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

Thank the Spammers for This

2009-11-20T19:07:00.002-05:00

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

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

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

Anyway, thanks again for reading.

Heal Thyself

2009-06-13T07:43:00.006-04:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"They told you?" I asked.

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

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

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

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

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

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

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

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

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

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

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

Not So Bad, Maybe

2009-06-04T00:02:00.000-04:00

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

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

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

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

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

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

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

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

Injured

2009-06-02T07:32:00.003-04:00

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

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

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

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

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

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

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

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

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

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

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

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

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

Yikes.

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

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

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

We'll see.

Ironic Justice at the Airport

2009-05-31T06:00:00.008-04:00

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

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

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

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

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

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

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

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

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

And why?

Because she refused to answer a few simple questions.

What's So Funny?

2009-05-29T11:13:00.002-04:00

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

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

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

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

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

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

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

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

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

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

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

You Know Your Patient is Dead When...

2009-05-28T06:31:00.001-04:00

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

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

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

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

"Who called the ambulance?" another EMT asked.

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

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

Memorial Day

2009-05-26T00:40:00.000-04:00

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

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

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

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

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

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

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

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

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

"What branch?"

"Army Reserve."

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

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

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

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

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

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

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

"Sure," he said.

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

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

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

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

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

If You Can't Do the Time...

2009-05-25T09:05:00.004-04:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Haste Makes Waste

2009-05-23T10:34:00.002-04:00

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

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

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

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

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

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

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

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

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

Death on a Motorcycle

2009-05-21T08:21:00.003-04:00

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

And now he was dead.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Even Simple Calls Can Be Rewarding

2009-05-20T06:55:00.002-04:00

We met the most delightful woman tonight.

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

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

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

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

Smart woman.

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

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

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

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

Follow Up: The Cardiac Arrest

2009-05-18T07:44:00.002-04:00

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

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

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

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

2009-05-16T16:35:00.001-04:00

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

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

"Do you feel lightheaded?" I asked.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Almost Back

2009-05-14T23:14:00.002-04:00

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

Thanks for your patience.

Here We Go Again

2009-05-10T09:41:00.003-04:00

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

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

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

More Than One Patient is No Fun

2009-05-10T07:03:00.001-04:00

It just figures.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But I still wish I'd been there.

Another Veterans' Resource

2009-05-09T19:41:00.004-04:00

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

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

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

One More Thing...

2009-05-07T12:07:00.002-04:00

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

Lesson Learned

2009-05-06T23:29:00.007-04:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Questions at the Walk for Hunger

2009-05-04T09:21:00.006-04:00

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

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

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

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

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

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

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

Number 3:

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

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

Walker: I want to sign up for the walk.

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

Walker: Can I still do it?

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

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

Me: Have a good time.

Number 2:

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

Me: Okay. What's wrong with him?

Walker: His legs are sore.

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

Walker: What should I tell him?

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

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

Number 1:

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

Volunteer: A walker?

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

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

Winning the Battle, Losing the War

2009-05-01T09:29:00.000-04:00

The inhaler said it all.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

No Sale

2009-04-29T06:44:00.001-04:00

Someone tried to use us for propaganda just now.

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

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

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

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

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

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

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

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

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

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

"Australia."

"Really? What part?"

"Sydney."

"Are you here for long?"

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

"Well, enjoy your stay."

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

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

A Call That Went Right

2009-04-28T07:07:00.004-04:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Little Variety, Please

2009-04-25T17:20:00.000-04:00

I want a shooting.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Emergency Departments Calling Ambulances for Emergencies

2009-04-22T07:47:00.002-04:00

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

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

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

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

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

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

As always, thanks for reading.

Random Thoughts from the Marathon

2009-04-21T06:45:00.003-04:00

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

I decided to run the Boston Marathon yesterday after all.

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

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

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

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

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

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

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

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

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

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

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

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

Marathon

2009-04-20T06:37:00.003-04:00

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

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

But I don't know whether I will.

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

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

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

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

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

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

I'm still trying to decide.

Phones

2009-04-19T10:40:00.005-04:00

Last week we went into the homeless shelter on Long Island. The patient was supposed to be having a cardiac event of some kind, but it turned out to be a mild case of pneumonia.

As we walked through the lobby, we saw at least a dozen shelter "clients" talking on cell phones. I didn't think anything of this, because you see cell phones everywhere these days. It certainly caught my partner's attention, though. He said, "I don't get this. These people can't afford a place to live, but they can afford cell phones?"

Then, outside, as we put our equipment back into the ambulance, he said, "Come to think of it, how do they keep their cell service? Where do the bills get sent?"

Not bad questions, I thought. I had to admit that I had no idea.

Since then, I've begun to notice that probably half the homeless people we encounter have cell phones. This strikes me as bizarre. These people sleep in doorways, and they eat other people's leftovers out of trash barrels, yet they have the ability to communicate electronically at will. Doesn't this seem a little backwards? I mean, when you don't have anyplace to live, how many truly pressing phone calls do you really have to make?

The idea that cell phones represent a method of getting help in an emergency is not lost on me. Phone companies are required by law to provide 911 service to subscribers even after their service has been cut off. And I recently heard about a Massachusetts government initiative that would give free cell phones to the underprivileged, to ensure access to emergency services. But the men in the shelter weren't calling 911. I could tell from the nature of the conversations that they were chatting to their friends. And so we come back to the original questions: Where did they get these cell phones? Who pays to maintain their service? And if they don't have a home address, where does the monthly bill go? To the shelter, perhaps?

Also not lost on me is the idea that cell phones have largely made pay phones unnecessary. I was looking for a pay phone the other day, having left my cell phone at home, and I was amazed at just how few pay phones still exist. From Kenmore Square I had to walk all the way to Boylston Street and Massachusetts Avenue--a distance of roughly a mile--just to make a quick phone call home. Pay phones used to stand on practically every corner, but not any more. Owning a cell phone has become a fact of life.

But even so, if I had to choose between eating and having cell service, I think I'd choose to eat.

Thanks to the anonymous reader who asked the question that prompted this post. If anybody knows the answers to these questions--where do homeless people get cell phones, who pays for the service, and how do the bills get paid--please feel free to educate us. This is not an attempt to belittle the homeless. I really have no idea how this works.

A Theft Doesn't Take Long

2009-04-17T00:30:00.003-04:00

Most choking calls have nothing to do with food. More often than not, they turn out to be seizures. The gurgling noise sounds to most bystanders like choking, so that's what they report to 911.

Every so often, somebody really does choke, of course. We responded to one such call tonight. When a woman swallowed some beef the wrong way at a Chinese restaurant, her companion jumped up and performed the Heimlich maneuver, relieving the obstruction just as she was about to lose consciousness.

By the time we arrived, the woman seemed fine. She agreed to an emergency department visit anyway, to make sure the Heimlich maneuver hadn't caused any damage. As we were walking out the door, a young man asked if we could call the police for him. When we asked what had happened, he said his car had been stolen.

"I'm a pizza delivery guy," he told us. "I was delivering a pie right next door, and I left my car for no more than five minutes. I saw the lights of the ambulance, so I rushed back out, and my car was right here. Now it's gone!"

The EMTs took the choking victim to the hospital. As we waited for the police, we learned more about the pizza guy.

"I'm a college student," he told us. "I took this job because it gives me free food. People order a pizza, and if it turns out to be the wrong kind, then I get to eat it. As long as I don't mind eating pizza every night, I never have to pay for my dinner."

Ten minutes went by, and still we were waiting. Unfortunately, a stolen-car report doesn't exactly rate a high-priority response from the police department. "Was it a nice car?" I asked.

"Nah. About ten years old. A Ford Escort. But my wallet and cell phone were on the front seat."

The police station was only a couple of blocks from the restaurant. "Hop into the ambulance," my partner finally said. "We'll bring you over there. You can make the report at the desk."

We delivered the man to the police station. He thanked us and trotted inside. All sorts of drama had taken place, but in the end, the only person we helped had nothing to do with our call.

Who Wouldn't Want to Help This Guy?

2009-04-15T01:30:00.001-04:00

He'd already called 911 once, for a nose bleed. An ambulance responded, but the man was more interested in arguing with the EMTs than in going to the hospital. So they left.

An hour later, he called back. This time he reported all sorts of medical problems--a headache, tingling in his arms and legs, even a toothache. Unfortunately, he gave the 911 operator the wrong address. The ambulance arrived for a second time, and the EMTs looked around, but the patient was nowhere in sight. So again they left.

A short time ago, the man called a third time. This time he insisted he was having a heart attack. The same ambulance was dispatched again. And because the call was now classified as a "cardiac disorder," we were dispatched as well.

The ambulances arrived together. We found the man in the doorway of an office building, eating dinner from a Styrofoam container. "My chest hurts," he said as we approached. "Take me to the hospital."

"Fine," one of the EMTs said. "Let's go."

The man stood up. He was packing up his food when the EMT interrupted him. "We can't let you take food in the ambulance," he said. "It's not a very sanitary environment. And besides, you've got some kind of sauce in there. It's going to get all over the place."

This sent the man into a rage. "This is my food! Mine! I'm taking it with me, and you can't stop me!"

"No, sir, you're not taking it," the EMT said calmly. "We'll take you to the hospital , but you'll have to leave the food here."

The man responded by muttering, "Dumb, stupid jackass," and slamming the food box into a nearby trash barrel. "There!" he shouted at the EMT. "Are you happy now?"

"Not especially," the EMT said.

The man looked as if he was about to have a stroke.

"Come with me," I said, trying to defuse his anger. The ambulance is right here. Step right in, and I'll take you to the hospital."

The man glared at me. "I want your name!" he shouted.

"You want my name?" I asked. "For what? What did I do?"

"You tried to say there wasn't any blood on that tissue!"

"Blood on the tissue? What tissue? I have no idea what you're talking about."

The man stared long and hard at me. "Are you honestly going to tell me," he snarled, "that you didn't talk to me about the tissue?"

I shook my head. "Sir, I have no idea what you're talking about. I asked if you wanted to go to the hospital. That's the only conversation I've ever had with you in my life."

One of the EMTs stepped in between us. "That was me you talked to, jackass! You called for an ambulance an hour ago. You insisted that your nose was bleeding, and it wasn't. You owe that other guy an apology!"

"Yeah, well..."

"Do you want to go to the hospital or not?" I asked.

The homeless man pointed at the EMT. "I'm not going anywhere with him!" Then, for some reason, he flopped down in the middle of the sidewalk. A young, well-dressed man who happened to be walking by said, "I feel sorry for you guys. I don't know how you deal with shit like that."

"Get up," one of the EMTs said, reaching for the man's shoulder.

"Get away from me!" the man shouted. "You have no right to touch me! I'm going to report you to the police!" He took out his phone and started to call 911 again. Just then, a police officer arrived.

The homeless man jumped up to plead his case. "These assholes put their hands on me! They won't take me to the hospital! I want you to arrest them!"

The cop stood there for a moment, sizing the man up. Finally he said, "These people are trying to help you. Do you want them to bring you to a hospital or not?"

"NO!" the man shouted at the top of lungs. "I DON'T NEED THEM! I'LL WALK TO THE FUCKING HOSPITAL!"

"Fine," the cop said. "You do that. But I'll tell you this. You're creating a nuisance. If you call again, I'm locking you up." Furious, the homeless man wheeled and stormed away.

"All that nonsense," one of the EMTs said, shaking his head as we walked back to our trucks, "and he doesn't even go to the hospital. And he threw away his dinner. He's going to regret doing that."

All I could do was shrug. We climbed into our cabs, and drove away.

Justice of Sorts

2009-04-13T01:30:00.000-04:00

We respond to a fair number of calls in jail cells. Most are not serious. Prisoners will do almost anything to get out of their cells for a while, even if it means faking an illness.

Midway through tonight's shift, we were sent to one of the city's police stations. Our patient was a twenty-one-year-old woman locked up for shoplifting. She claimed to have asthma, but she had no idea what kind of medicine she was supposed to be taking. When I listened to her breathing, she made gasping sounds. Then, when I put away my stethoscope, the gasping suddenly stopped, and she once again breathed normally.

Whether prisoners appear to be faking or not, we have to provide them with medical care. Since we couldn't do anything for her in the cell, I asked if she wanted an emergency department evaluation. Of course she said yes.

We explained the situation to the police officer in charge of the cells. He pulled out her file and scanned the charges. When the crime is minor, the cops will release the prisoner to us with instructions to show up in court the next day. Most times, the prisoner doesn't even wait in the emergency department to see the doctor, let alone appear in court. She'll disappear as soon as we get to the hospital, and eventually an arrest warrant will be issued.

This time, the officer shook his head. "She was picked up tonight for shoplifting, but she already had arrest warrants for assault, assault with a dangerous weapon, and assaulting a police officer. She's not going anywhere without bail. Not by herself, anyway. If she goes to the hospital, we'll have someone guard her."

We returned with the officer to the cell, where the prisoner was sitting on her bench, breathing comfortably. "You want to go to the hospital?" he asked.

The prisoner shook her head yes.

These situations put everyone in a difficult predicament. Once a prisoner has been locked up, she can no longer decide for herself whether to seek medical treatment. For this, she must rely on the police officer or deputy sheriff guarding her.

The officers take this responsibility seriously. They know that most of the prisoners who demand treatment are faking. But they also know that ignoring a serious illness can have disastrous consequences. And since we know more about illness than they do, they inevitably call us to examine the patient.

Unfortunately, we soon find ourselves in the same predicament. We can examine the prisoner, of course, and check her blood pressure and EKG. But we can't make any kind of definitive diagnosis. For that, she needs to go to a hospital, where they have laboratories, and x-ray machines, and other diagnostic tools.

Like the officer guarding the prisoners, we can't afford to guess wrong. So we almost always decide to bring the prisoner to the hospital. We tie up an ambulance, and a pair of EMTs or paramedics, and a police car, and two cops--all for a medical problem that might not even exist. But this can't be avoided. Better to transport her, and learn that it was all an act, than to find the prisoner dead in her cell the next morning.

And so tonight we arranged for the shoplifter to be transported. We informed the dispatcher that the ambulance would be tied up for a while, and the police officer requested a two-man unit to serve as her escort. "You're not being released," he told the prisoner. The officers will guard you at the hospital while you get treated."

The prisoner shrugged. She didn't care about the details. Getting out of the cell was all that mattered.

The cop started to walk away. But then he stopped and turned back toward the prisoner. "Since you've been arrested before, I'm sure you know that you'll miss the bail bondsman.

The prisoner had been staring at the floor, but now she looked up. "What does that mean?"

"It means you were going to get bailed out tonight, but now you'll come back here when you're finished, and you'll spend the night in jail."

A shocked look came to her face. "What? Why?"

"The bondsman only comes here once a day. He's going to come while you're at the hospital. So after you get treated, you'll have to come back here. Tomorrow night is the earliest you can get bailed out."

The prisoner looked horrified. "No, wait! I changed my mind! I don't need to go to the hospital! I'll stay here!"

So much for the asthma attack.

The cop just shrugged. "Sorry. Too late. You wanted to go to the hospital, so I called for an escort. Now that your medical problem has been documented, you have no choice. You've got to go."

The prisoner shot a furious glance at the cop, and then at us. This wasn't what she'd had in mind at all. Asthma was supposed to be her ticket out of jail.

But it wasn't. Tonight, ironically, it was the thing that kept her in.

Happy Ending for a Terminally Ill Patient

2009-04-11T04:01:00.002-04:00

The call came from the staff of a nursing home. One of their patients, a man with terminal lung cancer, had suddenly lapsed into unconsciousness. They'd called a commercial ambulance company to have him transferred to the hospital, but the company had no ambulances available. So instead of responding, it did what the public would do: The ambulance company called 911.

Halfway to the nursing home, the dispatcher gave us an update. "This patient has a DNR and DNI in effect." DNR stands for "do not resuscitate." DNI stands for "do not intubate." The patient did not want to be kept alive artificially. When the end finally came, he wanted to slip away quietly, with no CPR, no cardiac medications, no ventilators. He'd discussed this with his doctor and relatives, and they'd concurred.

There wasn't much point in sending paramedics to this call. No matter how bad the patient's condition was, we weren't going to do anything for him. He was to get a ride to the hospital, and nothing more. The EMTs who were responding to the call at the same time could handle that chore as well as we could.

Unfortunately, the 911 system of Boston EMS--like those of practically all EMS systems in America--isn't designed to take such factors into account. The patient was reported to be unconscious, and paramedics were available, so the dispatcher was supposed to send them, whether they'd actually be needed or not. I decided not to worry about it. If nothing else, it would probably be an easy call. I wouldn't need to start an IV, or intubate the patient, or do anything else.

We arrived at the nursing home just as the EMTs were arriving. The elevator deposited us on the third floor, and we located the patient's room at the end of a corridor. At first, I felt as if I'd walked in on the wrong patient. There were no nurses or doctors in the room--only a middle-aged man--a visitor, apparently--sitting in a chair beside an old man who appeared to be asleep.

The visitor introduced himself as the patient's brother. I asked what had happened. "He was fine until about forty minutes ago," he told me. "He was talking, and then he just stopped. He's been like this ever since."

"Does he have a DNR order?" my partner asked.

"No. Not that I know of."

The absence of a DNR would change everything, of course. We'd have to intubate the man, whether his death was inevitable or not. And if his heart stopped, we'd have to perform CPR. Nobody wants to die that way--with strangers pumping on your chest in a futile lifesaving effort. But without a DNR, we would have no choice.

"Let's check his blood sugar," I said to one of the EMTs. With no history of diabetes, this was unlikely to be the cause of his unconsciousness. This was the one cause that we could easily correct, however, so it wouldn't hurt to investigate.

The EMT took a drop of blood from the man's finger. A moment later, the screen of the analyzer flashed "22." His sugar had dropped to a fraction of what it should have been. No wonder he was unconscious.

Perhaps the cancer had spread to the man's pancreas, interfering with his insulin production. Whatever the cause, the low blood sugar had to be corrected immediately.

My partner removed a syringe filled with dextrose from the suitcase that holds our stock of drugs. I plugged it into the IV on the man's arm. The reaction was incredible. Within seconds, the man had begun to stir. Just a minute later, he was answering my questions.

A nurse came into the room. "Are you taking him to the hospital?" she asked.

I told her about the sugar. "Oh my God," she replied, noticing for the first time that her patient was now awake. "It never occurred to me even to check that!"

By this time, another woman had come into the room. This was the patient's sister, who also happened to be his health care agent. This gave her the authority to make health care decisions on behalf of her brother.

I told her what had happened. She asked if he still needed to go to the hospital. That decision was up to her and her brother, I said.

Leaning down over the bed, she asked, "Do you want to go to the hospital?"

"No," the patient groaned. "I want to stay here."

The biggest problem, I told the sister, was that we had no idea why his sugar had dropped so low. And because we didn't understand the cause, it could easily drop again. It might be safer, I said, for her brother to be evaluated in an emergency department.

Just then, the nurse came back into the room. She'd called the patient's doctor, who'd ordered an IV dextrose with hourly blood sugar checks. This would allow the nursing staff to keep his sugar at a safe level, while at the same time honoring his request to remain in his room.

The patient was glad to hear that he wouldn't need to spend the night in a hospital. The sister was glad that we'd brought him out of unconsciousness. In fact, everyone was happy with this outcome. Given that we'd expected to transport an unconscious man to the hospital, with no amount of treatment likely to make any difference, this was a very good result.

One of the EMTs summed it up best: "On the way to this call, I envisioned a dozen different outcomes. But this wasn't one of them."

Showing My Age

2009-04-08T12:03:00.002-04:00

Earlier tonight, someone tacked a set of defibrillator paddles to a wall inside our station. At first I assumed they were broken. Someone must have removed them from the machine and replaced them with a new pair.

But halfway through the shift, as I walked past those paddles for about the fourth time, it suddenly occurred to me that they couldn't have come from our defibrillator. Defibrillators haven't been equipped with those things for years. Instead we use disposable plastic pads that stick to the patient's chest. That's how we shock failing hearts these days: Stick the pads to the chest, plug them into the defibrillator with a pair of wires, push the "shock" button on the machine, and defibrillate by remote control.

Like many Americans, I first saw defibrillation on TV. As a little kid, I watched a pair of Los Angeles County paramedics lean into those paddles each week on NBC's firefighting drama Emergency. I didn't understand how defibrillators worked, but I loved the way the patient jumped in response to the electricity.

This started me thinking: What else has changed in the 24 years since I became a paramedic?

Here's what I came up with:

Then: Our cardiac monitors only showed one view of the heart. To look at other views, we had to peel the adhesive disc from the patient's chest, move it to another spot, and take another EKG.

Now: Our cardiac monitor/defibrillators, which cost upward of $12,000 apiece, show us twelve views of the heart simultaneously, with the touch of a single button. They also monitor the amount of oxygen in the patient's bloodstream, the depth and frequency of his breathing, and the amount of carbon dioxide he exhales. If his heart stops beating entirely, we can program it to function as a pacemaker. I'm looking forward to the next generation of defibrillators, which will probably come with IPod and DVD capability.

Then: Before treating a patient, we had to contact Boston City Hospital by radio, to ask a doctor for permission.

