to commit suicide. What made this call unusual was that she’d selected a most bizarre method of killing herself. Rather than cutting her wrists or swallowing a bottle of pills, she’d gulped down a bottle of laundry detergent.

She was lying on the floor of her living room, just a few feet away from a desktop computer. As I questioned her roommates about the night’s events, my partner scrolled through the information on the screen. A number of instant messages had arrived during the past thirty minutes from friends concerned about her welfare. Why are you so upset? Are you still there? What can I do to help? Please don’t do anything drastic. I love you. She must have sent e-mails to everyone she knew, telling them what she was planning to do.

This wasn’t really a suicide attempt, of course. It was a cry for help. People who truly want to die don’t alert their friends. They kill themselves alone and in silence, making it impossible for anyone to intervene. Men kill themselves by jumping off buildings or shooting themselves in the head. Women typically swallow handfuls of pills. This woman was smart enough to know that detergent wouldn’t kill her. The emergency instructions on the bottle warned to expect nausea and diarrhea. The only antidote listed was “water.” She wanted attention, not death.

Still, we have to take such incidents seriously. It’s always a mistake to ignore a halfhearted suicide attempt, experts warn, because halfhearted attempts signal more serious ones ahead. Downplay the detergent ingestion, and tomorrow she’ll drink bleach. Or something worse.

I tapped the woman on the shoulder and told her that I knew she was awake. I reminded her that to get help, she needed to talk. This approach doesn’t always work. Often, a patient will persist in feigning unconsciousness no matter how transparent the act becomes. This time, though, the patient opened her eyes and began to sob. I helped her to a chair and told her she’d be going to a hospital.“Nooooo,” she wailed sadly. “I want to go home.”

I asked where home was. It turned out to be a small town in Ohio. Less than a month earlier, she’d moved 600 miles to attend college. She’d never lived away from her family before.

It was then that I noticed a pair of homemade greeting cards taped to the wall beside the computer. Each one featured a crayon drawing of the patient holding hands with a young girl—the patient’s little sister, apparently. One of the cards said, “I hope you come home soon to visit.” The other said, “I miss you a lot already.”

Looking at those cards, I realized just how little I knew about the woman sitting in front of me. I knew nothing about her upbringing, nothing about her family life. It would have been easy for me to get angry at her, to resent her for manipulating us and wasting our time. She had pretended to be unconscious, after all, from drinking a non-lethal substance. But without knowing more about her, who was I to say that she'd done anything wrong? Maybe she was spoiled and desperate for attention. Then again, maybe not. For all I knew, she had a million good reasons for wanting to die.

Some people use suicide vindictively. They toss threats around like hand grenades. Do as I say, or I’ll kill myself, and it’ll be all your fault! Not everyone who threatens or attempts suicide is like this, however. Some people are just plain sad. Sad enough to hurt themselves, but not quite brave enough to end their lives.

As I walked her out to the ambulance, I was convinced that she fit into this category. She wasn’t playing around when she drank the detergent; she was asking for help. It was our job to get her that help. The last thing she needed was for someone like me to pass judgment on her.

For Want of a Seat Belt

Earlier tonight we responded to a collision in the tunnel that runs beneath the harbor. A silver Mercedes carrying five people had gone into a curve too quickly and skidded into a retaining wall. Since it was two o’clock in the morning and the downtown bars had just closed, we expected to find the driver and passengers drunk. What we didn’t expect was the brain matter on the ceiling of the tunnel, and the blood dripping down the tiles of the opposite wall, three lanes away.

The driver and two of the passengers were already out of the car, walking around in the roadway, claiming not to be injured. A female in the back seat had broken her arm. Two EMTs were inside the vehicle, immobilizing her. That left one passenger unaccounted for.

I asked an EMT outside the truck where the missing passenger had gone.

“He’s back there,” the EMT said, pointing to a white sheet on the asphalt some 100 yards behind the car. “We already pronounced him dead.”