Now: We make virtually all treatment decisions on our own. The physicians grew tired of answering the radio every fifteen minutes, so instead they developed a comprehensive series of "standing orders" that allow us to function almost independently. We no longer have to ask for permission to start IVs or give medications. We can decide for ourselves whether our patient needs a tracheotomy. We no longer have to consult with doctors about drug dosages, or the proper choice of a hospital destination, or what we should have for lunch.

Then: We carried something like fourteen different medications. We had one medication for asthma, one medication for heart attacks, and a couple of medications for cardiac arrest.

Now: We carry more drugs than a Walgreens. We have three different asthma treatments to choose from. For heart attacks, we can give metoprolol, adenosine, diltiazem, amiodarone, nitrogycerine, and aspirin. We have an impressive array of narcotics, too--morphine, valium, etomidate, vecuronium, and fentanyl. And if these don't cause the patient to hold still, we can always give succinylcholine, a potent substance that instantly paralyzes the entire body and stops the patient from breathing.

Then: Our ambulance was built on a Ford F-150 pickup chassis. It broke down frequently.

Now: The city buys some of the biggest ambulances on the market. Roughly the size of fire engines, they cost more then $200,000 apiece. When these trucks break down, I can't help asking, "What do you expect for a quarter of a million dollars?"

Then: I knew all of my coworkers. Some enjoyed responding to trauma calls, and others were strong clinicians. I knew which EMTs I could count on, and which ones had to be watched.

Now: The city has hired so many new EMTs that I regularly respond to calls with people I've never met before.

Then: The EMTs at the communications center based triage decisions on experience and common sense. If a caller complained of chest pain after getting kicked in the side, the EMT would think to himself, "That sounds like a rib fracture, not a heart attack." He'd classify it as an injury, and dispatch a team of EMTs. Most of the time, he'd be right.

Now: Communications personnel aren't allowed to waste time figuring out what happened. Instead, they are given specific questions to ask for each type of problem. A caller complaining of chest pain will be asked his age--and not much else. He might have broken ribs, or the pain might might be caused by pneumonia. But the EMT taking the call will never learn about these things, because he's no longer allowed to ask. You have chest pain? You're over the age of forty? I'll send an ambulance, and paramedics, and firefighters. You must be having a heart attack, because according to my triage cards, chest pain can only be one thing.

EMS has changed quite a bit during the past two decades. But I'm not entirely convinced that all of these changes have been positive. Sure, we provide more kinds of treatment than ever before. But is it possible that we've strayed too far from our original mission? Paramedics are not doctors, after all, and the ambulance is not a hospital. The more medications we administer, and the more types of procedures we perform, the longer it takes us to get the patient to the emergency department.

And isn't isn't that what we're really supposed to be doing? Bringing people to the hospital?

Photo by the author

So That's Where 911 Calls Come From

2009-04-05T09:14:00.001-04:00

I was away from the ambulance today, performing some military duty in the city of Brockton, Massachusetts. An Army transportation unit has been mobilized for deployment to Iraq, and along with two other legal officers, I was assigned the grim task of ensuring, among other things, that each soldier's will had been properly drafted.

On my way home, I heard a report on National Public Radio about an unusual long-distance 911 call. It seems that a young man in Oxfordshire, England had been communicating via Facebook with a young woman in the United States, and in the process had dropped some hints about harming himself. The female contacted local law enforcement authorities, who contacted national authorities in Washington, D.C., who contacted British authorities in London, who contacted police and EMS agencies in Oxfordshire. When the Police Constables and ambulance personnel arrived, they found the boy unconscious but alive. They took him to the hospital, where he is expected to recover.

That was quite a 911 call, I thought to myself. Or, quite a 999 call, as they call them in the UK. Someone reports an emergency in the United States, triggering an ambulance response in Great Britain.

Geographically, that's the longest 911 call I've ever heard about. Not that I haven't responded to some similar calls myself. It's not unusual for people to call police headquarters in Boston, to request that we investigate the welfare of a relative. The last time I responded to such a call, it originated in Nebraska. And before that, I responded to one placed in Sacramento, California.

Those are tricky calls to handle, because it's hard to gauge the veracity of the caller. The 911 operator is dealing with an anonymous voice at the opposite end of the country and passing the information along to us. It's not as if the caller is standing right next to the patient, or has even seen the patient recently. Usually, the report involves something like, "I've called my brother three times this week, and he hasn't answered the phone. Can you go and check on him? It's not like him to ignore me, so I'm worried about him."

What's the proper reaction to such a request? How far should we reasonably go? If we break down the door and find that the patient isn't home--as is often the case--then he'll likely present the repair bill to the city with a demand for reimbursement. On the other hand, if we leave without searching the building, and he's lying on the floor in a diabetic coma or something, the outcome can be much more tragic.

It's hard enough getting a straight story from a caller who's standing right next to the patient, let alone from someone who's merely theorizing about a problem that may not even exist. But that's the way we get some calls.

It's amazing that the situation in England ended as happily as it did. Plenty of things could have gone wrong. The boy might have been playing a practical joke on the girl who called. She might have misinterpreted his message. Or she might have ignored him. She might have reported the situation to a local authority who downplayed it as a trivial matter. Or the English authorities might have refused to act on the report. I can't begin to imagine how they tracked the patient down. Even today, with a 911 system that displays the caller's address on a screen right in front of the telecommunicator's eyes, we still get sent to incorrect addresses sometimes.

And yet, from a call placed in the United States, an ambulance responded to a correct address a continent away.

I find that incredible.

The Nurse Who Cried Wolf

2009-04-03T09:40:00.008-04:00

The call came in at the height of rush hour. A man was said to be having a heart attack at one of the city's numerous homeless shelters.

It took as a while, since traffic was so heavy, but eventually we arrived. A police officer was standing at the front door. He waved his arms in a downward motion, telling us to slow down. Perhaps it was a false alarm.

As I climbed down from the cab, I could see someone else on the sidewalk, an older man in a wheelchair beside the cop. "It's not a heart attack," the cop told me. "This is the patient. He was thinking about hurting himself."

"You're not having any chest pain?" I asked.

"No. I was upset before, and I was thinking about cutting myself, but I'm fine now. Really."

"I'm glad you're feeling better, but I'm just curious. Why did we get this as a cardiac call?"

"The nurse told me to say I was having a heart attack. He said I'd get an ambulance faster that way."

"Oh, he did, did he? What's the name of this nurse?" I asked.

"His name is Bob." Then, turning, he pointed to a man in a scrub shirt and said, "There he is, over there."

I motioned for the nurse to join us. "This man says you told him to say he was having a heart attack," I said. "Is that true?"

Bob laughed. "Oh, I was just kidding. I, um, was talking to somebody else."

"Well, somebody took you seriously. It was called in to 911 that way, and it came over the radio as a cardiac problem. We just came flying through rush-hour traffic because we'd been told this man was having a heart attack."

"Whoever said that must have been confused, because I never said anything about a heart attack to anybody."

This made me angry. "Now you're just lying," I said. "Less than a minute ago, you told me that you said it, but that you were kidding. Now you're telling me that you never said it at all. Both of those statements can't be true. So, which time were you lying? When you said it was a joke, or when you said you never talked about a heart attack?"

"I, um..."

I pointed to the man in the wheelchair. "We need to take care of this guy. I'll talk to you later."

By this time, an ambulance staffed by EMTs had arrived. As I told them what had happened, the patient started to wheel himself away.

"Whoa, where are you going?" I asked.

"I don't need an ambulance. I don't need a hospital. I was upset before, but I just want to forget about the whole thing."

"We really can't do that," I told him. "If you were talking about hurting yourself, then you need to talk to a doctor."

"I'd rather not."

Suddenly another man came over to us. He introduced himself as the shelter supervisor. He'd seen the patient wheeling himself away, and he was concerned because it appeared that we were refusing to bring him to the hospital.

Things were getting complicated. I felt as if I had to clarify the situation for the supervisor, but I also needed to coax the patient into the ambulance. I couldn't do both things at the some time. The supervisor seemed like a reasonable person, so I asked him to please be patient and wait for just a moment. I promised to explain once we'd sorted everything out.

Fortunately, he agreed. I turned my attention back to the man in the wheelchair. "How where you planning to hurt yourself?" I asked. "You said something about cutting yourself, didn't you?"

"I have a razor knife inside," he said. "I was going to cut my wrists in the bathroom."

This was a bad sign. The more concrete the suicide plan is, the more likely the patient is to carry it out. This man's plan was about as concrete as it could get. One way or another, he would need to be evaluated in the emergency department.

The negotiation lasted a good ten minutes, but in the end, we convinced the man to visit the ED. I helped the EMTs to lift him into their ambulance, and once they had gone, I went back inside to speak with the supervisor.

"Thank you for your patience," I began. "I'm sure it looked as if we were not going to take him, based on the fact that we wheeling away from us. But that wasn't the situation at all. He'd decided not to go, and of course we couldn't let that happen. Because you're right--he absolutely needed an evaluation. Rather than forcing him into the ambulance, we tried convincing him first. Fortunately, it worked. We never had any plan to leave him here."

"Thanks for clearing that up," the supervisor said. "Now, was there some other problem? Something involving our nurse?"

"There was. He told the patient to report that he was having a heart attack, so the ambulance would come faster. As you can imagine, we have a small problem with that."

The supervisor looked stunned. "Certainly. Let me assure you that I definitely get to the bottom of this. We have policies that prohibit exactly that sort of thing. I will take this very seriously.

That was great to hear. Not because I was anxious to make trouble for the nurse, but because the public generally doesn't consider the problem of fake 911 calls to be important. This guy really seemed to get it.

Suddenly it occurred to me then that I hadn't seen the nurse in a while. We respond to this shelter just about every night, which means that we'll with all of these people many more times in the future. There was no point in letting this devolve into an antagonistic relationship. As frustrated as the nurse had made me, I felt as if we should try to patch things up. The shelter supervisor offered to bring us to him.

My partner and I followed him into the shelter clinic. "Hi, Bob," I began. "Listen, we come here on calls all the time, and I don't want you to think we're trying to make trouble. Do you understand why this call bothered us?"

Bob remained silent for a moment, staring down at the floor. My goal was to open a dialogue, so we could put the incident behind us. But he expression told me that I was just making him angry.

"I never said to report a heart attack," he finally said.

"Well, somebody did." I didn't want to have another argument about what had been said, but there seemed no avoiding it. "Somebody called nine-one-one and reported a cardiac problem. The patient says you told him to do it. He's been honest with us about everything else, including the fact that he'd been thinking about cutting himself, so I tend to believe him. The two of you were the only ones involved, and he says you told him what to say. If I'm missing something, or if there's some other explanation, then please tell me about it."

Bob's shoulders and began to shake, and soon I could see that he was sobbing. My partner handed him a tissue, so he could blow his nose. We waited until he'd settled down, then I held out my hand. Reluctantly, he shook it.

The shelter supervisor escorted us back outside. "I'm sorry for the all the trouble," he said. "We try to reinforce the need for honesty among our clients, and we need to practice what we preach. We have strict policies about this kind of thing. Thank you for bringing it to our attention."

I have no idea what will come of this, if anything at all. It must difficult to recruit professionals for work in homeless shelters, and I have no desire to see Bob fired. But I suppose that's precisely why this aggravates me so much. If Bob really is a professional, then he has a duty to act like one. As a nurse, he should understand better than anyone else in that shelter that it was wrong to make what amounted to a false emergency call. It's bad enough that homeless people do this, but we can't necessarily blame them, because they sometimes don't know any better.

But a registered nurse? He knows better. And if he really doesn't understand that what he did was wrong, then he has no business working in that setting.

Should've Just Tied a String to a Door Knob

2009-04-01T09:01:00.001-04:00

We were called to a dental college just now, for a woman whose blood pressure had dropped while having a broken tooth repaired.

This wasn't an unusual occurrence, it seems. The campus police officer who met us at the front door said it was the third time today that one of their patients had gone out by ambulance. Apparently, a fair number of patients simply panic in the middle of procedures. Their blood pressures plummet, and some of them pass out.

This time, the patient was fortunate. She became pale, but remained awake. In fact, she didn't even want to go to the emergency department. When she learned that she was going to go by ambulance to another part of the hospital on the opposite side of the same block, she looked as if she wanted to curl up and die of embarrassment.

I have to give the dental staff credit. We respond fairly often to doctor's offices, to treat patients who aren't particularly sick. Often, it's purely a matter of the doctor panicking. Having not dealt with an emergency since medical school, a dermatologist or urologist or family practitioner might not be able to distinguish an asthma attack from a anxiety attack.

This time, though, the doctors did everything right. They took vital signs. The started an IV. They lowered the patient's head and raised her legs. By the time we arrived, they'd already compiled a list of medications the patient was taking, as well as the medications they'd administered during the procedure. And best of all, they remained calm, telling us what had happened in a professional, yet matter-of-fact way.

The patient's blood pressure had returned almost to normal, but it was still low enough to warrant a trip to the emergency department. As we wheeled the woman out through the waiting room, the other patients looked at us with horrified expressions. Trying to lighten the mood, I said, "Don't worry, folks. Not every dental procedure ends this badly."

The patient laughed. She thought it was pretty funny. Most of the people in the waiting room laughed, too.

But as we left, most of them still looked nervous.

A Chair, an Ambulance, and a Hospital

2009-03-28T09:22:00.002-04:00

Right at the start of the shift, we responded to one of the city's libraries, where a man was reported to be unconscious. Not surprisingly, he wasn't unconscious at all. He'd fallen asleep while reading a collection of English literature, and because he had the speakers of an MP3 player stuffed into his ears, he hadn't heard the librarian asking if he was okay.

The man was sitting in a wheelchair. According to the stencil on the back, it belonged not to him, but to Massachusetts General Hospital. Like many homeless people, he'd adopted it during a recent visit to the emergency department.

We wheeled the man outside. He refused to go to the hospital, claiming only to be hungry. When we told him that we didn't have any food, he wheeled off down the street.

Four hours later, the same team of EMTs who'd responded with us to the library was called to an intersection not far away. There they found the same man, crawling in the street. "What happened to your wheelchair?" one of the EMTs asked.

"They took it away," he said.

"Who?"

"The people at the hospital. I went over there to ask for some food, and the security guard said it wasn't mine. He made me get out of it!"

"Where are you going now?"

"Up to the bank. That's where I live. In the ATM lobby."

The EMT watched for a moment as the man started to crawl away. "No," the EMT finally said. "You can't do that. You're in the street. A car's going to run you over."

"I'll be fine," the man snorted. "I just need to get to the bank."

"We can't leave you in the street," the EMT said. "We're taking you to the hospital."

But the man wasn't having any of it. "I don't need no hospital," he said. "I just need to get another wheelchair."

"Well, I'll tell you what," the EMT said. "We have to bring you to the hospital. We'll put you in a wheelchair. Whatever happens after that is up to you."

They loaded him into the ambulance and brought him to the emergency department. Then they placed him in a wheelchair and rolled him into the triage area.

"What if I left right now?" the man asked.

"You can do what you want," the EMT told him. "We did our job. We brought you to the hospital. If you leave without being examined, that's your business." Looking across the vast expanse of wheelchairs that always remain parked just beyond the triage desk, the EMT then said, "I doubt they'll miss one of these chairs. But I recommend not drawing attention to yourself."

The homeless man spun around in the chair and aimed toward a steep ramp. Before the EMT could say anything, the homeless man rocketed himself downward at near-supersonic speed, and with a tremendous racket, flipped upside down, coming to rest between a pair of parked ambulances.

EMTs and security guards came running from every direction. "Are you okay?" they all asked simultaneously.

"Yeah, fine."

"What were you doing?" asked the EMT who'd brought him to the hospital. "I told you you not to draw attention to yourself! That doesn't include going nine hundred miles an hour into traffic!"

"Where'd this guy come from?" a hospital security guard asked.

The EMT told him what had happened. The security guard said, "Well, whoever took the chair away from him the first time is stupid. That's just making work for all of us." Together, the EMTs and security guards helped the man back into the chair. To the homeless man, the security guard said, "Go on, get out of here."

And so he did. After two ambulance responses, one crash, and two brushes with hospital security, he was right back where he'd started from, wheeling happily up the street in his borrowed chair.

A Call That Was for the Birds

2009-03-26T08:03:00.000-04:00

"I'll probably hear some more bird comments on the radio tonight," one of the EMTs said at shift change tonight.

I asked what he was talking about.

"You must not have been working," he told me. "A couple of nights ago, we responded to the John Hancock Tower. A cop had requested an ambulance because he needed a blanket. When we got there, a crowd was gathered on the sidewalk, and there was this hawk standing in the middle of all the people."

"A hawk?"

"A hawk. Somebody said it was a red-tailed hawk--not that I know the difference between one hawk and the next. Anyway, according to the cop, the thing had been unconscious on the sidewalk. Some lady said it had been lying there on its back, with its claws up in the air."

"What happened to it?"

"Well, I'm no detective, but I looked at the building's glass wall, and I saw a pair of scratches that looked just like the bird's claws. It must have been flying straight toward the building, and it realized too late that it was seeing a reflection, and not the sky. Apparently, it crashed right into the glass."

"Was it hurt?"

"According to the witnesses, it knocked itself unconscious. By the time we got there, though, it was sitting up and looking around. This other lady said she'd seen a program about hawks on the Discovery Channel, and that they'll remain calm if you cover them with a blanket. That's why the cop had called us--he wanted us to cover it with a blanket. But I'm looking at this bird, and it's about two feet tall, and it looks angry, so I didn't want anything to do with it. I gave the blanket to the cop. If the woman wanted to walk up to this enormous bird and drape it on him, I told him, then she should go right ahead."

"What happened to the hawk?"

"After a little while, it just flew away."

"So, what kinds of comments were people making over the radio?"

"Well, the next call we went to, somebody said, 'I'll bet your patient has the bird flu.' Stuff like that. But I suppose I have to expect those kinds of things. It's not every day that your patient is a bird."

Children Change Everything

2009-03-24T08:52:00.000-04:00

Watching the news between calls tonight, it was impossible to avoid stories of tragedy.

First there was the story of the FedEx cargo plane that crashed while landing in Tokyo. Apparently, a strong cross wind flipped it over just as it touched down. Both pilots died.

Then came the story of another plane crash, this one in Butte, Montana. Three different families, including seven children, died when a private plane crashed into a cemetery just short of its destination.

The second story bothered me more than first one. This is not to say that I don't feel badly for the pilots who died in the FedEx crash, or for the relatives who undoubtedly grieve for them right now. Because I do feel badly for them. Having worked on a medical helicopter for a time, I have a great deal of respect for all commercial pilots. By remaining calm under extraordinary pressure, they regularly save lives. Losing two of them in a crash that wasn't their fault certainly rates as a tragedy.

But as much as the loss of those pilots saddened me, the second story troubled me even more, for one simple reason: It involved children.

Tragedies involving children always cause me to tear up. They affect me more than any other kind of news.

I haven't always felt this way. When I first started working on an ambulance, a number of veteran EMTs and paramedics told me that calls for children were always the worst ones. Nothing bothered them more than seeing a child suffer, they said.

Early on, I didn't find that to be true. Even child abuse calls didn't bother me very much. Sure, those calls were sad. But no more sad than any other type of call.

Then I had children of my own, and everything changed. I could no longer work through a child abuse call without becoming emotional. Looking at a child who'd been struck by a car, I began to see my children's faces, and it troubled me to imagine them suffering. Suddenly I understood what my coworkers had been talking about. Since then, calls involving children have always bothered me more than any other type of call.

I've often wondered why tragedies involving children affect us so strongly. I suppose it's because we aren't supposed to outlive our children. When you're an adult, and one of your parents dies, well, that can certainly be sad. But it's not entirely unexpected. We're supposed to outlive our parents. That's the natural order of things.

But we're not supposed to see our children die. Nor are we supposed to see them suffer. We're supposed to protect them. When we can't do that, we feel helpless.

And that feels like the greatest tragedy of all.

Back from Military Leave

2009-03-22T11:19:00.008-04:00

I've just returned from Korea.

That was the Army assignment I mentioned in my previous post. With a trio of captains--John Fitpatrick, Jim Gettens, and Mike Jolin--I flew to an airfield near Seoul, where for two weeks we participated in joint readiness exercises with Republic of Korea military forces. Most Americans don't realize that the Korean War never ended. For more than fifty years, North and South Korea have honored a cease-fire. Because it's only a cease-fire, though, and not a truce, a state of war continues to exist between the two sides. Suspicions still run high, with spies occasionally getting caught on the wrong side of the border. Our exercise, which involved an aircraft carrier, airborne units, and something like 26,000 personnel from the Army, Air Force, Navy, and Marines, was designed to test South Korea's ability to repel an invasion from the north.

The Army severely limits what its soldiers can say about military operations in blogs. Because the work I did was classified, I can't say much more about it here. One thing that always amazes me, however, in jumping back and forth between my paramedic and military roles, is just how hard people work in the military. On the ambulance, if a 911 call takes us past the end of our shift, we put in for overtime pay. Not so when you're in the military. The Army has a doctrine called "mission first," which says, quite simply, that you will perform your duties until they have been completed, no matter how long that may take. Soldiers routinely work 12- and 15-hour days, seven days a week, with no extra pay. Even more amazing is the fact that you rarely hear anyone complaining about it.

During this exercise, we worked 60-hour weeks. In fact, during our 15 days there, we had just two brief opportunities to see anything of the country. For a couple of hours on Saturday afternoon, a Korean Army officer escorted us around the palace that served as the home and headquarters of the nation's emperors between the fourteenth and nineteenth centuries. Then, for a few hours the day before we returned, I had an opportunity to explore some of Seoul.