“What happened to him?”

“He must have been tossed out,” the EMT said, shrugging. “His body is completely mangled. He’s not in one piece.”

The EMT then pointed to two more white sheets, one in the center lane, the other in the far lane. “That’s his head,” he told me. “And that one over there, that’s his left arm."

“Oh, man.”

“Yeah. I told you he was a mess.”I crawled into the pickup truck to examine the injured female passenger. Bone was visible through a wound on her elbow. Other than that, she had only minor cuts and bruises. The EMTs were just about finished strapping her to a spineboard. She was young and attractive, a blonde-haired Hispanic. I asked her to tell me her name.“Rosaria,” she said. “Where’s John?”

“John? Who’s John?”

“He's my friend. He was sitting right next to me."

“Did he have his seat belt on?”

“I don’t know. No, wait…he didn’t. I had mine on, but he didn’t have his.”

Turning away from Rosaria, I whispered to the EMT standing outside. “The dead guy, where was he sitting when the car crashed?”

“Left side, rear.”

That would have put him in the seat nearest the wall. Suddenly it all made sense: With no seat belt to hold him in place, John had flown out the window during the collision. He’d been ground to bits between the tiles and the screeching vehicle, and was now on the roadway in several pieces, with parts of his brain on the ceiling. If he'd been wearing a seat belt, he would have stayed in the car, and he would have come through the accident like Rosaria: bruised but alive.

The EMTs loaded Rosaria into our ambulance. We started an IV on the way to the hospital. She probably had a concussion, or maybe it was the alcohol, but she became increasingly drowsy, and I had to keep nudging her awake. In a way, I was grateful for this. If she'd been more alert, I'm sure she would have asked about John’s condition. That was one conversation I didn't want to have.

Being a Saturday night, the hospital was busy even before we arrived with Rosaria. We wheeled her into a treatment room, where x-rays and a CT scan revealed nothing more serious than the arm fracture. Because the broken bone was exposed, which placed her at risk for infection, she went upstairs to the operating room for wound debridement. She left the emergency department under sedation, without ever learning what had become of John.

I went outside to the ambulance bay. There I came across a police officer who had been sent to collect the names of the injured. I provided him with all the information I had. Then I asked him about the cause of the accident.

"They were coming from a dance club," he told me. "They'd all been drinking, including the driver. He went into the tunnel at about a hundred miles an hour. The turn was too sharp, and he lost control.

"I asked how he’d learned all of this so quickly.

“Oh, it’s all on the tape,” he told me. “We have video cameras all through that tunnel. If you go over to the operations center, you can see for yourself.”

My partner and I looked at each other. We were thinking the same thing: For the first time, we had an opportunity to see what had happened before our arrival. It would be an eerie, yet fascinating experience. But would that be too morbid of us?

We couldn’t resist. We drove to the operations center, where a state trooper was sitting in the dark, watching a vast expanse of color television monitors. As we walked in, a figure on one of the screens was stepping gingerly through the tunnel, bending occasionally to pick up a tiny fragment of some kind. “See that guy?” the cop watching the monitors said. “He’s from the medical examiner’s office. He’s picking up body parts. The deceased was spread out all over the tunnel.”

We’d arrived too late to see the tape of the crash, he told us. Because the collision had resulted in death, the tape was being reviewed by investigators in a different building. If criminal charges are filed against the driver, the tape will be presented as evidence. We thanked the cop anyway, and went back in service.

As I climbed into the cab of the ambulance, I put on my seat belt like I always do. This time, though, instead of doing it mindlessly, as a matter of habit, I actually thought about what I was doing.I’ve heard arguments against seat belt use. Some people are afraid the mechanism will get jammed. They worry about being trapped in a fiery crash. Others consider seat belts too uncomfortable. The government has no right to require seatbelt use, they say, because it’s a matter of personal choice that affects nobody else.

These arguments are ridiculous. First of all, seat belts don’t jam. I’ve responded to thousands of collisions, and I’ve never seen anyone get trapped in a car—burning or otherwise—by a malfunctioning seat belt. Not one. But I've seen plenty of people die from being thrown out of vehicles—people who would have walked away uninjured if they’d just strapped themselves in.

People must be allowed to make certain decisions for themselves. I recognize that. But I don’t buy the argument that seat belt use affects only the wearer. Head trauma—the usual result of motor vehicle ejection—is ugly. Coma is not a peaceful sleep, as directors of movies and soap operas would have you believe. There are seizures, and involuntary muscle spasms, and constant choking on tracheostomy secretions. Somebody has to care for these patients, and somebody has to pay for it all.

Later this morning, a young woman named Rosaria will wake up in a hospital bed. She’ll be sore, and she'll be concerned about her arm. Eventually, though, she’ll get around to asking about her friend John.And when she does, the doctor or nurse who delivers the bad news will see firsthand just how profoundly one person’s seat belt decision can affect someone else.

Nursing Home Call

One benefit of working for a municipal EMS agency is that we don’t have to transfer patients from one healthcare facility to another. This chore belongs to the commercial ambulance companies—well, most of the time, anyway. A couple of years ago, the state passed a law requiring ambulances to respond to every emergency within five minutes, even when the emergency happens in a nursing home or health center. This created a wonderful loophole for the commercial ambulance companies. These days, whenever they don’t feel like tying up one of their ambulances with a transfer, they dump it on us, citing the five-minute rule. The ambulance company gets paid under its contract with the nursing home or health center, while we do the work.XSuch was the case at five o’clock this morning, when a nursing home at the western end of the city called its contracted ambulance service. For two hours the ambulance service insisted that all of its units were committed to other calls. Finally the staff of the nursing home grew tired of waiting and called 911 instead. That’s how we became involved.

The call was characterized as an “unconscious.” We were skeptical about this from the start—and rightfully so, I think. If the woman was truly unconscious, and if the situation really constituted an emergency, then why did the staff wait so long before finally resorting to 911?

We entered the room to find a white-haired woman snoring softly in bed. Nobody was with her. Her color was good, and to be honest, she didn’t look sick at all. She appeared to be sleeping.

Soon a nurse arrived with an aide. “We don’t know what’s wrong with her,” the nurse said. “Her vital signs are stable. Her blood sugar is normal. We just can’t wake her up.”

I tapped the woman on her hand. She blinked opened her eyes. “Hi,” I said. “How are you feeling?”

“Tired.”

“I’ll bet you are.” I felt sorry for the woman. The whole thing was silly. Imagine being awakened in the middle of the night by a bunch of strangers, for no reason at all. “I’m really sorry,” I said, trying to sound sympathetic. “But the nurses were worried about you. Do you feel sick?”

“No.”

“Do you want to go back to sleep?”

“Yes.”

“Okay. You do that. Good night, now.”

“Good night.”

I resisted the urge to make a condescending remark to the nurse. At five o’clock in the morning, I couldn't be bothered to pick a fight, not even to prove a point. It would be better for everyone if we simply left.

Out in the ambulance, I had the usual paperwork to complete. Even on a call like this one—a call where the patient wasn’t sick, and didn’t require treatment by paramedics—a report must be generated. Like everything else in medicine, documentation has grown increasingly complex in recent years, and we recently abandoned our three-page ambulance call reports in favor of a handheld computer, into which we tap the necessary information.

This time, when I came to the section marked “Type of Location,” I hesitated before checking any of the boxes. The only choice that really applied was “Skilled Nursing Facility.” I found this ironic, considering the circumstances under which we’d been called. The location did qualify as a nursing facility, I suppose. But whether or not it was “skilled,” well, that remains debatable.

A Call as a Form of Entertainment

We meet some interesting characters on this job.