I'm glad to be back. I enjoy going on military assignments, but I'm always happy to return home. Fort Lee, Charlottesville, Fort Benning, Fort Dix, Germany, and now Korea--I've hardly been home at all this year.

Perhaps now, for a change, I'll actually stay in Boston and work on the ambulance for a while.

Photo by the author

Back in Twenty-One Days

2009-03-04T09:01:00.002-05:00

I'll be out of the country for the next few weeks, on yet another Army assignment. Because I won't have Internet access, I won't be able to post any new material until I return to the ambulance on March 23. Thanks for your patience.

Questions and Answers

2009-03-03T09:30:00.004-05:00

The man on the stretcher was fifty years old. He wore several layers of clothing, all of which were soiled. Like most of the homeless people we encounter, he smelled of both tobacco and alcohol. Somewhat ironically, we'd found him in the lobby at one of the city's finest hotels.

He was complaining of chest pain. Asked if he suffered from any cardiac problems, he said, "Yeah, a month ago I had a heart attack. They put some tubes in my heart to keep the arteries open." That was the last coherent answer he gave us. From that moment on, the conversation went in circles.

"How long did they keep you in the hospital?" I asked him.

"A month."

"You had a heart attack a month ago? And they kept you in the hospital for a month?"

"Yeah."

"That doesn't make any sense. That means you're still in the hospital."

"Oh." He thought about it for a moment. "Maybe they didn't keep me."

"Okay. Let's talk about the pain you're having tonight. It started when you were walking?"

"Yes. I was smoking some cocaine, and then..."

"Whoa. Hold on. I thought you said you were walking."

"I was. After I smoked the cocaine."

"So, you smoked cocaine, and then you went for a walk. And that's when you felt the pain?"

"Yeah."

"Do you have any other medical problems? Diabetes? Asthma? Anything like that?"

"Diabetes."

"Do you take insulin or pills?"

"Insulin."

"How much insulin do you take?"

"I don't take insulin."

"Didn't you just say you had diabetes? And that you took insulin for it?"

"Well, yeah. But I didn't take insulin today."

"When's the last time you took it?"

"I don't remember."

"You're supposed to be taking insulin, but you can't even remember the last time you took it?"

To this he just shrugged.

"What other medications do you take?"

"Um, let's see. Isordil, nifedipine, and diltiazem."

Three medications for high blood pressure. Now we were getting somewhere. At least I'd confirmed one of his medical problems.

"Great," I said. "Are you allergic to any medicines?"

"Yup. Nefidipine."

"No, no," I said. "This time I'm asking if you're allergic to any medicines. Are there any medicines you're not supposed to take? Anything we shouldn't give you?"

"Nifedipine."

"But you said just a second ago that you take nifedipine. Do you take it, or are you allergic to it?"

"I'm allergic to it."

"You're confusing me. Do you take nifedipine?"

"Yes."

"Even though you're allergic to it?"

"Well, yeah. But I didn't take it today. I didn't take any of my medicines today."

"When's the last time you took them?"

"I don't remember. A long time ago."

"So, at the moment, you really don't take any medicines at all."

"No. Not at the moment."

The conversation was making me dizzy. While we were talking, my partner had started an IV. Normally, when treating someone with chest pain, we administer nitroglycerin. But this time, we hesitated. What were we dealing with? What was causing this man's chest pain? It might have been angina, or it could have been a dozen other things. The cyclical answers made it impossible even to guess at a diagnosis. We decided simply to bring him to the hospital. It was better to do nothing, we reasoned, than to risk worsening his condition by giving him medication he didn't need.

To treat a patient, you first have to decide what's wrong. And to do that, you need to do two things. You have to examine him, to look for physical signs of illness, and you have to question him, to see how he feels.

Part of the questioning process, as any health care provider will tell you, is to ask about the events that led to the request for help. Did you feel okay yesterday? How about the day before that? How do you feel right now? What were you doing when this started? Does anything seem to make it better? Make it worse?

There's another aspect of questioning, too, commonly known as the "past medical history." Has this ever happened before? What was the diagnosis last time? Do you have any other medical conditions? Sometimes a look at the past provides a clue about the present problem.

But what if the patient can't communicate this information? What if his answers don't make any sense? What should you do then?

It certainly makes the task more difficult. If the patient looks sick enough, you might have to forge ahead anyway, providing treatment strictly on the basis of physical findings.

But sometimes, as on this call, it's better not to do anything. Do no harm, as the ancient medical maxim says. Take the patient to the hospital, try not to get frustrated, provide only the treatment that's absolutely necessary, and hope that it all works out.

You Really Should See a Doctor About That

2009-03-02T07:03:00.001-05:00

We responded to a house in East Boston just now, where a man had fallen down a flight of stairs. Well, down three flights, actually. A neighbor had rung his doorbell to deliver a package to him, and he'd tripped as he'd left his third-floor apartment to come down and answer it. The poor guy had tumbled all the way to the bottom, where a team of EMTs had found him lying just inside the front door.

The man was seventy-eight years old. Considering how brittle older people tend to be, he was fortunate to be alive. He seemed to have no broken ribs or extremities. No fractured hips. His breathing, heart rate, and blood pressure all were fine. He did have a most impressive scalp wound, though. I'm not sure how it happened, but somehow the entire top of his head had peeled right off, exposing a six-inch circle of glistening skull.

And yet, he felt no pain. When I asked where he hurt, he just smiled up at me and said, "Nowhere, really."

The human body is a strange thing. How is it possible that some adults cry like infants when they receive an IV, while others don't even notice their own life-threatening injuries? The difference in pain thresholds from one person to the next really is quite extraordinary.

X-rays later revealed that he'd fractured his second cervical vertebra. Had this bone been knocked out of alignment, he would have become a quadriplegic instantly. But in this regard, too, he was fortunate. The fracture was stable, and he suffered no neurological damage at all.

Maybe it was the man's age that had kept him from feeling pain. Or perhaps it was the wine he'd been drinking with lunch, which had acted like a natural anesthetic. In any event, the man had suffered a grotesque injury without even realizing it. Several times he asked if it was really necessary to go to the hospital. I wanted to tell him, "Buddy, the top of your head is falling off, so, yes, you really need to go to the hospital." But of course I didn't do that. I simply said, "Yes, sir, you really need to go," over and over, wishing I had a mirror so he could see for himself just how badly he'd been hurt.

Some Patients Still Make Me Nervous

2009-02-27T07:41:00.004-05:00

After two decades on the job, sick patients don't scare me any more. Not much, anyway. A man can be having a severe heart attack right in front of me, and I won't get nervous. He's the one who's sick, not me.

While this might sound cold, it's actually a very good thing. In an emergency, you don't want the person taking care of you to be scared. You don't want his hands to shake as he starts the IV, and you don't want him to draw a blank when calculating how much medication to give. It's okay for the patient to be scared, and it's okay for his friends and relatives to be scared. But it's not so good for the paramedic to be scared.

Sometimes, though, this can't be helped. Every so often, you run into a situation where the patient will literally live or die depending on how well you do your job. This doesn't happen as often as one might think. Even when you're treating a patient in cardiac arrest, there's no reason to feel nervous. The patient's condition, as the old saying goes, is stable. He might be dead, but he really can't get any worse, no matter how incompetently you treat him.

Treating a patient in congestive heart failure is a different story altogether. In this condition, the heart pumps ineffectively, causing blood to back up through the arteries and into the lungs. If you identify it and treat it quickly, you'll save the patient's life. But if you confuse it with some other respiratory disease, or take too long to start the IV, the patient will die. Under that kind of pressure, even the most seasoned paramedic can feel a bit panicky.

The same is true of neurological emergencies. Just a few minutes ago, we responded to a popular restaurant downtown. The patient, a forty-year-old man, had been eating dinner with a colleague when he suddenly grabbed his head, as if feeling a tremendous headache. Then he collapsed to the floor. He didn't seize, exactly, but by the time we arrived, his back was arched and his arms were locked in a fully extended position. Known as "decerebration," this is an ominous sign. Generally it reflects a sharply rising pressure within the brain, from a tumor or some kind of hemorrhage.

He would need to be intubated. If the pressure in his brain rose high enough, his breathing could shut down. And besides, we had to protect his airway. In this condition, if he vomited, he might very well suffocate. It was my turn to perform the intubation. Slipping an endotracheal tube between the vocal cords can sometimes be a tricky procedure, but this time I faced an additional challenge: Because of the malfunction within the man's brain, his jaw was clenched shut. As long as he remained in decerebration, I'd never get his mouth open, let alone pass the tube into his trachea.

"Want to give him succinylcholine?" my partner asked.

Succinylcholine is a paralytic. It causes every muscle in the body to relax completely, making it possible to look into the back of the throat and perform the intubation. But this comes at a cost. Since the diaphragm is a muscle, it too gets paralyzed. To intubate this man, we'd have to stop his breathing completely.

Normally, intubation doesn't make me nervous. I've done it hundreds of times, on some very sick patients. But this patient had more to lose than most of the others. He wasn't in cardiac arrest. In fact, he wasn't even in respiratory distress. What if we paralyzed him, and then I couldn't get the tube into the trachea? We'd have started with a sick man, essentially, and killed him. I felt nervous just thinking about it.

But it had to be done. "Give him a hundred milligrams," I said to my partner.

He drew the medication into a syringe. Meanwhile, I prepared the intubation equipment. Soon I had everything laid out on the tiny counter beside the stretcher. A seven-millimeter tube, a length of cloth tape for securing it, a syringe for injecting air into the balloon that seals it in place--it was all ready to go. Now I just had to wait for the patient to stop breathing.

My partner injected the succinylcholine. He injected some midazolam, too, which would ensure not only that the man was paralyzed, but unconscious. Pressing a bag-valve-mask against the patient's face, I forced oxygen into him as his natural breathing slowed. His arms dropped to his sides. He was paralyzed.

Tilting his head back, I slipped the L-shaped laryngoscope into his mouth. Suddenly he vomited.

Food and wine gushed from his mouth, spattering my shirt and spraying the wall of the ambulance. The EMTs saw what had happened, and together they rolled the man onto his side. I reached for the wall-mounted suction machine to draw the fluid from his mouth. The ambulance reeked of garlic and alcohol.

We rolled the man onto his back. Again I inserted the laryngoscope. I looked deep into his throat, but I couldn't see the vocal cords. I didn't panic, exactly, but as the seconds ticked by, I grew increasingly anxious. The patient had been breathing on his own when we found him, but now, after we'd stopped him from breathing, I might not be able to secure his airway. We could force air into his lungs with a bag-valve-mask if necessary, but if he vomited again, he'd be in trouble. It scared me to think that in trying to make him better, we'd actually made him worse.

"We need to get some oxygen into him," my partner said, tactfully reminding me that I was taking too long to find the vocal cords. This was a hint that I should remove the laryngoscope and ventilate him with a bag-valve-mask for a couple of minutes before trying again.

"Just another second," I said. I knew I was taking a chance. The longer I searched, the longer the man's brain would be deprived of air. But the idea of failing scared me. I was willing to try just a little bit longer simply to know that it was done.

My partner trusted me, so he didn't press the issue. I could feel his eyes on me as I continued to search. Finally I saw it--the epiglottis, with the vocal cords underneath, and the entrance to the trachea beyond that. I slid the tube in, and tied it in place with a strip of cloth tape. An EMT connected the Ambu bag to the open end. He squeezed the bag, and I was relieved to see the man's chest rise. It was done.

We started toward the hospital. The man retched. With the tube protecting his airway, vomiting wouldn't matter as much. My partner gave him another dose of midazolam anyway. The patient seemed to relax.

As we wheeled the man into the emergency department, I relaxed, too. Eleven minutes had passed since we'd arrived at the restaurant, but it felt like a lifetime. It had been a stressful eleven minutes.

The attending physician sent the patient upstairs for a CT scan. The man had already undergone brain surgery once, we learned, for something known as an arteriovenous malformation. Essentially, he had been born with a tangle of blood vessels in his head that had already burst once, and now were bursting again. If he was lucky, he'd go back to the operating room, have it repaired again, and make a complete recovery.

And if not, then at least we didn't make his condition any worse.

Mechanical Difficulties

2009-02-24T15:43:00.010-05:00

As I walked into the station today, one of the day paramedics was describing a call they'd handled earlier. An elderly woman had fallen on an escalator at the State Street subway station, and her scarf had been drawn into the mechanism, strangling her. Already the incident had been described on The Boston Globe's website. Word of tragedy spreads quickly these days.

Several years ago, we responded to a similar incident. A worker on the overnight shift at a paper plant had reached into a huge machine to clear a jam. The rollers caught his hand and pulled him all the way in, up to his shoulder. We could hear him screaming even as we came through the front door.

The most difficult part of that call was getting the patient out. Firefighters removed some pieces of the machine, and used a cutting tool to rip the rest of it apart. All the while, the poor guy stood there screaming in agony.

He was going to be trapped for a while, so I started an IV on the opposite arm, to give him something for the pain. We decided on morphine. When a patient is having a heart attack, we usually give two milligrams. This man was in so much pain that we started with five. That didn't help at all, so we gave him another two milligrams. Still no good. Every few minutes we injected another couple of milligrams, until finally we ran out. We'd given him twenty-one milligrams of morphine--ten times the normal dose for the pain of a heart attack--and it didn't affect him at all. He was still experiencing so much pain that the medication didn't even make him drowsy.

After twenty minutes of this, he was finally freed. The wound was severe. Not only had his arm been crushed, but it had been "degloved." Essentially, the skin had been torn right off his arm, from his shoulder all the way down to his fingers.

I felt terrible, but we had nothing else to offer him. We wrapped his arm in dressings, wheeled him out to the ambulance, and took him away to a trauma center. He went to the operating room, but I have no idea how he made out after that. The surgeons may have performed a skin graft, but since his entire arm had been badly crushed, it was likely amputated at some point.

These kinds of crushing injuries are supposedly quite common in the Midwest, because so much machinery is used in farming. But we get a fair number of calls for people stuck in machines, too. Like the man at the paper plant, most involve various kinds of printing and paper machines.

Not all of them turn out quite so tragically. One of my favorite calls took place in the North End, at a popular Italian bakery. It was described over the radio as a "man with his hand stuck in a piece of machinery," so I envisioned a situation much like the one at the paper plant. But when we walked through the door, none of the employees seemed particularly upset. They directed us to a back room, where a young man stood in front of a sink. Lifting his hand from the soapy water, he showed me the problem: He'd been washing the funnel-shaped tips used for squirting frosting onto cakes, and in the process, he'd stuck his finger into one of them. And now, because of the jagged edges at the narrow end of the funnel, he couldn't get his finger out. The more he tugged at it, the deeper the jagged part dug into his finger.

In my pocket, I happened to have a Kelly clamp, a surgical instrument that looks like a delicate pair of pliers. In a matter of seconds, I pried back some of the jagged ridges and slipped the part from his hand.

The man was amazed at how easily the thing had come off. He'd felt certain that it would have to be removed at the hospital. All that remained was a tiny spot of blood on the tip of his finger, where the metal had pinched him. I stuck a Band-Aid over it.

As we walked back out to the ambulance, the owner of the shop presented each of us with a box of cookies. It was a happy ending for everyone concerned. The patient returned to work, and we had some dessert to go with our dinner.

If only the woman with the scarf and the man at the paper plant could have been so fortunate.

An Education in New York

2009-02-23T17:22:00.006-05:00

I'm out of the ambulance again, but this time it's only for a couple of days. The Army has sent me to a seminar on military law--in New York City, of all places.

I love coming to New York City. I spent fifteen days here in 1986, working as a paramedic intern with New York City EMS. It was an extraordinary experience, not only because of the medical opportunities it gave me, but because it took me into parts of the city that tourists never see. Housing projects, crime scenes, back alleys, subway stations--it was a lot like my current job in Boston, except that everything was bigger, dirtier, and somewhat more dangerous.

On the first day of my internship, I was told to report to the city's ambulance station at Coney Island Hospital, on the southern tip of Brooklyn. This disappointed me. I wanted to respond to "urban" ambulance calls--shootings, stabbings, overdoses, and people struck by subways. When I heard "Coney Island Hospital," I pictured a tent in the sand with a red cross painted on top. I imagined myself treating sunburn victims.

I couldn't have been more wrong. Coney Island was an 800-bed facility--thirty percent bigger than Boston City Hospital. Twenty of the city's ambulances operated out of its EMS station. And with a forty-square-block housing project right up the street, it did a brisk trauma business.

My first call was a heroin overdose. The experienced paramedic serving as my mentor (or "preceptor") acted as if he'd handled a thousand of these calls before--which, of course, he had. He let me do everything myself. I ventilated the patient with a bag-valve-mask, injected him with Narcan, and marveled at his immediate recovery.

Later that evening, we responded to a police station, where one prisoner had stabbed another with a fork. I didn't expect the wound to be serious. A fork didn't sound like a particularly lethal weapon.

Inside the cell, I listened to the man's chest. To me, his breathing sounded normal. Then my preceptor listened. "I think he has a pneumothorax," he told me. "Let's get going. We'll do everything else on the way to the hospital."

A pneumothorax is a collapsed lung. And when the x-rays were developed, that's exactly what they revealed. The experienced paramedic had based his diagnosis on a subtle change in the sound of the man's breathing. The paramedic intern had missed it completely. I realized then just how much I had to learn.

For the second half of my internship, I drew an assignment in the South Bronx. Late one afternoon, I responded with my new preceptor to a gloomy apartment building not far from Yankee Stadium. Right inside the front door, we found the body of an old man in an enormous pool of blood. A cop on the scene told us that somebody had tried to rob him in the doorway of his fourth-floor apartment. When he resisted, the robber shoved him over the railing.

Kneeling beside the man, I opened his mouth, just as I'd been taught to do in paramedic school. I looked at his chest to see if he was breathing. It didn't move. I felt at his neck for a pulse, but couldn't find one. For some reason, my preceptor wasn't stepping forward to help me. I assumed that it was a test of sorts, to see if I could handle the call on my own.

Pressing the bag-valve-mask against the man's face, I was about squeeze oxygen into his lungs when my preceptor stepped forward and placed his hand on my shoulder. "What are you doing?" he asked.

It was a strange question. What did he think I was doing? The man was in cardiac arrest. I was going to perform CPR, just as I'd been trained to do.

He didn't wait for an answer. "What's his EKG look like?" he asked.

Now I was really confused. His EKG? What was he talking about? When a patient goes into cardiac arrest from trauma, you don't waste time taking an EKG. The heart's not the problem. You treat the injuries, and you get the patient to the hospital--in a hurry.

"Attach the cardiac monitor. Take an EKG," my preceptor said.

Though it made no sense, I did as I was told. V-shaped waves marched across the screen. Not that it made any difference. With all of his blood on the floor, it didn't really matter whether the man's heart was beating or not.

Again I went to place the mask against the man's face. Again my mentor stopped me. "Lower the gain," he said, pointing at the cardiac monitor. "The gain's too high."

Hearing this, I concluded that he was either incompetent or insane. The gain controls the size of the EKG image. You can raise it or lower it, to make the waves appear bigger or smaller. But none of this made any sense. The man in front of me needed resuscitation. He needed a neurosurgeon and a hospital. Instead, we were wasting crucial time tinkering with a completely unnecessary EKG.

But since I was just the intern, I again did as I was told. I twisted the knob, and the waves on the screen became smaller.

For the third time, I picked up the bag-valve-mask. "The gain is still too high," my preceptor said. "I told you to turn it down."

I was furious. The man's life was on the line. When was he going to let me start treating him?

This time, I turned the knob all the way. The waves on the screen disappeared entirely. The heart was still beating, but the line traveling across the monitor screen now looked completely flat.

"That's what I thought," my preceptor said. "He's dead. C'mon. Let's get out of here."

I couldn't believe it. The man was not dead. Well, his heart hadn't stopped beating, anyway. He didn't have a pulse, and he wasn't breathing, but maybe we could still save him. How could a paramedic simply walk away like that?

For a moment, I thought about resuscitating the man anyway. If my preceptor didn't want to do it, then I would do it myself. But that was ridiculous, of course. For one thing, my preceptor and his partner controlled the ambulance. Without so much as a set of keys, I was hardly in a position to stage a coup. And for another, I wasn't technically a paramedic yet. I was just an intern. With my certification exam still a month off, I was permitted to do only what my preceptor told me to do.

I dragged the equipment sullenly back to the ambulance. I sat in silence as we drove away. After several blocks, my preceptor asked if something was bothering me.

"I don't understand what we just did," I told him. "The man's heart was still beating. His body wasn't stiff, and he didn't have any of the criteria that allow us to declare him dead. Why didn't we resuscitate him?"

I waited for him to get angry, but he didn't. "Let me ask you something," he said calmly. "The man fell four stories. He landed on his head, on a tiled floor. With head trauma like that, what do you suppose his chance of recovery is?"

"Pretty much zero, I suppose."

"Right. And it wasn't just the head injury that killed him. It was the blood loss, too."

Reluctantly I agreed.

"So, suppose we go in there, and we do CPR. We start IVs, and we intubate him, and we rush him to the hospital. Is any of that going to save him?"

"Probably not."