Earlier tonight we responded to a diabetic emergency in a housing project for the elderly. The patient, a 78-year-old man, was awake, but just barely. He was was unable to move, and he groaned in response to our questions. His blood sugar, which should have been between 70 and 120, had dropped to 18, apparently because he'd skipped dinner."This happens about twice a week," the patient's home health aide told us. "He's a stubborn old goat. I make him meals, but then he doesn't eat them, and this is what happens."I asked the patient if he was willing to drink some orange juice. He grunted something that sounded like yes. I dumped several packets of sugar into a glass, filled it with juice, and stirred it into a slurry. "You're going to need this," the aide said, passing me a hand towel. "He tends to make a mess when his sugar is low."I poured a few ounces of juice into the patient's mouth. "Swallow," I said. For a long time he just sat there, motionless, with his eyes closed. Finally he took a gulp.

I poured in some more juice. This time he refused to swallow. The juice dribbled down his chin and onto the towel. "I told you that was going to happen," the aide said, chuckling."If you can't do better than that, we'll need to give you a shot," I told the patient. He grunted in response. I tilted the glass again, and once more the juice drained out onto the towel.

Anticipating this, my partner had already set up the necessary equipment: a IV bag with tubing, a needle, and a pair of syringes--one filled with a sugar solution, the other containing vitamins that must be given along with the sugar.

The patient didn't flinch when I poked his arm with the needle. I injected the contents of the syringes into the IV tubing. Then we stood back to wait for a response.

It didn't take long. Less than a minute later, the patient mumbled something and opened his eyes. Waking from a diabetic coma can be a confusing experience, so I explained who we were and what had happened. "Your sugar was eighteen," I said."Eighteen?" the patient blurted, his eyes suddenly popping open wide. "Are you from the morgue?"

We couldn't help laughing. The home health aide laughed with us. She was a jolly, rotund black woman who was obviously quite fond of the patient in spite of his uncooperative nature. It was obvious, too, that she wasn't afraid to speak her mind to him."I cannot believe you," she snapped at the man in a thick southern accent. "Wasting the time of these nice people. I made you that fine dinner, and you never ate it.""I wasn't hungry," the patient said. "I took two bites and put it in the refrigerator. I was gonna eat later."

The aide scoffed in response. "That didn't do you much good, now, did it?" She was about half the age of the patient, but I couldn't help feeling as if I were watching an old married couple.

"Don't make no difference, anyway," the patient said, fully awake now and pointing at us. "These people are paid to be here. If they weren't here, they just be at somebody else's house."

His observation was an accurate one. Being a Saturday evening, he was right. There were plenty of other emergencies out there.

We checked his sugar again. This time it was 178. One of the EMTs gave him a plate of hot dogs and beans. The patient ate without hesitation. My partner phoned our supervising physician and received permission to discontinue treatment. Diabetics never agree to be transported. Once their sugar returns to normal, there really isn't any need for it anyway, since the emergency department staff only sends them home again. I was just about to remove the IV when it occurred to me that I'd never even offered to bring this particular patient to the hospital. "Oh, by the way," I said, "I'm supposed to ask if you want to go to the..."

The patient knew what was coming. "No, no. I don't need no hospital," he said, cutting me off with a wave of his hand. "And yes, I understand the risks. My sugar could drop again, and I might even die. Blah, blah."

He wasn't being sarcastic; he was just saving me the trouble of a detailed explanation. He'd heard the speech before--many times, obviously. He'd probably been through this routine as many times as we'd been.

On the wall behind the patient I spotted a framed Naval discharge. Taped to the glass was a photograph of a submarine. "What years were you in the Navy?" I asked."Forty-four to forty-six," the patient said. "Right at the end of the war. I tried to go in the army because they had this plan where they sent you to college for two years and made you an officer. But the recruiter took one look at me"--he paused to look down at his own black skin--"and he told me I wasn't the right kind of person for the program. He didn't have to come out and say it, but I knew what he meant."

I was speechless. Enough time had passed, however, that the old man seemed to have gotten over the incident. He continued his story."

I was young and brave and stupid, so I volunteered for the most dangerous duty I could find--submarines. On the first day, they put masks on us and pushed us out of a hundred-foot tower into a pool. A bunch of guys stood at the edge with hooks. Anyone who swam to the top passed. Anyone who had to be fished out with the hook failed. It was supposed to test our ability to escape from a sub if it sank. The whole thing made no sense. Who's gonna swim to the top from a sunken submarine? As soon as you escape, you're dead. The water pressure would've killed us. But those geniuses, they never thought about that."

He paused for a moment and looked around the room, probably to see if we were still interested. We were.

He pointed into his bedroom. Then, looking at me, he asked, "How many people could you squeeze into that room, standing up?"

"Ten or fifteen, maybe."

"They put twenty of us in a room that size. Couldn't hardly breath because were packed in so tight. Anybody who freaked, they failed. That was the claustrophobia test. Can't be claustrophic on a submarine, you know."

He was a delightful old man and I would have gladly listened to him all night. Unfortunately, it was time for us to go. Other calls were waiting.We helped him into a chair. He wanted to stay up for a while and watch television. As we prepared to leave, the aide said to him, "Next time, you eat the dinner I make you!"

"Next time make me something worth eating," the old man said.

The aide held up an empty Evian bottle, as if ready to clobber him with it. "Now, you behave, or else."

"You come after me, you'd better have something more than that," the man said, waving a fist in a mock show of defiance. Suddenly he turned to me. "On second thought, I'd better not tangle with her. She's a farm girl. Grew up on a farm in Mississippi. Farm girls are tough."

I left the apartment with a good feeling. All too often, we walk into emotionally charged situations. For one reason or another, at least one person always seems to be furious. But this call was different. The patient's stories were fascinating. The patient and the aide had a great rapport. Watching them together was like watching a television sitcom. And to top it all off, we were able to fix the patient without even going to the hospital.Too bad all of our calls can't go so smoothly. This one was actually fun.

Deposition

Sometimes we have to appear in court. That’s a part of the job. We respond to the scene of a shooting, and two years later we find ourselves standing in a dusty old courtroom, describing for a jury of twelve bored-looking citizens the size of the entry wound, the amount of blood on the street, and what we were doing at the precise moment our patient stopped breathing. My coworkers hate appearing in court. They find it just as tedious as the jury does. But I like it. I think criminal trials are fascinating. It’s fun to give the defense attorney a hard time when he’s cross-examining me. And besides, the city pays us overtime just to be there.

Over the years, I’ve appeared in close to 100 trials. Half have been murder trials. It came as no surprise, then, that I was served with a subpoena a couple of days ago. This one was unusual, though, because it had not come from the prosecutor’s office. In fact, it didn’t involve a criminal trial at all. I was to give a deposition as a witness in a lawsuit.

I had no idea what I’d be testifying about. The names of the parties didn’t look familiar. The secretary at EMS headquarters knew nothing about the case. She knew only that I was to appear at a downtown law office, and that I’d be met by an attorney for the city who would sit with me and prevent the other lawyers from asking unfair questions. I was just glad not to have been named as a defendant.

This was a much more civilized affair than a criminal trial. The receptionist asked if I needed any bottled water. The twelfth-floor conference room afforded a commanding view of the city. There were no scowling prisoners, no bored jurors, no public defenders barking out objections. The parties to the lawsuit weren’t even there. One lawyer smiled and introduced himself as counsel for the plaintiff. Another smiled and introduced himself as counsel for the defendant. An old lady sat in the corner, typing a transcript of the whole thing, while the attorney from the city—my lawyer—sat in the opposite corner, watching in silence.