"No. And in the meantime, what are we doing to the crime scene? We're tracking through the blood, putting our hands and footprints all over everything, and then we leave with the body. Do you suppose that'll make the detectives' jobs any more difficult?"

"I'd imagine so."

"Sure it would. And in the end, what do we accomplish by working that guy? He's still dead, and now it's even harder to catch his killer. Does that sound like the right thing to do?"

"I suppose not."

"You don't sound convinced."

"I'm not. According to the rules, we should have treated that guy and brought him to the hospital."

"Maybe. But sometimes you have to do what you feel is best."

And that was the end of it. We continued on in silence, and I didn't bring it up again. We worked together for a few more days, and then it was time for me to go home.

Twenty years later, I don't know whether he made the right decision or not. I'd like to think that he walked away from that patient because he really did believe it was the right thing to do, and not because he was too lazy to attempt resuscitation.

But even if he made the wrong choice, I can't fault him too much. Every day in this job, we have to make difficult decisions. There's not always one correct answer. Sometimes you have to do what you think is morally right, regardless of what you learned in school, even if it means bending or breaking the rules.

As a paramedic intern, I couldn't grasp that. I believed in doing everything by the book, because that's the way I'd been taught. Only now, with experience on my side, do I understand what that preceptor was thinking. I don't necessarily agree with his conclusion, but at least I can finally understand his thought process.

Heroin

2009-02-20T00:01:00.001-05:00

Heroin overdoses tend to occur in cycles. We'll respond to a couple of these calls every shift for a week or so, and then they'll disappear for a while, only to begin again a few weeks later. The reason for this, I suppose, is the lack of quality control. No two heroin distributors cut their product in exactly the same way, and when an unusually potent batch hits the street, a wave of overdoses is sure to follow.

We're stuck in one these cycles right now. Every night for the past three weeks we've had at least one overdose, and on some evenings we've seen as many as four. It doesn't seem to be letting up. And we're not getting these calls only in Roxbury and South Boston, where heroin has always been a problem. This time around, we 're seeing overdoses in practically every neighborhood.

The latest one happened just a few minutes ago. Unlike most overdoses, which begin with a frantic call to 911 after the patient is found to be unconscious, this one started as a domestic dispute. A woman asked the police to check on her boyfriend, who'd swallowed some pills after they'd fought.

We found the man unconscious in the courtyard of a housing project, with snow falling on him. He'd already stopped breathing. His girlfriend looked on with concern as we lifted him into the ambulance. We checked the size of his pupils, and they were tiny--a sure sign of narcotics use.

The EMTs who'd responded to the call with us both were relatively new. One of them breathed for the man with a bag-valve-mask, while my partner injected him with Narcan. I instructed the remaining EMT to remove the man's clothing, and to carefully look for used needles. I told her to search for weapons, too, because unconscious patients often behave unpredictably as they wake up.

A moment later, as if on cue, the EMT said, "Whoa. Look at this." She held up a huge folding knife. It had been tucked inside the waistband of his jeans.

Gradually the man started to breath again. My partner and I remained with the patient, while the EMTs drove the ambulances to the hospital. I kept watching him, waiting for him to come around, but he never did. He remained deeply unconscious even as we rolled him by stretcher into the emergency department.

When I first joined EMS, I actually looked forward to treating patients like this. There was nothing more exciting than treating someone who had stopped breathing. Not because I wanted anyone to suffer, but because I wanted to put my skills to good use. All EMTs and paramedics feel this way. You want to make a difference, and treating a critically ill patient is the best way to do that.

Back then, I'd often wait weeks or even months for the next cardiac or respiratory arrest to come along. But not now. Thanks to the present heroin epidemic, we're seeing them just about every night. This is good for the new EMTs, because they're getting plenty of practice, but for the heroin addicts and their families, it isn't good at all.

I have no idea why this is happening. It might have something to do with the quality of the heroin on the street, or perhaps it's just that drug use is on the rise.

Whatever the reason, something needs to be done about it.

Just for Show

2009-02-19T09:31:00.002-05:00

We responded to a house in South Boston this evening, for a man in respiratory distress. Before we arrived, he stopped breathing entirely. By the time we made our way inside the building and up to his family’s apartment, he had gone into cardiac arrest.

Several relatives had gathered in the kitchen. They looked concerned, but not especially distraught. At least they weren’t wailing and throwing themselves on the floor, the way some people do when they grieve.

We continued into the bedroom, where the patient was sprawled across the floor. EMTs were performing CPR. I knelt at the man’s head and inserted a tube into his trachea. My partner couldn’t find any veins, so he used an electric drill to screw a catheter into the man’s tibia. Known as an “intraosseous infusion,” it's a grisly procedure to watch, but it can save the patient’s life by allowing us to inject medications directly into the bone marrow.

The man was nearly eighty years old. Looking at the cardiac monitor, I saw that the line was flat. He wasn’t going to survive. People rarely come back from a flat-line cardiac arrest, especially not at his age. And to make matters worse, the man’s son had said something to the EMTs about liver cancer. I knew what would happen next: We’d give the man three doses of cardiac medications, but his heart would not respond, and in the end, we’d turn off the cardiac monitor and declare him dead.

My partner prepared the first two syringes, one containing epinephrine, the other containing atropine. He injected them into the tube of fluid that was dripping into the man’s leg. One of the EMTs kept pumping on the man’s chest, while I squeezed oxygen into his lungs. We watched, and we waited.

And then something bizarre happened.

The man started breathing.

At first it was just a single breath. But then came another, and another. Soon he was breathing deeply and regularly. I felt at the man’s neck for a pulse, but still couldn’t find one. I looked again at the cardiac monitor. V-shaped waves marched across the screen now, slowly and irregularly. Apparently, his heart was beating just powerfully enough to keep his respiratory system functioning, but not powerfully enough to generate a pulse.

This put us in a curious predicament. As long as we kept pumping on his chest, he would continue to breathe. And as long as he kept breathing, the rules would not permit us to stop treating him. I’d never seen anything like it. In theory, this cycle could go on forever.

My partner gave the man another dose of cardiac medications. It made no difference. The EMT kept pumping on his chest. The man kept breathing.

“Let’s try pacing him,” I said.

My partner pushed some buttons on the cardiac monitor. The idea is to send small, regular jolts of current through the skin and into the heart, causing it contract at regular intervals. Sometimes it works. This time it didn’t.

I returned to the kitchen, to explain the situation to the family. I began by asking about the cancer.

“It’s liver cancer,” the man’s son told me. “The doctors just discovered it last week.”

“Did they give you a prognosis? Can it be treated?”

“No. They said it was terminal.”

“Have you talked about resuscitation? Sometimes, when a person has a terminal condition, he’ll ask not to be kept alive. Did the doctors talk about this with your father?”

“No. He would want everything done. And we want everything done, too. Please, do everything possible to keep him alive.”

I assured him that we were already doing everything that a hospital would do. But at the same time, I cautioned him against optimism. As gently as I could, I explained that his father would probably not live through the day.

The son took it well. So did the relatives sitting around the kitchen table. I returned to the bedroom, where my partner and the EMTs were getting ready to carry the man outside. Soon the ambulance was yelping toward the hospital. We administered another dose of epinephrine along the way, but it didn’t change anything. In fact, as we pushed the stretcher into the emergency department, his breathing gradually slowed until finally it stopped altogether.

A huge crowd of doctors nurses waited for us in the treatment room. Someone wheeled an ultrasound machine to the bedside. After looking at the image, the chief resident announced what we’d suspected all along—that the man’s heart was not beating strongly enough to keep him alive. As soon as the chest compressions were halted, he’d be dead.

“How long has he been in cardiac arrest?” the resident asked me.

I looked at the clock. “A little more than an hour.”

“And the family’s coming here?”

“I believe so. They didn’t want to come in the ambulance. His son told us he was going to drive over.”

“Shouldn’t they be here by now? How far away do they live?”

“Not far. A couple of miles, maybe. And traffic is really light today. It took us eight minutes in the ambulance.”

The doctor shook his head and thought for a moment. “I don’t want them to rush over here, thinking that we’re keeping him alive, only to find that we’ve already pronounced him dead. Not until I break it to the relatives. Do we have a cell number for the son?”

One of the EMTs handed a piece of paper to the doctor. Picking up a phone, he punched in the number. The son answered. I listened as the doctor explained the situation. The son, apparently, was driving toward the hospital at that very moment. The doctor asked if he was in a position to pull to the side of the road, because they had an important matter to discuss. I could tell from the doctor’s reaction that the son was refusing to stop. “Okay,” the doctor finally said. “We’ll talk after you get here. Drive carefully.”

Hanging up the phone, the doctor stared at the clock. “I guess we have no choice. We’ll keep the resuscitation going. He’ll get here eventually, I guess.”

And so it continued. In the treatment room, the ventilator kept up its whooshing sounds. An orderly kept pumping on the man’s chest. Nurses kept injecting medications into the IV. The man on the gurney was dead, and he was going to remain dead, but the pronouncement of death would be postponed for the benefit of the surviving family members.

Five minutes passed. Then ten. Still no sign of the son. Fifteen minutes. Twenty. Half an hour later, the resuscitation effort kept going, with no sign of improvement—and no sign of the family.

“Where the hell are they?” one of the residents finally said to nobody in particular.

“I don’t think they’re coming,” said a nurse in response.

“Why wouldn’t they come?”

“This guy has a strong history of alcoholism,” someone else observed. “Maybe he was a jerk. Maybe the family is glad to see him go.”

“But to let him die, without even coming to the hospital?” asked a nursing student. “That’s just cold.”

Whatever the reason, the family never showed up. For two hours and twenty-one minutes, the resuscitation effort continued. Two doctors, four nurses, two student nurses, two orderlies, and a respiratory therapist kept working on the man, not because they believed they could save him, but because they thought it would ease the suffering of the surviving family members. It was a noble gesture, but in the end, it accomplished little.

The doctor pronounced the man dead, and the relatives who were supposed to benefit from the resuscitation effort never even knew it had happened.

Of Hookers and Stings

2009-02-17T11:59:00.005-05:00

I saw an article in The Boston Globe the other day about an effort by the Boston Police to halt prostitution. The article, which consisted of a single paragraph buried deep inside the news paper, didn't contain many details. It mentioned only that a sting operation, called Operation Squeeze, had led to the arrest of some two dozen would-be "johns," and that their cars had been confiscated.

Reading this piece, I had to smile. During my time on the night shift, we passed many hours watching these kinds of operations. From the cab of the ambulance, parked in the shadows of a side street in Chinatown or the South End, we'd watch as the drama unfolded like a well-choreographed play.

Operation Squeeze isn't meant to catch prostitutes. It's meant to catch potential customers, known as "johns." That's what makes it a sting. Female police officers dress as hookers, and when a driver stops to proposition her, backup officers swoop in to arrest him.

Because we work so closely with the police, we know most of the cops by sight. It was funny to see the female officers, whom we'd known for years, passing themselves off as streetwalkers. Some would really get into it, wearing tight, ultra-short dresses, shiny stilettos, and gaudy jewelry. Despite this ridiculous getup, they tended to look better than the real hookers. While this certainly made it easier to lure johns, it sometimes gave them away. Real-life hookers don't look anything like Julia Roberts in Pretty Woman. Instead, they tend to be dirty, scrawny, pathetic characters, addicted to crack or heroin. Johns occasionally became suspicious of the undercover officers because they looked a little too good.

Because the night shift sometimes passed slowly, Operation Squeeze became a source of entertainment for us. It was like watching the TV show Cops in real life. We'd park a couple of blocks away and wait for a customer to approach the female officers. We never had to wait long.

Generally, the car would circle the block a couple of times. Some johns wanted to look at the commodity before buying, I suppose, while others probably sensed a trap. But it never made any difference. In the end, all of them seemed to stop--even the nervous ones.

Before long, the undercover cop would signal to her backup that an offer had been made. That's when the excitement started. A pair of unmarked police cars would roar in from opposite ends of the block, trapping the john's car in between. Male cops would order the john out. The reactions of the johns ranged from benign resignation to outright panic. While the officers were handcuffing him and walking him around the corner to a marked cruiser, a tow truck would haul away his vehicle.

We encountered plenty of prostitutes even when Operation Squeeze wasn't in effect, of course. Some were actually quite personable. They'd smile and wave as we'd pass, and sometimes we'd ask whether it had been a good night for business. The response was rarely enthusiastic. Usually they'd shrug and say something like, "Not bad." I guess it's hard to get worked up about such an unpleasant occupation.

More frequently, though, the hookers were simply nasty. Many were not engaged in the business of prostitution at all. Their goal was to rob customers without ever engaging in sex. They'd catch a well-dressed man as he stumbled out of a strip club, and they would pretend to make a sales pitch, asking if he "wanted some company" while pressing up against him. From there, the situation always played out the same way. The man would say he wasn't interested, but he would stop just the same, allowing the woman to fondle him, with no intention of ever hiring her. Meanwhile, with her other hand, she was lifting his wallet.

This would happen right in front of us, and it always left us in a moral quandary. Should we alert him to the robbery? Or did it serve him right for trying to take advantage of the hooker? There was no right answer. Sometimes we'd call out, "Where's your wallet?" which would cause the hooker to glare at us before storming away, knowing that her larceny had been thwarted.

But other times, we'd simply drive away. The way we figured it, the man had gotten what he deserved.

Addict

2009-02-15T23:20:00.008-05:00

The woman was crying. She met us at the door and directed us upstairs. It was her boyfriend, she said. He'd overdosed on heroin again.

Heroin seems to cause more trouble for this city than any other drug. In other parts of the country, methamphetamine has become the drug of choice. But not here. Whenever we respond to an overdose, it always seems to involve heroin.

This time, the man was sprawled across a bedroom floor. He'd stopped breathing. While an EMT forced oxygen into his lungs with an Ambu bag, my partner drew Narcan into a syringe. He passed it to me, and I popped it into his arm.

Narcan is the antidote for a narcotic overdose. It works remarkably fast, often in less then one minute. First the patient starts breathing again, and then he wakes up. If only all medications worked so effectively.

In the old days, we used to start an IV first, then we'd inject the Narcan into the plastic tubing. But that was before the age of HIV. Today, to reduce the likelihood of getting stuck by a contaminated needle, we skip the IV altogether, injecting the medication straight into the patient's muscle, and depositing the used needle immediately into a special biohazard container.

In paramedic school, we were taught to administer one milligram of Narcan. If the patient didn't wake up, we were to give a second milligram. That's the way most paramedics do it. This wakes the patient slowly, they believe, making him less likely to put up a fight.

I started thinking about this practice one day, and it didn't seem to make any sense. Addicts always go through a state of confusion while they wake up. They don't recognize us during this period, and they don't understand what we're trying to do to them. So they try to fight us off. Once they're fully awake, and they understand the situation, the combativeness usually subsides.

Giving the Narcan in small increments struck me as a mistake. By waking the patient slowly, we were merely prolonging the period of confusion. The longer these patients remained confused, the longer they'd try to fight with us.

So I decided to try something different. On one call, I gave the entire two milligrams at once. It took a few minutes to take affect, as all medications do, but then the patient opened his eyes and asked what had happened. There was no struggling to sit up; no swinging of fists with eyes half closed. Instead, he calmly asked a simple question: "What happened?"

That's what I did today. I injected the entire two milligrams, and sure enough, the patient opened his eyes a moment later. He lay quietly as I explained what had happened, and then he asked politely if he could sit up.

We had to bring him to the hospital, of course, because heroin sometimes remains in the system longer than Narcan does, and the patient sometimes stops breathing again. Unlike many addicts, this patient did not object. He walked to his closet, put on a sweatshirt, and declared himself ready to travel. Too bad all addicts can't be so cooperative.

As we walked down the stairs to the ambulance, I spotted a toddler-size basketball hoop in the hallway. That bothered me. I don't hate drug addicts the way some of my colleagues do, and I'll treat them with respect as long as they don't give me a hard time. But this hoop reminded me that drug addiction doesn't harm only the addict--it also ruins the lives of everyone he associates with.

We continued to the ambulance. As we rode toward the hospital, I asked him some questions, more out of curiosity than because of any need to know. I started by asking him how long he'd been addicted to heroin.

"I just started back up," he said. "I used for a long time. Finally I quit, and I've been clean for more than a year now. Until today."

"What happened today?" I asked. Most relapses seem to happen for a reason--the death of a loved one, the breakup of a relationship, something like that.

"Nothing, really." he shrugged. "I don't know what I was thinking. I was at this kid's house, and some people were using, and suddenly I just used, too. It was stupid."

I believed what he was telling me. Most addicts aren't nearly so forthcoming. "When you quit before, how did you do it?"

"Cold turkey. One day, I just decided I wasn't going to use anymore. And I didn't."

"Maybe you can do that again."

"Yeah. I hope so."

As heroin addicts go, he seemed like a nice kid. We talked some more while the triage nurse filled out some forms. Then another patient was wheeled in behind us.

"What's this?" the triage nurse asked.

"Heroin overdose," one of the EMTs told her.

The nurse pointed to the new patient, and then to ours. "Did they come in together?"

I began to say no, but the same EMT said, "We picked up this patient right down the street from that one. They'd been at the same house. I think they shot up, but walked away in different directions before passing out."

The nurse gave us a room assignment. As we wheeled our patient through the emergency department, a doctor approached. After learning what had happened, he looked at our patient and said, "We never get any sixty-year-old heroin addicts. Know why?"

The kid shrugged.

"Because they're all dead."

Then he walked away.

The patient looked at me. I didn't know what to tell him. It was a true statement, of course, although the message might have been delivered without the sarcasm. When I lecture addicts, I stick to the facts, talking about how close they'd come to death, reminding them that their next overdose might be their last. Not that this does any good. We see the same faces, week after week, leading me to believe that none of these people ever gets the message.

Finally a treatment room became free. We wheeled the patient in, and had him slide across to the hospital gurney. He thanked us.

I wished him well as I walked out the door. And I meant it. For his sake--as well as for the girlfriend and the child.

When It's Your Time to Die

2009-02-13T10:00:00.008-05:00

One day each month, all City of Boston EMTs and paramedics are reassigned to a day of training. Doctors review unusual cases at these sessions, and guest speakers talk about everything from the latest medications to Weapons of Mass Destruction responses.

At this week's event, one of the physicians presented "Pre-Hospital Save Awards" to EMS personnel who had resuscitated a patient in the field. Seven EMTs and paramedics received these awards. Some of us got more than one. To qualify, the patient had to survive hospitalization and be discharged alive.

Award ceremonies have always made me feel self-conscious. To the extent possible, I try to avoid them. I understand that these things are meant to boost morale, but I simply don't enjoy the attention.

"Save" awards make me especially uncomfortable. The success of a resuscitation, I believe, is largely a matter of circumstances beyond our control. EMTs and paramedics could run the most efficient resuscitation effort possible, but because the patient happens to be 96 years old and has already suffered two heart attacks, he will never come back to life. Perhaps the effort will fail because the patient had been in cardiac arrest for twenty-five minutes before anyone discovered him. Does that make the EMTs or paramedics any less proficient? No. It's purely a matter of unfortunate circumstances.

I don't put much stock in the concept of fate. To some extent, though, I believe that some patients will live, while others will die, and that we have little power to change that. I've watched patients live who really should have died--patients who were old, with all sorts of serious health problems, who remained in cardiac arrest for a long period of time before finally coming out of it. And I've also seen the reverse: young, healthy patients who did not come back in spite of timely, aggressive resuscitation efforts. Why do some of those patients die, while older, sicker ones live? There's no logical explanation.

Just last week, we responded to a home in South Boston, where an 80-year-old woman had gone into cardiac arrest. She'd suffered from high blood pressure for years, and she'd recently developed diabetes--both of which take a toll on the heart. To make matters worse, nobody had seen her collapse. Her daughter had called 911 after walking into the house and finding her on the floor. There was no way to tell how long she'd been down.

This woman had everything going against her. Older age, a heart damaged by years of disease, long down time--statistically, she was dead even before we showed up. By policy, we're permitted to stop a resuscitation effort after three rounds of cardiac medications have been given. We assumed this would be one of those times.

I threaded a tube into the woman's trachea. My partner started an IV. Firefighters and EMTs took turns doing CPR. I injected the first dose of epinephrine and atropine. Nothing happened. The EKG remained flat.

I gave a second dose of medications, and then a third. The EKG didn't change. The woman still wasn't breathing, and still had no pulse. It was time to declare her dead.

The woman's relatives had gathered in the kitchen. I was about to go in there, to let them know that we were going to stop the resuscitation, when I glanced one last time at the cardiac monitor. It was no longer flat. Waves were marching regularly across the screen.

"Somebody check for a pulse," I said.

One of the EMTs felt the woman's neck. "Yeah," she reported. "She's got one."

We packed up the patient and the equipment and made a run for the ambulance, hoping to transport her before her heart stopped again. We had no reason to think this woman would live. And yet, apparently, she wasn't ready to die.

I don't know what happened to this woman. I have no idea whether her heart kept beating or not. She might have gone to the morgue, but for all I know, she's sitting up in the cardiac care unit right now, talking with her daughter. Against all odds, she may have survived.

Can we take credit for this? Certainly not. We performed the procedures correctly, but any paramedic could have done that.

If she does survive to be discharged, then I suppose we'll get another one of those "save" awards. That makes no sense to me. She's not going to stay alive because of an extraordinary resuscitative effort, worthy of commendation.

She will live because it wasn't her time to die.

Fire and Smoke

2009-02-12T00:36:00.005-05:00

Winter normally is the season of building fires. I've stood on many cold sidewalks over the years, waiting for victims of burns and smoke inhalation to be carried out to us. I suppose this is due to the improper use of space heaters. People take drastic steps to keep warm, including measures that are not particularly safe.

This year, the number of fires is down. Or perhaps it just seems that way. Most fires happen at night, and after twenty years on the overnight shift, I became accustomed to three or four fire responses each week. Now that I work mostly in the evening, I suppose I miss many of them.

Last night we responded to a fire for the first time in quite a while. The streets around the building were clogged with fire apparatus, and with the evening rush hour still going on, this caused a traffic jam several blocks long. We inched up the street, traveling against oncoming vehicles in the wrong lane, stopping every few yards to thump across a hose line. Finally, just as we arrived, an EMT came over the radio, telling us to stop. "We've got a victim," he said. "Don't come any closer, because the street is blocked down here. Stay in the intersection. We'll bring him out to you."

A minute later, the EMTs approached with a man on their stretcher. His face was blackened with soot. "He was up in the top floor bedroom," one of the EMTs reported. "He woke up to find his bedroom in flames. No burns, just smoke."

We lifted him into our ambulance. As I was about to shut the door, a man and a teen aged boy approached. "This is his son," the man said. "Can he go to the hospital with his father?"

"Of course," I told him. Then I looked at the boy. "Were you in the building? The one on fire?" If he was, then he might need treatment, too.

"No," the boy said. "I was up at my friend's house."

"Okay. Stay here for just a second. We need to do a couple of things, but I promise not to leave without you."

I closed the door and turned back toward the father. My partner was listening to his breathing with his stethoscope. "Sounds clear," he announced. "No wheezing yet."

That was a good sign. Irritation of the breathing passages sometimes causes them to become constricted, even in non-asthmatics.

"Look up," I said. The man lifted his face toward the ceiling. Shining my flashlight into his nose, I could see that the hairs in his nostrils were singed.

Next I looked in his mouth. The roof was black. The guy must have inhaled a ton of smoke. And judging from the burned hairs, some superheated air, too.

My partner connected a carbon monoxide analyzer to the man's finger with a wire probe. "Six percent," he said a moment later. A smoker's bloodstream normally carries two percent carbon monoxide. A nonsmoker's, less than one. The man on the bed had inhaled a dangerous amount of smoke. He needed to be in a critical care unit, fast.

"Time to get moving," my partner said.

"Will you need us for the transport?" one of the EMTs asked. "There are no other ambulances here."

"No, we'll be okay," my partner told him. "Go ahead back to the building."

I climbed out the back door, went around to the cab, and unlocked the door for the patient's son. "Are you sure you didn't take any smoke?" I asked, once he'd settled into the passenger seat.

"No, I wasn't even home."

"Good." I shifted the truck into drive. The diesel roared. I notified the dispatcher, and we started toward the hospital.

"Your father's doing okay," I said as I drove. "He took a lot of smoke, and he'll probably be fine, but he'll need to spend some time in the hospital."

"Okay," the boy said. Maybe he was in shock, but he didn't seem overly concerned.

Suddenly the boy's cell phone rang. He clicked it on. "Hello? Yeah. We had a fire at my house. My IPod was in there. Okay. See ya." He clicked the phone off.

To mention his IPod, but not his father, struck me as odd. Maybe I was reading into the conversation, but it seemed like an unusual sense of priorities.

Even so, he was just a kid, and I figured that on some level he was probably worried, so I tried to make conversation while driving. "What happened in the house?" I asked. "Do you have any idea how the fire started?"

"No. I was up at my friend's house. His sister came running into the room. She said there were fire trucks on my street. I ran home, and I got there right when they were bringing my father out."

By this time, we were approaching the hospital. "Follow us," I told him. "We're going into the emergency department."

We unloaded the stretcher and wheeled it inside. My partner had called ahead by radio, and a team of doctors and nurses was waiting for us in the emergency department. The resident in charge was impressed by the amount of carbon in the man's throat. He ordered some x-rays and other tests, and placed a phone call to the ICU.

We had to leave quickly. The dispatcher had other calls for us to handle. Some time later, my partner called the hospital to check on the man's status. His trachea had swollen from inhaling so much smoke, leaving the doctor no choice but to intubate him. By the end of our shift, he was on a ventilator in the ICU, sedated.

Smoke inhalation is a deceptive condition. The patient can appear perfectly stable for a long time, but then his throat will suddenly swell, causing him to suffocate almost without warning. Or he can suddenly develop fluid in his lungs, causing him to drown. They teach us these things in paramedic school, but until you see them for yourself, you'd never believe how quickly a smoke inhalation victim can deteriorate.

Hopefully, this man will be okay. I feel as if everything was done right, by us as well as by the hospital staff. He arrived at the hospital quickly, and he had a tube inserted into his trachea before the swelling became a problem. But you never know. Complications can set in. He could still develop pulmonary edema or pneumonia. We'll just have to wait and see.

But at least he wasn't burned.

Pets

2009-02-10T08:58:00.001-05:00

A woman called 911 tonight and shouted hysterically, "Send an ambulance, quick! My baby is having a seizure!"

A few minutes later, an ambulance arrived. Walking into the apartment, the EMTs found a woman cradling a sick cat. Yes, a cat. The woman had called an ambulance for her pet.

While this kind of call is rare, it was not the first time anyone had called Boston EMS for an animal. A long time ago, a veteran EMT told me about the time he responded to "someone hit by a car," and the patient turned out to be a dog. They found it bleeding and nearly unconscious in the street, surrounded by a crowd of onlookers. The EMT and his partner dutifully assembled the necessary equipment, immobilized the dog's spine, and lifted it onto the stretcher and into the ambulance. As far as I know, this remains the only time a Boston EMS unit has ever delivered a patient to Angel Memorial Veterinary Hospital.

More recently, a Boston EMS paramedic tended to an injured horse. Spooked while pulling a carriage full of tourists near Quincy Market, the horse bolted through congested downtown streets and was severely injured when the carriage overturned. A veterinarian was called to the scene, but in the meantime, a police officer enlisted the services of the paramedic, who had once worked as a veterinary assistant. She understood equine anatomy and knew where to inject medications. Because a horse is much bigger than a human patient, she emptied the drug box into him, giving him all the painkillers available.

I've never been called to the scene of a pet emergency. Once, though, as we drove through Chinatown on a summer evening, we heard an unusual noise through the truck's open window. It seemed to be coming from a pile of trash outside a restaurant, and it sounded like, well, quacking. We climbed down from the cab and rummaged through the boxes, until finally, in a wooden crate at the bottom, I discovered a live duck that a chef had literally thrown away.

At first we were going to free it right there. But then we thought about it, and we realized that a Chinatown street is no place for a duck. So we put it into the back of the ambulance, crate and all, and drove it over to the Common. We released it into the Frog Pond, the setting of the children's book Make Way for Ducklings. That seemed appropriate.

Another time, while I was still working as an EMT, we responded to an apartment building in the North End, where a young man had hung himself in his closet. It was a tragic situation, of course, as all suicides are, but the thing I remember most about that call was the dead man's dog. It was a big, beautiful Siberian Husky, and we found it sitting on the bedroom floor, staring up at the remains of its owner.

That was a heartbreaking sight. It was sad that the man had committed suicide. It was sad that he had died so young. But for some reason, those facts didn't bother me nearly as much as the sight of that dog.

I don't know why this bothered me so much. Maybe it's because animals are innocent, in much the same way that children are innocent. They never cause their own health problems, but instead tend to suffer at the hands of others. Or maybe it's because we become immune to human suffering, simply because we see so much of it.

Whatever the reason, I'd be happy not to deal with any more animals at work. It's just too depressing.

I'll take care of the humans, and leave the pets to the ASPCA.

An Allergic Reaction -- or Something

2009-02-08T01:10:00.003-05:00

When I was a child, I didn’t know anyone with a food allergy. Restaurants didn't post warnings about their use of nuts, and schools didn't designate special tables in their cafeterias for students who couldn't tolerate certain food items.

Now, though, food allergies seem to be everywhere. We respond to a couple of these calls every week. A surprising number of children carry epinephrine now, to be self-injected in case of exposure.

And so I have to wonder: What’s going on here? What has changed during the past couple of decades? Why do so many people have so much trouble with food?

The answer, it seems, might have to do with the testing process. An article in The New York Times recently discussed the extraordinary inaccuracy of allergy skin tests. Up to half of these tests may yield false positive results, some doctors say, causing millions of people to be deprived of foods unnecessarily. While the number of true food allergies has indeed gone up over the years, so too has the rate of overdiagnosis.

These things make sense. I’ve responded to hundreds of “allergic reaction” calls during the past twenty years, and almost none of these patients was suffering from a life-threatening condition. Two of them had enough trouble breathing to require epinephrine, but the rest had nothing more serious than a sore throat or a slight rash. In fact, the vast majority of them had no symptoms at all. They called 911 simply because they'd eaten something they weren’t supposed to have, and they were afraid of what might happen. But nothing ever did.

We saw an example of that tonight, I think. Early in the shift we responded to a downtown college, where a woman was supposed to be having an allergic reaction. She was sitting on a bench, scratching furiously at her own forearms. The school nurse had called us because the student allegedly had an allergy to shrimp. The student had made the all-too-common mistake of eating Chinese fried shrimp, thinking it was a chicken finger.

We looked at the woman closely. She had no rash and no hives. Her face wasn't swollen, and she wasn't breathing particularly fast. In fact, aside from the itching, it didn't look like an allergic reaction at all.

My partner asked a few questions, partly to see if the woman could speak clearly. Swelling of the airway is the most dangerous aspect of an allergic reaction to food. Patients who can't speak clearly must be treated aggressively, or they may die.

This woman refused to talk. It wasn't that she couldn't talk; rather, she had become too panicked to try. She just sat there, eyes staring wildly at us, scratching like crazy.

We decided to give her some Benadryl to alleviate the itching. My partner drew it up in a syringe and handed it to me. I injected it beneath her skin. Even before the syringe was empty, the scratching subsided.

"Feel better?" I asked.

The woman nodded.

"Want to go to the hospital?"

Another nod.

"Okay." I pointed to the stretcher. "Come on over. Have a seat." The woman stood up and climbed onto the bed. Behind her, my partner rolled her eyes. I knew exactly what she was thinking: The Benadryl couldn't possibly have made any difference. Before it can begin to work, it must first be absorbed and circulated through the body. In this case, the symptoms went away even as the needle was hitting the skin. She was cured even before the medication had entered her body. It worked only because the patient believed it was working.

This woman had been diagnosed with a food allergy. She'd eaten the prohibited substance, and she felt certain that she was having a reaction. But she wasn't. We'd checked her from head to toe, and there was no evidence anywhere of even the mildest physical sign of allergy.

So, I'm pretty sure that doctor was right. Many people have been misdiagnosed with food allergies. As a result, many people people panic over reactions that will never occur.

I'll bet this woman is one of them.

To read the New York Times article on food allergy misdiagnosis, go here:

http://www.nytimes.com/2009/02/03/health/03well.html?em

Back to the US, back to the ambulance

2009-02-07T19:58:00.003-05:00

I've returned from active military duty in Germany, and I'm back on the ambulance. For anyone still interested, look for new posts beginning tomorrow.

I'll keep them up as long as our patients remain interesting.

Maybe the End of the Blog...Again

2008-08-20T15:34:00.002-04:00

I'm writing this post from Wiesbaden, Germany.

Barely three weeks after returning from a week of Army training in New Jersey, I was activated and assigned to the 1st Armored Division, headquartered 20 miles west of Frankfurt. I'll likely serve here until the end of the year. The work is nothing like EMS, but it's enormously rewarding. Soldiers come to me for advice on all sorts of legal problems, from credit card fraud and disputes with local shopkeepers to help writing their wills.

Obviously, it'll be a while before I return to the ambulance. I found it impossible to keep this blog going while I was active duty the first time, and this deployment will be no different. Even if I have material to write about, I'm just too busy to post.

I can't honestly say whether I'll resume blogging after I return to the U.S. It's been a fascinating experience, and it was quite a thrill to receive so much feedback from readers all over the world, but blogging takes an awful lot of time, so we'll just have to see what happens. I'm not going to make any promises.

In any event, I'd like to thank all of you for reading. This site has had more than 112,000 visits since it opened two years ago, a response that exceeded my wildest expectations. It's been fun writing for you, and even more fun to read your responses.

Old Enough to Know Better

2008-08-11T09:13:00.002-04:00

Every so often, you hear paramedics and EMTs talking about a bad batch of heroin, one that causes a slew of overdoses.

This is not an urban legend.

In fact, it happened tonight. We responded to three calls during our shift. All three were heroin overdoses in the same neighborhood.

The was nothing unusual about the first two calls. The third one caught our attention, though. The patient, according to the message on the computer in the ambulance cab, was 67 years old.

“Better late than never,” my partner remarked.

We don’t often encounter heroin addicts that old. Or even 40-year-old addicts, for that matter. By that age, most addicts have either quit or died.

This one was alive and more-or-less well, sitting on a couch in his living room. He looked at us sleepily as we entered the room. “What’s going on?” he asked.

“We’re here to check on you,” I told him.

“Me? Why me? I’m fine.”

“Somebody reported that you were unconscious.”

“No way. I’m fine.”

“Well, since we’re here, will you let us check you out? It’ll make everyone feel better.”

The man shrugged. “Sure.’

That’s a funny thing about heroin addicts—they are generally quite willing to submit to an examination. They do this, I suppose, for the same reason that people consent to searches of their cars by the police—in doing so, they hope to appear less guilty.

It doesn’t often work. The addict consents to the examination, and invariably we discover signs of drug use. Apparently, we’re not as naïve as the addicts think we are.

That’s what happened in this case. The man’s pupils were constricted. His skin was clammy. His heart was racing.
No doubt about it—he was high.

“What time did you use?” I asked him.

He reacted with a stunned expression. “Use? What are you talking about? I didn’t use.”

“Let’s be honest. You have all the signs of heroin use. Plus, somebody called to report that you were using heroin.”

At this he became indignant. “Who called? I have a right to know!”

“Think about it,” said the cop who’d responded with us. “You’re in your own house. Who would know about it?”

It took a moment for the question to register, but then an almost-comical look of shock came to his face. “Somebody in my house? Somebody in my own family?”

The cop simply nodded.

“So, we need to go the hospital,” I said, picking up where I’d left off.

“But I didn’t use any drugs!” he insisted.

I wanted him to admit that he’d used, because that would make it easier to coax him into treatment. Suddenly, I had an idea. The patient wasn’t exactly a Rhodes Scholar, and by changing my approach, I hoped to trip him up.

“How did you take the stuff?” I asked. “Did you shoot, sniff, or take pills? Each way gets absorbed into the body at a different rate. We need to figure out how much stuff is left in your system.”

This wasn’t exactly the truth, of course. In fact, it made little or no difference which method he’d used. By changing the focus of the question, however, I hoped to distract him, to make him forget that he’d never confessed.

It worked perfectly. “All right,” he said, shaking his head slowly. “I snorted it.”

“Thank you for being honest. Now we can get you some help. Let’s go outside to the ambulance, and we’ll bring you to the hospital.”

Again the man hesitated.

“Come with us,” said the EMT supervisor who’d also responded. “Your mother is worried about you.”

I looked at the supervisor. “His mother?”

“Yeah. She’s out in the kitchen.”

“How old is she?”

“I’m not sure. Eighty, maybe? Ninety?”

“The eighty-year-old mother is concerned about her seventy-year-old addict son,” I whispered. “Now I’ve seen everything.”

The supervisor grinned.

“Can I ask you a question?” the patient said.

“Sure.”

He was standing up now, staring beyond me at the wall on the other side of the room. He opened his mouth, but said nothing.

“Mister Phillips? Did you have a question?”

He snapped back to the conversation. “Um, yeah. Can I...”

His eyelids sagged, and he appeared ready to fall asleep on his feet.

“Mister Phillips?”

“Yeah. Can I…”

Gently I turned his body toward the door. He opened his eyes and began to walk.

The sixty-seven-year-old addict was on his way to the emergency department.

Denial

2008-08-08T09:05:00.003-04:00

Heroin addicts respond to us in three different ways. Some wake up fighting, either because they are confused, or because they hate us for ruining their high. Others wake up apologizing. Frequently, though, they wake up in denial, refusing to accept just how close to death they actually were.

We responded to one such call today. Thanks to a crazy traffic pattern, we were fortunate even to get there. The patient was in a hotel room, and the switchboard operator initially told us to enter by way of the loading dock. After we’d driven to the one-way street on that side of the building, she called back and told us to enter through the front door. Past the hotel we went, intending to go around the block, but we found the next three intersections blocked by a gas company construction crew. Finally we gave up and made a u-turn. As we drove back in the opposite direction, we passed a man who gestured furiously with his arms, visibly upset that we’d passed him twice in less than a minute with our siren blaring.

A security guard met us at the main entrance. He led us up to a suite, where the patient lay unconscious on the bathroom floor. A team of EMTs had arrived shortly before we did. One of them had been blasting Narcan into the man’s nose, causing the man to stir just as we entered the room.

I asked the EMTs if they’d searched the patient for needles. Having been stuck with a contaminated needle once—and nearly a second time earlier this year—I always make this a priority. On this call, the EMTs were diligent. “There are syringes and condoms everyplace,” one of them told me. “We put the needles in a pile over there.”

By this time, the patient was trying to stand up. The security guard, a weightlifter-type with a shaved head, placed an enormous hand on his shoulder and told him not to move.

“I’m fine,” the patient said. “I’m getting out of here.”

I thought we were in for a fight. The patient surprised me by laying back down.

A police officer came into the room. The EMT told him what had happened. The cop asked the patient all the usual questions—name, address, date of birth, social security number.

Again the patient tried to stand. Again the security guard held him down. “Let me get up!” the patient said, clearly annoyed. “I didn’t do anything!”

Hoping to avoid an unnecessary altercation, I squatted beside the young man and asked his name.

“Mario,” he replied.

“Hold on for just a second, Mario,” I told him. “You’ve only been awake for a couple of minutes. We don’t want you to fall down.”

“No, I’m fine.” He struggled to his feet. I motioned to the security guard that it was okay. Mario eyed the guard suspiciously. “Am I under arrest?”

The guard didn’t answer. Instead, he asked a question of his own. “Are you a guest here?”

“No.”

“Then you’ll be arrested for trespassing.”

A police officer arrived. After conferring with the EMT and security guard, he decided not to arrest the man after all, but to release him for hospitalization.

“Come on,” the EMT said, motioning toward the door.

“Where are we going?” Mario asked.”

“To the hospital.”

“I don’t need a hospital. I didn’t use any drugs.”

“Yeah, you do. You were unconscious, and you stopped breathing.”

“So, give me some Narcan.”

The EMT shook his head in frustration. “We already gave it to you. That’s what woke you up.”

“Where’s my buddy? We were shooting up together. He was supposed to stay with me.”

“I have no idea. You were alone when we got here.”

“Did my buddy call you?”

“No,” the security guard said sternly. “Somebody found you. You buddy was long gone.”

The man glared at each of us. “I was fine until you guys did this shit to me.”

I couldn’t help wondering what, exactly, we had done to him that he didn’t like. Breathed for him? Kept him alive? Reversed his overdose? Apparently, he was having a fine day until we came along and thoughtlessly saved his life.

It was like dealing with a five-year-old. I didn’t use any drugs. I didn’t do anything wrong. I don’t need a hospital, because there’s nothing wrong with me. It’s my buddy’s fault. It’s the paramedics’ fault. It’s everybody’s fault but mine.

Deny, deny, deny.

The cop checked his criminal record over the radio. The result didn’t surprise me. Mario had been convicted twice previously—once for larceny and once for robbery—and he has another criminal case pending.

One thing did surprise me, however. As we walked out to the ambulance, somebody was waiting for Mario. It was his buddy, the guy who was thought to have run away.

That never happens. In all the years I’ve worked on an ambulance, not once has one addict hung around after another addict has overdosed. Knowing that he will get in trouble, the friend always takes off before we—or the cops—arrive.

The whole thing could have turned out worse. Mario walked peacefully to the truck. He didn’t try to escape on the way to the hospital. He wandered away from the emergency department, but one of the EMTs spotted him and the security guards dragged him back to his room.

He frustrated us, but at least he didn’t get violent.

Stabbed

2008-08-06T08:34:00.003-04:00

The shift was nearly over. Any moment, our relief would walk through the door, and I would have two days off.

But then the tones came over the radio.

Someone had been stabbed in a housing project not far away. We climbed back into the truck, started the diesel, and waited for the electric door to rise. The siren yelped as we sped out into traffic. For so late in the evening, the streets were unusually crowded.

A few minutes later, we turned into the complex. There would be no difficulty locating the patient. Despite the late hour, the whole neighborhood seemed to have turned out. People of all ages - even little kids - ran toward us, pointing and waving toward a rear courtyard.

The patient himself was upright, staggering along the sidewalk, a rag pressed against his neck. One of the EMTs directed him into our truck. He collapsed onto the stretcher.

We rolled him onto his side. He had four wounds in all, two on his back, one right in the nipple, and one on the side of his neck. We were most concerned about the neck wound. It was in a bad location, directly over several large veins, arteries, and nerves.