I was there to testify as a witness for the defense. The defense lawyer handed me an ambulance report I’d written three years earlier and asked if I remembered the incident. I didn’t. Apparently, I’d witnessed an extremely minor collision even before we were sent to our first call of the night. In the report, I’d written that one car had “gently tapped” another. We took the driver who’d been struck from behind to the hospital, even though her car had not been damaged at all. She was complaining of pain in her left wrist, yet she was carrying a heavy pocketbook with her injured hand. When I asked if she had any pain in her neck, she said no. Now she’s suing the other driver for many thousands of dollars, claiming permanent and severe neck damage, or something like that.

The defense lawyer asked me to read my report aloud. After I’d finished, he leaned back in his chair, looking quite content—satisfied, I suppose, that he’d made his point.

Then it was time for the plaintiff’s lawyer to question me. By this time, I knew what to expect. He would try to make me look as if I didn’t know what I was talking about.

“Do you have any formal training in biomechanics?” he asked, smiling sneakily.

“I took a physics course in college. Does that count?” I wasn’t going to make things simple for him. If his goal was to discredit me, I wanted him to work for it.

He smiled again, and went on to his next question. “When you say that the car was ‘gently tapped,’ what speed are you talking about? Ten miles an hour? Twenty? Thirty?”

“I can’t answer that. There’s no arbitrary point that divides ‘gentle’ from ‘not gentle.’ When I said ‘gentle,’ that’s exactly what I meant—gentle.”

“But surely you can put a number on that.”

“No, I can’t. When I said ‘gentle,’ I wasn’t referring to a specific speed. I meant ‘gentle’ as in ‘not hard.’”

This seemed to throw him off for a moment. I’m sure he was expecting me to name a precise speed, something he could disprove in court. By refusing to give him the answer he wanted, I’d interrupted the flow of his questioning. He leafed through his notes for a couple of minutes while the rest of us waited. I was proud of myself.

“I don’t suppose you inspected the bumper pistons before going to the hospital?” Another sneaky smile. Of course I hadn’t. And he knew it. Not that it mattered.

I smiled right back at him. “No, I don’t suppose I did.”

This continued for another ten minutes or so, the lawyer asking ridiculous questions in a vain attempt to make a case out of nothing. He seemed disappointed that I wasn’t getting flustered. I knew, though, that it made no difference whether I was a biophysical engineer or not, and it made no difference that I hadn’t measured the amount of play in the vehicle’s bumper pistons with calipers. I saw what I saw: one car tapping another one gently, causing no damage. And I heard the driver tell me in her own words that she didn’t feel any pain in her neck. Maybe the woman will be lucky, and she’ll get an especially gullible jury. Maybe she’ll win her case. I certainly hope not, though. The whole lawsuit is ridiculous.

At the end of the proceedings, both lawyers thanked me for coming. I walked to the elevator with the city attorney. “What a bunch of crap,” I said to her.

“Yeah,” she replied. “It sure is.”

The Way We Treat Our Children

I heard a troubling story just now from a paramedic on the day shift.

Yesterday morning, paramedics from my station were sent to a residence to investigate a report of a baby crying. This was the only information they were given. It didn’t sound like much of an ambulance call, but they went on the call without asking any questions.

At the scene, they discovered that the situation had actually begun the previous evening. While getting ready for bed, a man heard what sounded like an infant crying outside his window. He went into his yard to investigate, but the search yielded nothing. He finally gave up and went to sleep.

Early this morning, a roofer at a construction site next door heard crying, too. So did a woman who lived nearby. Three people had now heard the same sound, but nobody could figure out where it was coming from.They formed an impromptu search party, and they wandered from one backyard to the next, trying to pinpoint the noise. As they searched, they hoped they were wrong. They hoped it wasn’t a baby at all.

But it was.