I asked if he'd seen the weapon. I wanted to get an idea of the blade length. "I never saw anything," he said. "He came up behind me, stuck me, and ran away."

He spoke in a high-pitched, extremely nasal voice. This was an ominous sign. I'd never met the man before, but I had a feeling that he didn't normally talk this way. I wondered if his throat was filling with air, putting pressure on his larynx. I wondered if the knife had lacerated his trachea.

Gently I pressed against the skin around the wound. I felt a crunching sensation beneath my fingers. Just as I'd suspected, air was beginning to fill his neck. He needed an operating room immediately. Otherwise, he'd suffocate.

"We'll do everything on the way," I said to the EMTs, trying to convey the urgency of the situation without alarming the patient. The EMTs understood. A moment later, we were racing toward the trauma center, a pair of ambulances yelping and wailing through downtown streets.

My partner started an IV. I contacted the hospital by radio. This patient could not afford to be delayed at triage. He needed to get into a treatment room immediately.

As we approached the hospital, I told the patient what to expect. "You'll go into an area called a Trauma Room," I said. "A bunch of people will do a lot of things all at once. They need to make sure your condition is stable. Try your best to cooperate. That's the best thing you can do to help yourself."

He nodded that he understood.

We arrived at the emergency department and wheeled the man inside. Doctors and nurses stood in the trauma area. We dragged the patient across to the hospital gurney. He was still awake.

The hospital staff closed in on him, touching, examining, reporting various findings to a nurse taking notes on a clipboard. I was glad that I'd told him what to expect.

Someone rolled in a machine called a FAST scanner. I've forgotten what the acronym stands for, but it represents the latest in ultrasound technology, allowing doctors to inspect damaged organs on a computer screen right there in the emergency department. This time, the FAST confirmed our suspicions. The trachea had been cut, and air was filling his neck. He was fortunate to remain alive.

The doctors knew, just as I had suspected, that the man's breathing could stop at any moment.

"You want to intubate him?" one resident asked another.

"Not here," the second resident said. "I'll do it in the OR. With an injury like this, too much can go wrong."

A police officer came in. I directed her to the trauma bay, where our patient was just about to depart for the operating room.

"Any chance I can get his clothing?" she asked.

It would be needed for evidence. Months or years later, if a suspect was caught and the weapon recovered, the man's shirt would be produced at trial. An assistant district attorney would hold it up for the jury, demonstrating how the holes in the fabric matched the locations of his wounds, and how the size of the weapon matched the sizes of the holes. I retrieved the man's shirt and pants from the floor of the trauma room, dropped them into a paper bag, and handed them to the officer.

The hospital staff wasted no time. Two nurses and a doctor wheeled his gurney to an elevator. He was on his way to the operating room even before we'd returned to the ambulance.

I wondered, as we drove back to our station, what the fight had been about. The man had claimed not to see his assailant, but I doubt he was telling us the whole story. I've heard that line before, from dozens of shooting and stabbing victims, and every time it turned out that the patient not only saw the perpetrator, but actually knew him. People talk all the time about random acts of violence, but there's rarely anything random about a person getting stabbed four times.

This time, though, I don't think we'll ever learn what happened. Maybe the detectives will get him to talk. That's not our job. We did what we were supposed to do, treating him, getting him to the hospital quickly, making sure the hospital knew how serious his condition was.

I'd be interested to know how he makes out. Otherwise, it's out of our hands.

Dead

2008-08-04T21:14:00.006-04:00

The woman in the back room was dead.

She was 90 years old, and her son had been giving her a dialysis treatment in her apartment when suddenly she'd lapsed into unconsciousness. He'd called 911 immediately, but we arrived less than five minutes later to find that her heart had stopped.

One of the EMTs pumped on her chest. Another one squeezed oxygen into her mouth and nose with an Ambu bag. My partner started an IV. I tilted her head back to insert a plastic endotracheal tube through her mouth and into her lungs.

Her mouth had filled with liquidy vomit. There was no time to get the electrical suction machine, so I turned her head to the side and let it drain onto the mattress. Again I looked into her throat. This time I could see her vocal cords. I slipped the tube in between them, connected the Ambu bag to the end of the tube, and turned the duty of ventilation back to the EMT.

The IV was running. I took a pair of syringes from the drug box - one containing epinephrine, the other filled with atropine - and passed them across the bed to my partner. He injected them into the IV tubing. We continued the CPR, and we watched the cardiac monitor, and we waited.

Nothing happened.

We repeated the process. More epinephrine, more atropine. There was still no change.

I went into the living room to describe the situation to the woman's son. The son spoke only Spanish, but a neighbor volunteered to translate. "We've done everything the hospital would have done," I told him, "but her heart hasn't responded. We'll give her one more dose of medications, and if that doesn't work, we'll stop the resuscitation effort and call the medical examiner."

The son took the news well. His expression grew appropriately sad, but he didn't break down or through a tantrum, as some people do. He thanked me through the translator. I told him I'd come back, either way, in a few minutes.

I returned to the bedroom. Nothing had changed. My partner had given the third dose of epinephrine and atropine, but the line traveling across the monitor remained flat. The woman was dead, and no medications were going to change that.

I changed my portable radio from the dispatch frequency to a medical frequency. The CMED operator set off a tone at the Boston Medical Center. The on-duty emergency medicine resident answered. Before we terminate a resuscitation effort, we must consult with a physician. This is purely a technicality, but the procedure must be followed.

I described what had happened. I reported the medications we'd given. "The patient remains in asystole," I said, "and she meets the criteria for field termination. And so, at this time, we'd like to..."

I took one last glance at the monitor. The line was no longer flat. Sharp vertical waves marched steadily across, 140 times per minute.

"Does she have a pulse?" I asked.

One of the EMTs felt her neck. "Yeah, she does. She has a carotid pulse."

I keyed the microphone again. "Just a minute, BMC," I said into the radio. "The situation is changing."

I watched the monitor for several seconds, making sure that her heart would not stop again. It didn't. I looked at the EMT. "She still has a pulse?" The EMT nodded yes.

"BMC, the patient now has a pulse. We're not going to terminate the resuscitation after all. We'll come to your facility, and we'll be there in about ten minutes."

"Okay," said the doctor.

I should have been happy that the woman's heart was beating again. But I wasn't. She was nearly a century old. Even before her collapse, she'd been confined to bed, getting daily treatments to clean out her failing kidneys. Patients who are young enough, and healthy enough, sometimes recover from cardiac arrest. The odds of complete recovery are not good, but occasionally it happens. This woman was neither young nor healthy, though. Even if we succeeded in keeping her alive, she would never wake up. At best she'd remain in a nursing home, totally helpless, and soon she would die again. It would be easier on the son, I thought, if she just expired right now.

"This call has been kind of interesting," one of the EMTs said.

"What? The cardiac arrest?"

"Yeah. It's my first one."

Quietly, so as not to let the son overhear, I said to my partner, "He has a perfect record. Every cardiac arrest he's ever worked has survived."

The EMT smiled.

We rolled the patient onto the metal frame we'd use to carry her down the stairs. Suddenly, the EMT at the patient's head looked concerned. "There's something wrong with this bag," he said. "I'm having a really hard time getting oxygen into her."

I placed my stethoscope to the patient's chest. The most serious problem with endotracheal tubes is that they sometimes wind up in the wrong place. Insert it into the esophagus, rather than the trachea, and the patient will suffocate.

It seemed to be in the right place. I could hear air moving in and out of the lungs. I asked my partner to listen, too, just to make sure. He shrugged. "Sounds good to me," he said.

That's when I noticed something odd about the woman's chest. The left side looked bigger than the right. I pressed my palm against her sternum, and I could feel a crunching sensation beneath the skin. We see this often in patients who have been shot. Her lung had collapsed, and air was leaking into the chest cavity.

"Look at this," I said to the EMTs. "She's got a pneumothorax."

They were impressed. You don't see a collapsed lung every day.

To relieve the pressure in the thoracic cavity, we stuck an enormous needle into the woman's chest wall. Air whoshed out. I pressed on the woman's chest, and it deflated like a punctured beach ball.

Her heart had stopped again. We resumed the CPR. The EMT's perfect record wasn't safe yet.

We carried the woman down to the ambulance. All the way to the hospital, I wondered what had caused her lung to collapse. Had I pushed the endotracheal tun too far into her lungs? Had I punctured her trachea while looking into her throat with the laryngoscope? A short time earlier, I'd been thinking that death was not the worst thing that could happen to this woman. Now I was worried that perhaps I'd killed her.

"What do you think?" I asked my partner. "What do you suppose happened?"

Even as I asked, I realized that I'd overlooked the obvious. I'd seen an inhaler on the woman's bed. She had emphysema. The lungs of emphysema patients often have weak spots, called "blebs," that can blow out under the pressure of ventilation.

"I'll bet it was the CPR," my partner said. "She's ninety years old. Her ribs probably snapped like toothpicks. One of them must have punctured her lung."

We wheeled her into the emergency department. Her heart still was not beating. The room filled with doctors, nurses, and medical students. The interesting cases always draw a crowd.

I went outside to get the portable computer we use to document calls. By the time I came back, the resuscitation effort was over. The doctors had decided that a 90-year-old renal-failure patient couldn't survive the loss of one lung. Whether it was the emphysema, a rib fracture, or something else, the cause didn't matter.

The woman had been dead, and then alive, and now she was dead for good.

Just an Ambulance Driver

2008-08-02T18:15:00.009-04:00

I’ve made a concerted effort recently not to complain so much. The world is changing, and my job is changing, and the people we encounter are changing. There’s no point in complaining about these things, because complaining won’t fix them.

Tonight, though, I couldn’t help it. We ran the entire night, eight calls in eight hours. Not one of them was serious.

We began with a heart attack call at an East Boston housing project. Or, at least it had been classified as a heart attack. Someone called 911 and said the woman was experiencing chest pain. She wasn’t. She complained only of being nervous. Someone had stolen her Klonopin, she told us. She lets all of her neighbors come into her apartment to borrow things, she said, and one of them must have stolen her medicine.

So, of course, she wanted an ambulance to bring her to the hospital to get another prescription. Because that’s what you do when you need more pills, don’t you? Take an ambulance to an emergency department? Refilling a prescription is indeed a life-threatening emergency.

On the way to the hospital, she talked about her predicament with great emotion. “Why doesn’t my doctor believe me?” she demanded to know. “He said on the phone that he wouldn’t write me a new prescription. He says he has to guard against drug abuse. Does he really think I’m going to abuse Klonopin? Nobody abuses Klonopin.”

“If nobody abuses Klonopin, then why would somebody steal yours?” I asked.

She never answered the question. Instead, she changed the topic.

After that, we went to a senior citizens’ complex for a man who couldn’t breathe. Or so we were told. In fact, he’d suffered a stroke nearly ten years ago, and has breathed through a tracheotomy tube ever since. Tonight, while a nurse was checking up on him, she attached some kind of adapter to the outside of the tube, something that was supposed to help him talk. This made no sense to me at all, since, according to one of the man’s daughters, he’s been in a coma for almost a decade.

When the nurse saw him struggling to breathe, she immediately removed the new piece. The man’s breathing returned to normal. We talked to all three of the patient’s daughters, and they agreed that he looked just like he always does. But the nurse insisted on sending him to the hospital. She’d already talked to a doctor, she said, and she wanted him to come in for an evaluation. So off we went to the hospital, with a patient whose problem had been resolved, based on the word of a nurse who had panicked, on the orders of a doctor who was miles away.

Next we went to a homeless shelter. Like our first call, this one was billed as a cardiac problem. One of the shelter volunteers came outside to meet us. “He’s really intoxicated, and he’s putting up quite a fight,” he said. “I don’t know if he’ll want to go with you.”

“Then why did you call us?” my partner asked.

“Well, he wanted to go outside to smoke, and when I told him he couldn’t, he said he had chest pain and wanted to go to the hospital.”

A drunk man was demanding an ambulance after having being denied the opportunity to smoke. It didn’t sound like much of a cardiac problem to me. But there was no point in debating the issue. We went inside to look at him.

“What’s happening tonight?” I asked the man.

“Got pains in my chest,” the man snorted, glaring at me angrily.

“How long have you had these pains?”

“Since yesterday.”

“Off and on? Or continuously?”

“The whole time.”

“Have you ever been to a hospital for these pains before?”

He looked at me as if I were an idiot. “Yeah. Yesterday.”

“You went to the hospital yesterday for this pain? And you’re still having it?”

“Yes! That’s what I’m telling you!”

“Well, what did the doctor say yesterday?”

“He didn’t say nothin’.”

I can’t stand it when people say that to us. No doctor in the history of medicine ever discharged a patient without explaining the diagnosis. Even if a doctor admits that he can’t identify the cause of a patient’s illness, he will always tell the patient something. And if you were discharged without being told anything, then wouldn’t you be curious enough to ask what the diagnosis was?

Not this man, apparently. When I asked again what the doctor had told him was wrong, he said, “Look. Are you going to take me to the hospital or not?”

Yes, sir. Right away, sir. Step outside to our ambulance. We’re the highest-paid taxi drivers in the city.

Next we went to our favorite destination: a neighborhood health center. According to the doctor there, our patient had come in with dangerously low blood pressure, so she’d started an IV.

The man was sitting up in bed, looking quite comfortable. I asked him how he felt.

“Pretty good,” he said.

“What made you come to the health center today?”

“I was feeling a little tired.”

“You feel okay now?”

“Yeah. Sure.”

I took his blood pressure. It was 140 over 80. Normal.

“Want me to walk out to the ambulance?” the man asked.

“No, that’s okay. We’ll wheel you out on the stretcher. If you’re feeling tired, we don’t want you walking around.”

We started toward the door.

“Wait!” the doctor called. “You can’t leave yet! I haven’t written my report!”

This left me speechless. The City of Boston operates just five paramedic units on the day and evening shifts, and one of them had been tied up on a call that could have been handled by a taxi. I can understand an ordinary citizen making this mistake, because many people just don’t know any better. But this was a doctor. She’s supposed to know how the health system works. And she wanted to keep twenty percent of Boston’s paramedic resources waiting while she trotted off to her office to write a report.

I’d had enough. I was about to tell her not to bother writing her report because we were leaving without it. Fortunately, my partner intervened. “You can fax it over to the hospital,” he said. “It’ll get there before we do.”

This sounded like a good idea to the doctor. I felt like screaming as we wheeled the man outside.

After that, we went to a nursing home. A nurse had called 911 because the patient had felt lightheaded briefly. By the time we arrived, he was feeling fine. But the nurse insisted that he go to an emergency department. She was concerned because his heart rate was low.

We checked the man’s pulse. It was 68. The low side of normal.

“Do you have high blood pressure?” I asked him.

“Why, yes. I do.”

“Do you take medication for it?”

“Yup. I take something called Toprol.”

“Thank you, sir. That’s helpful to know.” Toprol keeps blood pressure in check by slowing the heart rate. His heart was beating slowly because it was supposed to be beating slowly. Once again, we were taking a patient to the hospital on the instructions of a healthcare professional who didn’t understand that his condition was normal.

And finally, with twenty minutes left to go in the shift, we were sent to the opposite end of the city, where a woman was having trouble breathing. After cleaning a bathroom, she’d sat down to smoke. Now she was having trouble catching her breath.

Imagine that. Feeling short of breath after smoking.

Fortunately, a pair of EMTs arrived on the scene before we did. Recognizing that we couldn’t do anything to fix the patient’s smoking habit, they cancelled our response.

Returning to the station, I realized why I felt so frustrated. It wasn’t because the people who’d called us didn’t seem to understand the definition of an emergency, although that was certainly true. And it wasn’t because we had been kept busy all night on non-urgent matters, making us unavailable for true emergencies—although that was certainly true as well.

What really bothered me was the way our job has changed. Together, my partner and I had more than forty years of experience handling emergencies. We are extremely well trained. We’re certified in CPR, and Advanced Cardiac Life Support, and as hazardous materials technicians. We’ve attended Advanced Trauma Life Support courses alongside physicians, and Critical Care Transport courses alongside flight nurses. We’ve handled hundreds of cardiac arrests, and hundreds of shootings, and at times, we’ve even rescued people from fires and wrecked vehicles.

And what did we spend our night doing? Driving healthy people to the hospital without even treating them.

Now, don’t get me wrong. I’m not saying that I’m too good for this kind of work. I’m not above taking care of a stroke victim, or a man who nearly fainted, or a woman suffering a panic attack. But this isn’t the way the system is supposed to work. Wheelchair vans exist for a reason. They are supposed to be used for the transport of people who can’t get around on their own, but don’t have a medical emergency. Something is clearly wrong with a system that utilizes highly trained, highly paid, experienced health care providers to transport relatively healthy people back and forth to hospitals, where they don’t even rate a bed in the acute section of the emergency department.

And yet, that’s all we did tonight.

I’m not sure where the problem lies. Maybe nurses who work outside of hospitals need to have better training in the identification of emergencies. Maybe doctors need to be told that city ambulances are not taxis. Maybe the city should buy more vehicles, and hire more EMS personnel. Maybe the people taking the 911 calls should be allowed to ask more questions, to get a better idea of what’s really going on at the scene.

But what do I know?

As far as most people are concerned, I’m just an ambulance driver.

An Italian View of American EMS

2008-07-31T00:15:00.005-04:00

Tonight we had a visitor, a physician visiting from Italy who wanted to see how American ambulances operate. Unfortunately, he didn’t learn much about emergencies. He learned more about crazy people.

Right at the beginning of the shift we responded to an intersection in the Back Bay, where a man said he’d been hit by a car. We arrived to find a man standing beside a bicycle. He was about twenty years old and covered with tattoos.

“You’re the one hit by a car?” I asked.

“No,” said a Department of Homeland Security police officer who’d come upon the incident. “He rode his bike into a bus. He’s a courier.”

“So, nobody got hit by a car?” I wanted to make sure we didn’t have more than one patient.

“No, he’s the only one injured.”

“What part of you hurts?” I asked the courier.

He stared off into space and spoke in a soft, distracted voice. “Everything feels so…far away,” he said.

“Be specific,” I said. “What part of your body is hurt?”

“I feel…” Another pause. “Like everything is drifting away.”

“Try to concentrate,” I said. “Please. What part of your body hit the side of the bus?”

“I didn’t hit the side of the bus,” he told me. “I hit the back. The driver stopped too quick.”

Great. I can’t get the guy to tell me where he’s injured, but he wants to debate which part of the bus he crashed into. As if it mattered.

“We’re not the police,” I said. “We’re the ambulance guys. And that means we’re not interested in whose fault it was. We just want to know whether you’re injured. Let’s start at the top. Does your head hurt?”

“It’s all hazy.”

I was getting frustrated. He was wearing a baseball cap. I removed it and ran my fingers over his scalp. “No bumps or cuts,” I said. Then I pressed gently against the back of neck, from the base of his head right down his spine. “Anything hurt here?”

“No.”

By this time, another ambulance had arrived with a pair of EMTs.

"Let me ask you a different way,” I said to the courier as they walked over to us. “Are you feeling any pain in any particular part of your body?”

“My knees.” Finally, information we could use.

“Okay, so, your knees hurt. And that’s all?”

One of the EMTs had caught the end of our conversation. He didn’t even need a report from me. “You want to go to the hospital?” he asked the courier.

“Yeah.”

“Okay. C’mon.” He waved toward his ambulance.

“Do you want me to lock your bike?” I asked.

The courier fished into his pocket and produced a key. I took it and locked the bike to a fence, then gave the key back to him in the ambulance. The EMTs brought him to the hospital. We told the dispatcher we were clear, and immediately she sent us on another call. This time, the patient was a middle-aged woman who had called from her South Boston apartment. She was sitting in a wheelchair in her living room, inhaling oxygen through nasal prongs.

“You’re having trouble breathing?” I asked. That’s what the dispatcher had told us. And that’s what the patient had told the 911 operator.

“My oxygen tank isn’t working,” she said. “It’s bubbling.”

We looked at the tank. It seemed to be working just fine. As for the “bubbling,” well, we had no idea what she was talking about. Nothing in the apartment was bubbling.

“Your oxygen seems to be okay,” I said. “But I see that you have emphysema. Are you having trouble breathing today?”

She shook her head no. I listened to her chest. She wasn’t wheezing.

“My ear hurts,” she said. Then, even before I had a chance to reply, she said, “My leg won’t stop moving. It just keeps going.”

I couldn’t keep up. She was developing medical problems faster than I could address them. So far, we were up to three: malfunctioning oxygen tank, earache, uncontrollable leg movement.

“Which problem did you call us for?” I asked.

“Just take me to the hospital,” she said.

“We will. But when we get there, they’ll want to know what’s wrong with you. So, which is the real problem, your ear, your leg, or your breathing?”

“Oh, God. My head hurts.”

Make that four complaints. Then she grabbed her stomach. “I feel queasy. I had meat loaf for lunch. I don’t think it agreed with me.”

Five complaints. Looking at my partner, I motioned to the bed. We were getting nowhere. Might as well just take her to the hospital. We lifted her onto the stretcher and wheeled her out the hallway. The door closed on our way out.

Downstairs, in the ambulance, the patient asked, “Did you lock my door?” A fine time to think about that. It probably would have been better to ask about it before we’d left the building.

There was no point in getting upset about it. I was already convinced that the woman was insane. “That’s a brand new building,” I told her. “Don’t the apartment doors lock automatically?”