It was the roofer who lifted the cover of the trash can. Inside, he saw blood. Lots of it. Then he saw the baby. It was a boy, with his umbilical cord still dangling from his belly. He was tiny—less than a day old, certainly—and even the roofer, who had no medical training, could tell that the child had been born prematurely. He was still crying, but just barely, and he was blue from a lack of oxygen. The roofer called 911.

The baby was still in the trash can when the paramedics arrived. “He was the coldest thing I’ve ever touched that wasn’t an ice cube,” one of the paramedics would later say. The baby had a pulse, but his heart was beating at about twenty times per minute, a rate incompatible with life. Crying or not, he would soon be dead with a heart rate that low.

The paramedics wrapped him in blankets. They breathed for him. They performed CPR on the way to the hospital. A pediatrician theorized that the cold nighttime air had actually worked to the baby’s advantage, slowing his metabolism and preserving his brain and other vital organs. He responded remarkably well to emergency treatment and was admitted to the Neonatal Intensive Care Unit. He’ll probably survive, the pediatrician said, but it’ll be a long time before anyone will know whether he suffered permanent brain damage.

In Massachusetts, as in many states, a “safe haven” law has been passed that allows desperate mothers to leave their newborns at hospitals and fire stations without recrimination. It was enacted specifically to prevent situations like this one. The law was publicized through a series of television advertisements featuring amateur rap and hip-hop artists. Apparently, the mother of this baby never saw any of these ads. Or maybe she did, but felt she'd get in trouble anyway.

Some acts defy understanding. I responded to a call once where a mother chased her six-year-old daughter around the house with a hatchet. The little girl ran from room to room, screaming in fear, begging for the mother to stop. Finally the hatchet connected with the girl’s head and she went down bleeding. The mother stood over the girl and chopped repeatedly into her skull, once, twice, three times. We arrived to find blood all over the walls and floors of several rooms, with brain visible through holes in the little girl’s head. She was dead.

I never did learn what caused the mother’s tirade. She may have been drunk, or crazy, or perhaps she was just angry and snapped. I didn’t care then, and I don’t care now, because to me it makes no difference. Nobody should die like that, especially not a little kid.

I feel the same way about the abandoned baby. Was the mother scared? Is that why she threw away her newborn? Was she embarrassed? Was she afraid that her family or boyfriend would be upset?To be honest, I’m not interested in why she did it. That was a helpless baby she abandoned. Her baby. She was supposed to take care of him, to protect him, to love him. But instead she threw him out in the trash like the remains of last night’s dinner, leaving him to die from exposure or dehydration or starvation. Nothing explains or justifies that—not fear, not embarrassment, and certainly not inconvenience.

A few days from now, the police will probably identify and locate the mother. That always seems to happen when a baby is abandoned. Someone will recall seeing a woman who appeared to be pregnant, then suddenly wasn’t, and the witness will tell someone else, who will then call the police. Images will run on the evening news of the mother being led into court to be charged with child endangerment, and her lawyer will make the usual excuses for her: She’s young. She was terrified. She had nobody to turn to. She knows it was wrong, but she panicked. And some viewers will actually feel sorry for her.

Not me. I won’t feel sorry for her at all.

I’ve seen children die. I’ve seen parents devastated by the deaths of their children. To most parents, that is the single worst tragedy that can happen to them—worse, even, than dying themselves. I can’t begin to imagine how I would feel if one of my children suddenly died. And yet, there are people in the world who are capable of striking their own children down with axes, and throwing their own babies away like garbage. How is that possible? How can some parents be willing to give their lives for their children, while others literally throw their children’s lives away and think nothing of it?

Like I said, some acts defy understanding.

Sympathy

Not every patient deserves our sympathy. Work in a big-city EMS system for a while, and you can't help reaching this conclusion. Night after night, we respond to calls where the patient is drunk, or has overdosed, or has injured himself through an act of sheer stupidity. These people invite disaster through their own actions, and most of the time they get what they deserve. It’s hard to feel sorry for someone who falls down and splits his head open after drinking three six-packs of beer. Likewise, it’s hard to feel sorry for the patient who picks a fight, gets himself stabbed, then bursts into tears as the IV is about to be started, because “needles hurt.”