“No. You have to lock the door with the key.”

“Did you bring your keys with you?” If she didn’t, she’d be out of luck. We were outside of the building, and with no keys, we wouldn’t be able to get back in.

She reached into her pocketbook. “Here.”

I stayed with the woman and the Italian doctor in the back of the ambulance. My partner ran upstairs and locked her door. He returned to the ambulance, gave her the keys, and started to drive us to the hospital. A minute into the trip, the woman asked me if we’d locked her door.

“Yes,” I told her. “We just gave you back your keys. Don’t you remember?”

“Oh. Yeah.” She paused. “It’s really hot in here. Do you think it’s hot? I think I’m running a fever.”

Complaint number six.

“My lung feels hot.”

“What did you say?”

“My right lung. It feels hot. I think it’s burning.”

In the emergency department, the nurse asked what was wrong with the woman. She was seated at a desk, prepared to enter the information into a computerized triage program.

“Can you enter ‘everything’ into that program?” I asked.

The nurse scanned the screen. “Sure. There’s a box marked, “multiple problems.” Does that sound right?”

“Yup.”

“So, just for the record, what are these ‘multiple problems’ that she’s complaining of?”

“Let’s see. Earache. Headache. Upset stomach, from meatloaf. Her oxygen tank is broken. Her lung is burning. Oh, yeah—and she says her leg won’t stop moving.”

“What did you say about her lung?”

“She says her right lung is burning.”

The nurse just stared at me, dumbfounded. “That’s what I thought you said.” She handed me some papers. “Room two. Put her in room two.”

I felt sorry for the Italian doctor. He’d come all the way to the United States to see how we handle emergencies. So far, he’d seen nothing but crazy people. "Is this ambulance service anything like your service in Italy?” I asked.

“No, not at all,” he said. “Ours is much worse. You have very nice ambulances here. Very big. Ours are small. And we have no paramedics. In Florence, where I work, a doctor goes to the emergency in a car. A volunteer meets us there with the ambulance, and he drives us to the hospital.”

“Really? A doctor goes to every emergency?”

“Oh, yes.”

“How about the volunteers who drive the ambulances? Do they have very much training?”

“No. They have no training at all. They volunteer because they feel obligated to the community. They work on the ambulance for a couple of months, and then, when they get tired of it, they quit. Last week, a man met me on the scene with the ambulance. He was seventy-nine years old. On the way to the hospital, I could hear the mirror hitting parked cars. I asked if he was okay, and he said he was sorry, he’d fallen asleep. He’d been working in his garden all day, and he was too tired to stay awake all night.”

“And he was driving you to the hospital?”

“Yes. The next day, he quit. So, you see, you are very fortunate here in America. Your paramedics are much better than the volunteers we have in Florence.”

I took that as a compliment. As bad as my attitude can be at times, it was good to know that I’m more skilled than a seventy-nine-year-old gardener.

No Simple Solution

2008-07-29T07:53:00.012-04:00

For twenty minutes at the beginning of the shift, the radio was quiet. Taking advantage of this rare phenomenon, I climbed from the cab of the ambulance and strolled into McDonald's. If I've learned anything from this job, it's that you should always eat when you can, because you might not get another chance.

On my way inside, I passed a homeless man on the sidewalk. He was sitting with his back against the wall, wearing a filthy, blue-and-white striped vest. In his hand was a ten-dollar bill.

He stared at me as I passed. His face looked familiar. I knew I'd brought him to the hospital before, but I couldn't recall his name. He didn't ask me for any money. In fact, he didn't say anything to me at all. I wondered where the ten dollars had come from.

The line in the McDonald's was short. I bought a cheeseburger and Coke and returned to the ambulance.

The homeless man had not moved. Now, though, he was surrounded by ambulance personnel. My partner was standing over him, along with a pair of EMTs.

"What happened?" I asked.

"Somebody called for him," my partner said.

While standing inside the McDonald's I'd heard a call go over the radio for a "man on the ground." The location was a block away, though, and since the call wasn't given to us, I hadn't paid much attention to it. Apparently, the call had been placed by another homeless man who didn't even know where he was. How sick could this man be, I wondered, if I could walk past him without even knowing he was a patient?

"Are you sick?" one of the EMTs asked him.

The man waved him away. "Leave me alone," he grumbled.

"Somebody called us, so we we need to check on you. Are you sick or hurt in any way?"

"No. I'm fine. Get away from me."

"Well, since you've been drinking," the EMT's partner said, "we need to make sure you can take care of yourself. I'll tell you what. If you can get up and walk on your own, we'll leave you alone."

The man struggled to his feet. He took a few steps. "There. Happy? I can walk." This happens all the time. Called to check on someone who wants no help, we get treated as if the whole thing was our idea.

We returned to the ambulance. The EMTs returned to theirs. The homeless man wandered over to a park, where we saw him begging tourists for money.

A call came over the radio for a cardiac problem. It was for us. We responded, but it turned out to be a false alarm. Ten minutes later, we returned to the same corner where we'd come across the homeless man.

As we came to a stop at the curb, a security guard approached. "There's a man over here who needs help," he said. "He's on the ground and..."

Looking beyond the guard, I saw a familiar blue-and-white striped vest. This time he was curled on the sidewalk, his hands beneath his head, sleeping peacefully.

"We'll take care of him," I said.

Again we climbed down from the ambulance. I tapped the man on his shoulder. He opened his eyes. "This isn't a great place to sleep," I said. "People will keep calling us, and we'll have to keep waking you up."

"Yeah, fine," the homeless man snorted. I offered my hand and pulled him into an upright position. He turned and walked away.

Tones blared over the radio. It was a heroin overdose, in South Boston, for us. This time it wasn't a false alarm. We gave the patient some Narcan, which woke her up, and we took her to the hospital. As we stood in the emergency department, waiting for the nurse to triage our patient, an angry voice demanded to be set free. It was a man on a stretcher, a patient who'd arrived in another ambulance just before us.

The voice grew louder. "Let me go!" the man shouted. "I'm fine! I don't need no goddamned hospital!" He wiggled on the stretcher, finally managing to get one arm free, and flailed for a moment before an EMT grabbed his wrist.

I couldn't help noticing the man's shirt. It was dirty, with blue and white stripes. Sure enough, it was the man from the corner - the same man who'd twice refused our help, and the help of other EMTs. He now had a tiny scrape on his forehead.

I asked the EMTs what had happened. "We get him all the time," one of them said. "Usually he doesn't want any help. This time he fell and bumped his head. People were going to keep calling for him, so we decided just to bring him in."

The homeless man went into one treatment room, and our heroin overdose went into another. As I wheeled the stretcher back to the ambulance, I found myself questioning my own decisions. Should I have brought the man to the hospital earlier? If I had, perhaps he wouldn't have fallen.

That certainly would have been the safer choice. And from a legal standpoint, the better one. An intoxicated patient cannot legally refuse care, because he cannot fully appreciate the consequences of his actions. In theory, we should force all intoxicated people to the hospital, no matter how strenuously they object.

But that's just not practical. At last count, more than 6,000 people lived on the streets of Boston. The vast majority are homeless, and the vast majority have drinking problems. We get dozens of calls for such people each shift, nearly all of which come from concerned citizens who know nothing about the person for whom they are calling. We could eliminate any chance of liability by taking every one of these people to the hospital, and we could justify this decision by pointing to the patient's intoxication. This patient can't refuse treatment, because he's been drinking.

This would have disastrous consequences. People with serious medical problems would have to wait for ambulances. Waiting times in emergency departments, already long, would grow longer. Overnight, the city's ambulances and hospitals would literally fill up with homeless people.

And is that really what's best for the homeless person? When they need help, they should get it. But a lot of times, they just want to be left alone. Do they lose this right simply because they can't stop drinking?

I don't have the answer. In theory, a person loses the right to refuse care when he becomes too intoxicated to think clearly. We must exercise good judgment in determining whether someone has crossed this line. Sometimes we guess wrong. But taking everyone to the hospital, without giving any thought to the desires of the patient or the needs of the public, is not the answer.

Not What We Expected

2008-07-26T09:35:00.001-04:00

The call was classified by the 911 operator as a cardiac problem. The patient was in a saloon. It's possible for someone to have a heart attack in a bar, I suppose, but it never seems to work out that way.

We arrived to find an elderly man squirming in a chair. He looked awful. His eyes had a look of panic, and his skin was pale and cool.

I tried to get him to sit still, but he was too anxious for that. Every time I convinced him to sit down, he immediately jumped back up again. That's the way patients in congestive heart failure act. Maybe he was having a heart attack after all.

Normally, I would never allow such a patient to walk to the ambulance. I'd lift him onto the stretcher and wheel him outside. But this man refused to hold still. He kept lunging for the doorway, and instead of wrestling him to the ground, I finally decided to let him walk.

Fortunately, the truck was right outside the door. He climbed inside, and sat sideways on the stretcher, but then he refused to turn around. I wanted to get him to the hospital, but we couldn't move the ambulance until we'd secured him properly.

We tried to work on him, but he fought us every step of the way. I couldn't listen to his breathing because he kept shrugging away from my stethoscope. He repeatedly yanked his arm away as I tried to take his blood pressure. Taking an EKG was out of the question. With his skin so wet, and his body squirming so much, we couldn't get the wires to stick.

We could continue to fight with him, or we could just go to the hospital. I didn't much care for the idea of transporting him without treatment, but the idea of sitting there in the street, watching him deteriorate further, appealed to me even less.

I remained in the back of the ambulance with the patient. My partner drove toward the emergency department. Then, something bizarre happened. For no obvious reason, the man calmed right down.

I took his blood pressure. It was normal. I noticed that his sin had dried up. His color had improved.

"Has this ever happened to you before?" I asked.

"A couple of times," he told me.

"What caused it the last time?"

"My drinking."

Delirium tremons - a nervous disorder caused by sudden withdrawal from alcohol - can cause such behavior. It can also cause seizures and even death. Since the man smelled of alcohol and had been picked up from a bar, this condition hadn't even crossed my mind. But it did now.

"How much did you drink today?" I asked.

"A few nips."

"Is that a lot for you? Or not very much?"

"Not very much."

"Usually you drink a lot more?"

"Yeah. Way more. Vodka, mostly. Sometimes gin."

So that was it. We had indeed witnessed an episode of withdrawal. Some people think that a patient must abstain totally from alcohol to go into the DTs. But that's not true. A sudden decrease in the amount of alcohol can have the same effect.

Not only was the man comfortable now; he actually appeared happy. After a while, he began to sing. It's Howdy Doodie Time...Howdy Doodie Time...

I couldn't believe my eyes. A moment earlier, he'd been fighting with me. Now he was performing.

The ambulance came to a busy intersection. Up in the cab, my partner flipped on the siren. The patient hiccuped. Or at least I thought it was a hiccup.

But then he did it again. Suddenly I made the connection - every time the siren sounded, he made the same noise. The patient wasn't hiccuping at all. He was imitating the siren. Whoop! Whoop! Whoop!

He arrived at the hospital in grand form, chatting happily to anyone who came near. The triage nurse took one look at him and said, "Oh, him again."

"You know him?" I asked.

"Oh, sure. Is he here for an alcohol problem? That was his problem yesterday. And the day before that, and the day before that."

I looked across at the patient, who was singing happily to himself on the stretcher. "I guess you could say that," I told the nurse. "An alcohol problem. That's why he's here today."

A couple of times each week, we respond to "cardiac" calls where the patient is simply drunk. Sometimes it's the patient who calls, and sometimes it's someone else - someone who cannot distinguish a drinking problem from a heart attack. We can't fault people for making these calls, because most callers to 911 have no medical training, and therefore cannot be expected to figure the whole thing out.

This one was unusual, though. It appeared that the caller had been right. The patient certainly appeared to be suffering from a cardiac event of some kind.

This time, the situation fooled even us.

It's All Relative

2008-07-21T21:12:00.004-04:00

Those of you who read this blog regularly know that I'm away on military duty - again. I'm not working in an ambulance this week, but some things about the Army remind me of EMS, and vice-versa.

Those of who us work in EMS complain a lot - sometimes, with good reason. People bleed on us, and vomit on us, and sometimes they try to kill us. Not many people enjoy these things.

But it could always be worse. If the military has taught me anything, it's that life as a paramedic could always be worse.

Sure, it's hard work carrying a patient down three flights of stairs - especially in the summer, in an apartment building without air conditioning.

But crawling through dirt for hours at a time beneath a blazing sun is a lot more difficult. And I'm not even in Iraq, where the temperature is about 30 degrees hotter.

Unless we're going on a raid with the police, I never wear the bulletproof vest the city has issued me. I know I should, but I've never been able to get used to the thing. It's too hot, and too bulky.

But those vests, which are thin, and flexible, and fit beneath a uniform shirt, are nothing compared to the Individual Body Armor (IBA) issued by the military. You've seen IBA before - those are the suits with the high bulletproof collars that make Soldiers and Marines look like Gladiators. That stuff is REALLY bulky. And unbearably hot. After wearing IBA for just one week, I've come to realize that my bulletproof EMS vest isn't so uncomfortable after all. And even if I don't start wearing my vest when I return to the ambulance, the likelihood that a bad guy will shoot at me is actually quite low. But those men and women over in Iraq and Afghanistan? People shoot at them every day.

Life as a paramedic could always be worse.

When I get blood on me in the ambulance, it doesn't generally come from anyone I know. Occasionally I'll recognize a patient, having brought the same person to the hospital once or twice before, but it's almost never anyone who is really close to me. It's hard watching a patient suffer, but at least the patient tends to be a stranger.

How horrible would it be, though, if the person dying in front of me was another paramedic? If it was my partner? Or my best friend? That doesn't happen very often to paramedics. But it happens all the time to Soldiers.

Today we had some training that was really quite exciting. The Army has built an entire city out in the middle of a forest, complete with streets, alleys, two- and three-story buildings, and fire escapes. Working in teams of four, we had to advance through this city, armed with real M-16s loaded with blanks, watching out for enemy combatants along the way. And we did encounter plenty of bad guys. Drill sergeants dressed as Iraqi insurgents fired on us with AK-47s from rooftops, and windows, and doorways. Occasionally an IED would explode in the street. We had to fire back and dive for cover.

As paramedics, we go into dangerous buildings all the time. Places where drug dealers live, and addicts, and criminals of all sorts. But at no time during my 23 years with EMS has anyone tried to blow me up with a bomb. Nor has anyone shot at me with a machine gun. I've kicked in plenty of apartment doors as a paramedic, but I've never found armed soldiers waiting for me on the other side.

It could always be worse.

This evening, we went through another exciting training exercise. Soldiers get killed all the time in convoy ambushes, and as stable as HMMWVs are, they sometimes roll over while avoiding an ambush or after striking an IED. To train us how to react, we were placed in an up-armored HMMWV that had been turned into a simulator, like the ones Air Force pilots use to practice emergency landings. One minute we were sitting in the vehicle, pretending to drive confidently down the road, when suddenly it was tumbling on its side, tossing us around the inside. It was a disorienting experience, of course, and when the vehicle finally came to rest upside down, we had to remove our seat belts, lower ourselves to the roof, unlock the door, and crawl out into the sand. We had to find our weapons, of course, because we had to defend ourselves against the people who'd attacked us. As quickly as possible, we were to set up a defensive perimeter around the wrecked HMMWV and wait for help to arrive.

I've been in ambulance crashes before, but nothing like that. My trucks have always remained upright. Having gone through a simulated roll-over, I can say quite confidently that I don't envy Soldiers who survive real rollovers - especially ones that are caused by mines or IEDs.

I'm not going to stop complaining about ambulance work, of course. It's a dangerous, messy, and at times brutal business. When I do find myself complaining, though, I'll try to remember that some jobs - and in particular, the job of an infantry Soldier - are even more dangerous, more messy, and more brutal.

And if nothing else, then before I complain, I'll try to remember that life as a paramedic could always be worse.

Changing Uniforms Again

2008-07-18T17:43:00.002-04:00

Even though I just came back from five months of military training, the Army has requested my presence at Fort Dix, New Jersey, for a week of training that begins tomorrow. The schedule includes some additional time at the firing range, IED training, some law classes, and my favorite, something called "MOUT," or Military Operations in Urbanized Terrain. This is the stuff you see on televised new reports from Baghdad - soldiers advancing into alleys, kicking in doors, sweeping buildings, taking insurgents into custody.

I'll bring my laptop, and I'll blog if time and conditions permit. And if not, I'll begin posting again when I return to EMS on July 25.

Thanks for reading.

Did Anyone Actually See It?

2008-07-17T01:08:00.000-04:00

The first caller said that a man had been run over by a van. The second caller said it was a little boy.

It happened on a street in one of the city’s housing projects. The weather was pleasant, and by the time we arrived, two dozen residents had wandered over from the front steps of their apartment buildings to take a look.

The victim was not a boy at all. It was a girl. She was seven years old, and she was remarkably cheerful under the circumstances.

I examined her briefly. She did not appear badly injured. There were scrapes on her elbows and knees, but nothing more. I asked the firefighters who’d arrived before us what had happened.

“Somebody said she flew through the air,” one of them told me. “Landed on her face in the middle of the street.”

While my partner worked with the EMTs to immobilize the little girl, I went back to the street to survey the damage.

“Which car hit her?” I asked one of the cops.

“This one here,” he said, pointing to a yellow Honda.

“Any damage on it?”

“Not really,” the cop said. He bent over and pointed to one of the directional lights. “This thing popped out, but it didn’t even break. There are no scratches or dents anywhere.”

“Somebody said the car hit her hard enough that she flew through the air,” I said.

Before the cop could reply, a woman held up her hand. “That’s not true,” she said. “I was standing right here when it happened. The girl was barely tapped. She stumbled, and then she fell down, but she didn’t fly nowhere.”

“I saw it , too,” said another woman. “Like she said, the girl fell down. But she didn’t get hit too hard.”

I returned to the ambulance. The girl was now strapped to a backboard, ready for her ride to the hospital. She looked around the inside of the ambulance, looking not at all concerned.

“Well, I talked to a bunch of different witnesses, and we’ve got several different stories,” I told my partner. “This is either a boy or a girl. A grownup or a child. She may have been struck by a car or a van, and she may have been knocked down, or tossed through the air, or maybe she stumbled and fell. Several different witnesses, several different versions."

"It's like that movie 'Vantage Point,'" said my partner. "The one where six different witnesses report six different versions of an event."

One thing was clear: The girl was not seriously injured. The EMTs took her away to the hospital, and I was left wondering how it was possible, with so many conflicting statements, that the so-called witnesses had even been watching the same accident.

Tales from the Harbor Unit

2008-07-16T10:47:00.002-04:00

I’ve been detailed once again to the Boston Police Harbor Patrol. For a couple of days this week, and a couple of days later in the month, I’ll respond with a pair of officers to emergencies on the water.

The Harbor Patrol monitors not only the regular police frequencies, but also those used by the Coast Guard. Today, just as I reported for work, a voice came over the radio, asking for help several miles outside the harbor, south of the city.

“Vessel requesting assistance, this is Coast Guard Sector Boston,” answered a female Coast Guard communicator. “Say your location and nature of your distress.” She spoke with the calm, professional demeanor of an air traffic controller. Clearly, this was not her first time handling an emergency.

“We’re taking on water,” the anxious boater reported. “We can’t make it to shore.”

“Say the number of persons on board, a description of your vessel, and your precise location.”

“It’s a light blue sailboat,” the other voice said, sounding much more anxious now. “We’re sinking outside of Hingham Harbor. There are two people in the boat and one person in the water.”

Listening to this exchange, I found myself getting caught up in the drama. How long would it take for help to arrive? Were there children involved? How well could they swim? I imagined them panicking as they jumped or fell into the sea.

It’s funny, but I rarely feel anxious at emergency scenes. The chaos, the blood, the panic of the victims – it’s all become second nature. It was different listening to an emergency happening miles away. Handling an emergency is one thing, I suppose, but listening to an emergency from the sidelines is something else. I felt strangely helpless.

The Coast Guard notified the harbormaster in Hingham, who responded at high speed in a powerboat. It took a while to locate the victims, but everyone was finally brought to shore.

After the crisis had ended, one of the Harbor Patrol cops, a former Coast Guardsman himself, told a related story.

“I was working in the Comm Center one time, just like that woman we just heard,” he said. “And there was this ship coming over from China that took on water. The guy who called on the radio was Chinese, so he didn’t speak much English. I asked all the usual questions – size of the ship, location, number of people on board – because I needed to know what kind of help to send.”

The cop paused for a moment, laughing at the recollection. “The guy didn't answer any of my questions. He was just too scared. And it seems funny now, because the whole thing turned out okay. He shouted, 'Never mind color of boat! Halfway down! You come now!'"

Homeless People as Victims

2008-07-14T11:35:00.003-04:00

It's impossible to go through an EMS shift in downtown Boston without encountering a homeless person. With something like 6,000 people living on the streets of this city, they seem to be everywhere. For the most part, they really don't bother me. Unless they abuse the system by calling 911 repeatedly, I treat them no differently than any other patient.

Tonight, as we walked back to the ambulance after responding to a false alarm, we came across one such person. He was not particularly old - fifty years old, perhaps. He was sitting in a wheelchair, waving an empty paper coffee cup at everyone who passed by.

One of the man's legs had been amputated. On the wheelchair beside him, I could see a bottle of Vodka. Propped up against him was a sign that said simply, "Disabled veteran. Give money."