The same might be said of people who call 911 for minor problems. Stomach cramps, headaches, sore throats, earaches—these complaints don’t even warrant a trip to the doctor’s office, much less an ambulance ride to the emergency department. But we get called for them anyway, and we do our best to treat these people with courtesy, rather than contempt. We don’t always succeed.

Every so often, though, a patient comes along who has no real emergency, but merits our sympathy anyway. We encountered one such patient tonight. He was 78 years old, and he’d called 911 because he couldn’t breathe. There was nothing wrong with him physically—nothing that required immediate treatment, at least. He was not suffering from asthma, or emphysema, or congestive heart failure. In fact, he quickly told us that he’d felt this way before, as a result of anxiety. It was a panic attack, pure and simple.

To make matters worse, he hadn’t exactly kept himself in shape. He was extremely overweight. If you don’t take care of yourself, then of course you’re going to get sick.As he told us his story, though, we found ourselves feeling genuinely sorry for him. His wife of 36 years had died only the week before. It was a heart attack that claimed her. There was no lingering illness, no way to prepare for her loss. One day she was alive, and the next she was gone.

At 78, his friends have all passed away or moved into nursing homes. His wife was his whole world. They did everything together. Now he faces a future of uncertainty. He wakes up each morning to a silent apartment, where he eats alone, reads alone, watches TV alone. He has nobody to confide in, and he’s having a difficult time adjusting to these changes. His greatest fear is that he, too, will suddenly get sick and die. It happened to his wife, and God knows it can happen to him.

It turned out that he wasn't overweight because of laziness or poor self-control. Some years earlier, he'd lost both of his legs, one above the knee, the other below. He’s confined to a wheelchair now and doesn’t have much opportunity for exercise. Even so, he does his best to remain independent. A nurse stops by a couple of times each week to drop off some insulin and needles, but other than that, he asks for no help.

We listened patiently while he talked. Normally we'd rush him along, not wanting to tie up two paramedics and a pair of EMTs on a call that isn't even close to being an emergency. But there was something about this man that made us want to stay awhile. Maybe it was because he hadn't brought his problems on himself. He was just a helpless old man whose life had taken some seriously bad turns.

After a while, he began to sob. This only made us feel sorrier for him. I found myself looking away. He was miserable enough already. The last thing he needed was a bunch of people staring at him while he cried.At one point, my partner asked if he cooks for himself. He wiped away some tears, sniffed, and smiled sadly for an instant. “I’ve got to,” he said. “I’m Italian.” After all that had happened, he still had a sense of humor.

Near the end, as we were getting ready to leave, I looked around the cramped apartment. There were the usual decorations: black-and-white photographs of him and his wife as happy newlyweds, newspaper clippings, a calendar autographed by a Congressman. But the item that really caught my attention was a baseball cap. Sitting on a kitchen table, amid stacks of bills and bottles of medications, it was embroidered with the words “Chosin Few”—a reference, no doubt, to the bloody engagement fought by the Marines at Korea’s Chosin Reservoir. Above the logo was a tiny replica of a Combat Infantry Badge. Below it, there was a small Purple Heart.

The man is a hero. He fought for his country, and he came away severely injured. He is not a weak man, obviously; he was wounded in battle, yet he never even mentioned his military service to us. But on this particular night, he was scared--as anybody in his position would have been. What he needed, more than anything else, was somebody to talk to.

This patient never asked for our sympathy, but he deserved it. He never asked for our respect, but he'd earned it. We stayed in his apartment for twenty minutes or so. We let him talk for as long as he wanted, then we made some suggestions about home health aids and visiting nurses. As the EMTs brought him away to the hospital for a checkup, we told him to call us back if he ever needed us again.

And for once, we really meant it.