In the past, I would have been tempted to drop a handful of coins into his cup. He was a wounded veteran, after all, and I've always had tremendous respect for anyone injured in military service. Rightly or wrongly, I tend to have more sympathy for homeless veterans than for anyone else on the street. Alcoholics and drug addicts sometimes wind up on the street because of their own poor choices, but soldiers never choose to get wounded.

On this day, though, I couldn't help thinking back to Fort Benning, where a month ago I witnessed an extraordinary sight. Early in the morning, as I ran around the post, I passed a company of Rangers running in the opposite direction. Rangers are probably the toughest soldiers in the entire Army, and so, as usual, they were maintaining a rapid pace.

I looked at the soldier at the front of the group, a sergeant who was gradually pulling away from the rest of the unit. I couldn't believe my eyes. He had a prosthetic leg, yet he was running faster than some of the Army's toughest, strongest soldiers.

Later that day, I asked about him. Having lost his leg to an IED in Iraq, he'd spent countless months in the hospital, undergoing numerous operations to repair the damage. Anyone else would have retired on a medical disability, but not this soldier. As soon as he was strong enough, he returned to his unit.

How much different was this Ranger from the man begging for money in the wheelchair? And that got me to thinking: It's tragic to be wounded in combat, obviously, and it's tragic, too, that non-veteran homeless people suffer from various disabilities. Does this give them license to simply give up, though, without making any effort whatsoever to play a useful role in society?

And yet, that's exactly what many of them do. They play the role of victim. It's not as if they don't have options. Free health care is available. Free counseling, too. Job training. Subsidized housing. Detox. Support groups.

But to improve your status, you need to work at it. You must actually make an effort. For many of these people, it's easier to play the role of victim. Poor me. Life has been difficult. I have an injury, or a health problem. I can't be bothered to take a class, or apply for a job, or sign up for the assistance of a social worker. I'd rather just sit here and ask you for money.

I expect a fair amount of criticism for this post. I realize that it's easy for me to criticize a homeless person without being homless myself. I want to make clear, though, that I am not talking about all homeless people here. Some are genuine victims, and they deserve sympathy.

But when I think about that sergeant, and everything he endured to recover from an injury over which he had absolutely no control, I find it much more difficult to feel sorry for anyone who lands on the street because he squanders his rent money on drugs or booze.

That Was Fast

2008-07-12T19:32:00.006-04:00

Late this afternoon we responded to a fast-food restaurant in the Back Bay, where a homeless man had stopped breathing after injecting himself with heroin in the restroom.

By the time we arrived, the EMTs had carried him out to the hallway. They were squeezing oxygen into his mouth and nose with an Ambu bag, along with a mist of Narcan, the antidote for narcotics. Like so many other addicts we've treated recently, the man didn't respond. Apparently, the potent batch of heroin that hit the streets last week has not yet run out.

I injected some Narcan directly into the man's arm muscle. As we continued to breathe for him, waiting for the Narcan to take effect, a customer tried to step over us.

"Whoa," one of the EMTs said, holding out his arm. "Where do you think you're going?"

"I need to use the bathroom," she said. "Can't I go down there?"

The nerve of some people. A man's life hung in the balance, but that was of no consequence to the woman. She had to go to the bathroom. If it had been her brother on the floor, you can bet she would have waited.

Finally the man groaned. He sat up and looked around. We lifted him onto the stretcher and brought him to the hospital.

On my way home at the end of the shift, I stopped at a convenience store to buy a soda. Across the street was a park, where homeless men and women were receiving cups of soup from an outreach van. Even in the dark, I recognized one of the faces. It was our friend the addict, the man we'd resuscitated just a short time earlier.

In a sense, he'd gone home even before I did. Only a heroin addict could do that. Unlike patients who stop breathing from heart attacks or trauma, addicts never go to intensive care. Just a short time after their near-death experiences, they return to the street, going about their business as if if nothing unusual had ever happened.

Another Loss

2008-07-10T01:54:00.003-04:00

This has been a bad summer for Boston EMS.

First we lost Irwin Hirsch, chief of trauma surgery at Boston Medical Center and proponent of prehospital medicine.

Now we've lost another close friend. Dr. Charles McCabe, longtime physician in the emergency department at Massachusetts General Hospital and professor at Harvard Medical School, died earlier this week from cancer.

"Charlie," as he preferred to be called, was a talented doctor. Calm, knowledgeable, decisive. He could run a resuscitation effort as well as anyone, and he always did so confidently, with none of the angry barking of orders that happens so frequently in emergency departments.

He was more than just a superb clinician, though. He was possibly the nicest physician I've ever met. He treated everyone like a friend, and he loved talking with EMTs and paramedics. Like Dr. Hirsch, he treated us more like colleagues than underlings.

He loved practicing medicine. Some time ago, he developed a neuromuscular disorder that left him partially paralyzed. Having already practiced for more than three decades, nobody would have faulted him for retiring. But not Dr. McCabe. He drove up to the hospital every morning before dawn, and with the help of an EMT or security guard, slid from his vehicle into a wheelchair, from which he would oversee the workings of his department for the rest of the day.

Knowing what kind of person he was, it didn't surprise me to learn that he wished to ban somber clothing at his memorial service. Everyone should wear bright colors, he said, because "this would not be a time for tears, but for joy."

He wanted this day, he said - like all the other days of his life - to be a "beautiful one."

A Different Kind of Difficulty Breathing

2008-07-09T10:29:00.004-04:00

Three or four times each shift, we respond to calls for difficulty breathing. Along with chest pain, this is the most frequent condition we encounter.

Usually, the patient suffers from a chronic respiratory disease, such as asthma or emphysema. Sometimes the patient’s heart has failed, causing fluid to back up into the lungs. Tonight, though, we handled a breathing problem of a different type.

The patient was close to 100 years old. She’d lived alone in the same apartment for more than six decades. Early this afternoon, as she passed through the kitchen, she bumped against a knob on her stove. She sat in her living room until dinnertime, watching television for nearly six hours as her home filled with natural gas. All things considered, she was fortunate not to blow herself up.

By the time her son came over for a visit, the woman was gasping for air. He threw open the windows, but his mother doesn't get around well, and she was too heavy to carry. He couldn’t get her out of the house.

We arrived to find her seated on the bed. The room still smelled of gas. I listened to the woman’s chest. For some reason, her lungs were filled with fluid.

“Can breathing natural gas cause you to go into pulmonary edema?” one of the EMTs asked when I reported what I’d heard.

I had to admit that I had no idea. The big danger with natural gas, of course, is the risk of explosion. I’d never encountered a patient who’d inhaled natural gas for a prolonged period.

I deferred to my partner on this. “I’m not sure about pulmonary edema,” he said, “but it can certainly asphyxiate you.”

Then came another wrinkle. When my partner explained the situation to the son, the son said, “Her nurse was here yesterday and said her blood pressure was low. She told my mom not to take her blood pressure pills any more. Could that have anything to do with it?”

Most definitely, we told him. In fact, it was probably the lack of blood pressure medication, more than the gas, that was causing the difficulty breathing.

We carried the woman to the ambulance. On the way to the hospital, we started an IV. I gave her an injection of Lasix—the same medication that was supposed to be controlling her high blood pressure, until the nurse stopped her from taking it. She improved greatly in a matter of minutes. She arrived at the emergency department in great spirits, talking to us about the weather.

In a sense, this was an ordinary call. It was a case of congestive heart failure, something we see four or five times each week. What made the whole thing interesting was the gas leak. That added a challenge to the diagnosis. Plus, it made the situation somewhat bizarre. I mean, let’s face it—emergency or not, there’s nothing terribly interesting about an elderly woman getting sick. But an elderly woman who fills her home with natural gas for an entire day, and survives to get sick from an unrelated problem? Well, that’s not something that happens all the time.

100,000 Visits

2008-07-08T12:04:00.003-04:00

Congratulations to Bri N., of Tacoma, Washington, and Dani Boronofsky, of Brookline, Massachusetts, for becoming the 100,000th readers of Other People's Emergencies. In a bizarre turn of events, they logged on at precisely the same moment from opposite ends of the country, and the Sitemeter software assigned both of them the same visit number - 100,000.

Bri has been following this blog for almost four months. She has an interest in EMS because she has required emergency medical care several times in her life. Dani grew up listening to the "war stories" of his mother, a surgical trauma nurse at Massachusetts General Hospital. He hopes to enter law school soon, and plans to become an EMT in the meantime.

I will send Bri some Boston EMS paraphernalia. Since Dani lives locally and is interested in an EMS career, I will do my best to arrange a ride-along for him for one shift.

Thanks again to everyone for making this blog more popular than I ever could have imagined, and for all of your supportive comments during the past couple of years. And congratulations Bri and Dani! Thanks for reading!

TS

July Fourth

2008-07-05T11:17:00.014-04:00

I love working on Independence Day.

Each year, the City of Boston hosts a spectacular party on the Fourth of July, with a Boston Pops concert on the Charles River, followed by a thirty-minute fireworks display. A half million people turn out for this event every year, and with so many people crowded into such a small area - many of whom drink to excess, despite an overwhelming police presence - the whole thing invariably devolves into chaos by the end of the night.

Many of my colleagues have decided that the annoyance is not worth the overtime money. Scores of tourists seek directions. Drunk and obnoxious people cause havoc. And, of course, there's always a crushing stampede at the show's conclusion. This is not a good event to work if you don't like crowds. But for me, it's one of the best events of the year. I don't mind giving directions; I don't mind drunks; and there's no better place to people-watch.

I worked a double shift, from 8 a.m. until well into the next morning, on a bike. Early on, as the first spectators were gathering in front of the Hatch Shell, I saw an elderly man pedalling his own bicycle down Storrow Drive, the highway that parallels the Esplanade and the river. There was nothing inherently wrong with this, since Storrow had been closed to traffic for the day, and people love to take advantage of this by roller-blading or bicycling up the middle of the street. What made this sight unusual was that man carried four chihuahuas on his bike: two in a basket on the front, a la Dorothy and Toto, and one in each saddlebag on the side. Each dog wore a knitted sweater.

Approaching the back of the Hatch Shell, the man ran into a State Police horse trailer - almost literally. A trooper was backing the trailer onto a grassy spot, and the bicyclist, who wasn't watching where he was going, swerved at the last moment to avoid it. The bike toppled over, and the dogs tumbled out. Neither the man nor the chihuahuas were hurt, and the trooper apologized, even though it had not been his fault. The man gathered up his dogs, uttered a few choice expletives, and rode away.

Later, as the crowds began to grow, I spotted a young woman walking her bunny on a leash down the middle of the same highway.

By noon, I was receiving a steady flow of information requests. Most people asked about the best place to view the fireworks. Some wanted restaurant suggestions. My favorite question came early in the evening, when the bulk of the spectators were arriving. "Are we on the Boston side of the river, or the Cambridge side?" one of several young women asked.

"People ask us for directions all the time," I told her, "But this is the first time someone has approached me without knowing what city they're in!" The women all laughed, including the one who'd asked the question.

She took a map from her pocketbook. "Welcome to Boston," I said. "Now that we've established where you are, where are you trying to go?" This drew another round of laughter.

Not everyone was so jovial. A man and a woman strolled up to me with an eight-year-old boy in tow. "Where's the fireworks!" the man shouted. It sounded more like a statement than a question.

"They get launched from a barge over there, in the middle of the riv..."

The woman interrupted. Pointing in the opposite direction, she said, "We can see it from over there, right?"

"Well, yeah, but..."

"See?" she barked at her companion. "I told you we could go over there!"

The man glared at her. "I KNOW we can go over there! But we can see it better from over here!"

The man looked to me as referee. "Don't you think we should go that way?"

The boy had been standing quietly, but now he asked politely, "Excuse me, but if you were going to watch the fireworks, where would you go?"

I gave him my answer, and unlike his mother and stepfather, he listened patiently to the answer. The grown-ups, meanwhile, started bickering again. The boy tried to settle the argument himself, saying, "Mom! Dave! He says we should go this way!" The grownups continued to quarrel as they walked away, with the boy trailing after them, pleading with them to listen to my advice. I felt badly for him.

This year, the crowd was mercifully tame. A report came over the radio about a spectator falling onto Storrow Drive from a bridge, but we saw only a fraction of the alcohol-related injuries of past years. With the concert underway, we received a report of a foot injury not far from where we were standing with our bikes. We rode through the crowd to a park bench, where a state police officer stood over a young man. An EMT was already there, having arrived in a six-wheeled all-terrain vehicle. "I can handle it," he told us. "It's just a stubbed toe." Looking down at the man's foot with my flashlight, I could see what he meant. The injury was nothing more than a scratch.

A short time later, we responded to another call from a trooper. This time, the patient was a young woman, four months pregnant, who had tripped and fallen over a curb in the dark.

"Where are you hurt?" I asked.

"I'm not hurt, really," she said. "I just have a funny feeling, like butterflies in my stomach."

"Do you feel like you're bleeding down there?"

"Nope."

"Do you feel dizzy, or nauseous, or anything else unusual?"

"Nope."

I took her blood pressure and heart rate. They were normal. "There's really not much else we can do for you out here," I told her. "But if you're concerned, we can get you a ride to the hospital. They can do a more thorough examination there, just to be safe."

"I don't need that. I'm going to be okay, right?"

I hesitated, choosing my words carefully. "Probably. But I can't check you very well out here. In the hospital, the doctor can do a complete examination."

"I'm not in my first trimester. The baby's only in danger if it gets injured in the first trimester. Isn't that true?" The woman knew what she wanted for an answer, and she was intent on getting me to say it.

"Well, generally, yes. But if a baby gets slammed hard enough, it can be injured at any stage of the pregnancy."

"I didn't fall that hard!" she snapped angrily. "So the baby's going to fine, right?" She'd gone from wanting my opinion, to arguing with me over the answer, and back to asking for my opinion again - all in one brief conversation. Incredible.

"I wasn't here," I said. "I didn't see what happened to you. I have no idea how hard you fell. The baby will probably be fine, but the only way to be certain is to go to the hospital."

This only made the woman angrier. "Is my baby going to be okay or not?"

"Probably. But I don't have x-ray vision. Like I said, the only way to be sure is to go to the hospital."

"I don't want to go. I think the baby's fine."

"Are you sure?"

"Yeah. I'm fine."

"Well, if you change your mind, or if you feel worse, tell one of the troopers, and he'll call us back over."

"Fine."

The state police officer looked surprised to see us leaving. "She says she doesn't hurt," I told him. "She says she just feels funny. I told her to let you know if she feels worse."

"Um, okay," the trooper said. "Thanks."

By this time, the fireworks were almost over. We returned to the place where we'd been standing. During a brief lull in the show, a young couple approached us.

"When do the fireworks start?" the man asked.

"When do they start?" I asked, unable to concel my amazement. "They've already started. In fact, they're almost over. All that smoke over there - that's from the fireworks."

An expression of shock came to his face. His girlfriend looked disappointed. "Why don't they last for an hour?" he demanded, as if I were personally responsible for dictating the length of the program.

"I don't know why. They just don't. The fireworks have always lasted about thirty minutes."

"This is it, then?" he said with extraordinary sarcasm. "Boston's big Fourth of July show? Not very impressive, if you ask me." He wheeled and left, his girlfriend trudging sadly behind him.

"Sorry to have disappointed you," I said with my own touch of sarcasm, in a voice too low for the man to hear.

We handled a few more calls as the crowd departed, including a combative, intoxicated man in protective custody at a nearby police station. After that, our long day was over. At some point, I learned, a little girl had become separated from her mother. That was a scary thought. Search parties were organized among the various police agencies, the National Guard, and EMS, but after two hours, as we prepared to leave, she still hadn't been located. As we returned to Special Operations headquarters, I heard one of the National Guardsmen saying to another, "They want us to search again, and this time they want us to check all the trash barrels."

An ominous comment, if ever there was one.

Another Take on Floaters

2008-07-04T00:25:00.001-04:00

For the past year or so, a blog called "UniversalHub" (http://www.universalhub.com/) has posted regular excerpts from this site. It's a fascinating blog, really, consisting mainly of Boston-area human-interest stories not quite significant enough to make The Globe or The Herald.

Today, UniversalHub posted an excerpt from my "Floaters" story. In response, a reader calling herself "SwirlyGrrl" told a story of her own, about an encounter with a dead body on the Charles River. It was an interesting story, and since it described a "floater" from a different perspective from my own - the perspective of the caller to 911 - I thought I'd repeat it here:

When I was in college, I rowed crew on the Charles. Our practices were often early in the morning, starting in the boathouse as dawn broke.

One morning, while we were rowing in the basin by the Museum of Science, the coxswain (facing down river) started screaming.

Us rowers, facing the other way, didn't know why she started screaming, but we all instinctively dropped our oars and skidded the boat to a stop without any direction.

Bump!

We hit a floater just as we stopped. She popped under, to one side of the rudder, and back out beside me. I was the bowman rowing to port, and was closest to her. She was face down, green-blue hospital johnnie, dark hair. I popped my oar out of the oarlock, and used it to flip her over just in case she was still alive (but mostly out of denial and the need to "do something").

I'll never forget her porcelain face...no lines...totally slack and peaceful - like Resusci-Annie [a manequin used for practice in CPR classes] almost - and probably not too much older than any of us were (I was 19 years old at the time) and very dead, judging by her stillness and bluish cast.

Meanwhile, Coach in the launch was on the horn to the state police. She pulled up and told us to head back into the MIT Boathouse and get to the weights, while she stayed with the body. I kept my oar in my lap as the rest of my eight backed up, so I wouldn't whack the unfortunate waterlogged lost one, then popped in to help the turn once we were clear.

We found out later that she had wandered off from MGH in the night. Not sure if anybody ever knew why.

Floaters

2008-07-02T10:46:00.003-04:00

A couple of days ago, we were called to help a man out of a bathtub. After that call, I couldn't help thinking about other patients we've pulled out of water.

We call them "floaters," for obvious reasons. After drowning, their bodies float to the surface. Eventually, someone spots the body and calls us.

Some people become floaters by accident, drowning after falling off a pier or a boat. We've had a few of those. Several years ago, we were called to a dock at the waterfront, where a fisherman had found a body in the water. I learned from the next morning's newspaper that the dead man had been drinking on a harbor cruise, and had fallen over a railing. Nobody knew what had happened until the boat docked without him.

More often, though, floaters go into the water on purpose. They commit suicide. Sometimes they jump from bridges, hoping to die from the fall. As the tallest such structure in Boston, the Tobin Bridge is a favorite location. Sometimes they jump into the water with the intention of drowning. Given the panic that must ensue, this has never struck me as a particularly effective way to kill yourself. Certainly there are more peaceful, less traumatic methods.

The body of a drowning victim is not a pretty sight. It gets worse, of course, the longer the body remains in the water. After a while the skin sloughs off, until finally bone becomes visible. And then there are the effects of marine life. Fish often feed on the exposed flesh, accelerating the process of decomposition.

The most gruesome floater I ever attended was found behind a waterfront hotel. The body belonged to a man, but there wasn't enough left of his face to determine how old he'd been. I doubt he'd been in the water for long, because the skin beneath his clothing was intact. Fish had eaten away all of the exposed areas, though, giving him the appearance of a well-dressed skeleton.

As I stood on the dock writing my report, a crew from the Medical Examiner's office arrived. The lead technician was a crusty old guy who'd seen everything. "Well, what do we have here?" he asked, squatting as if to speak to the dead man. He reached down, stuck his fingers into the open eye socket of the skull, and plucked out a live crab. "You're not supposed to be in there," he said to the tiny animal. Tossing it into the sea, he went about the business of packaging the body as if nothing unusual had happened.

Not every attempt at suicide by drowning has an unhappy ending. Recently we responded to a South Boston restaurant, where a man announced to dozens of outdoor diners that he was about to kill himself. As they watched, he jumped over a railing into the ocean. The coldness of the water surprised him, though, and he immediately climbed back out.

The customers at the restaurant were not impressed. In fact, they barely looked up from their meals when we arrived. Nobody approached us; nobody told us what had happened. Finally, after I asked somewhat loudly whether anyone had seen a man in the water, one diner pointed up the street and said, "He went that way. I think he changed his mind."

The Sights--and Smells--of the City

2008-06-30T13:40:00.001-04:00

This job tests your resilience in lots of ways. During the winter, at fire scenes, you stand in the freezing cold for hours at a time. In summer, you sweat as you carry obese patients down hot stairwells. You’re expected to remain awake in the middle of the night, while the rest of the world sleeps, and, sometimes, to go eight hours or more without a meal. You deal with angry people, and on every shift you see something unpleasant.

And then there are the smells.

There’s nothing like the odor of a decomposing body. It smells a bit like sour milk, only a hundred times more potent. The odor of a burned body is almost as bad. Sour milk combined with a burned meal—that’s the closest I can come to describing it.

Our first call tonight was on the Common. The man was twenty-eight years old, but looked fifty. He was immense. He had passed out on the grass, then vomited.

By the time we arrived, the EMTs had already loaded him into their ambulance. He was breathing at an extraordinary rate—nearly fifty times per minute. One of the EMTs removed a sandwich bag full of syringes from the man’s pocket. His partner checked the man’s blood glucose, and found it to be 481—four times as high as it should have been. That’s why he was breathing so fast. His body was trying to blow off the acid that forms as sugar is burned up.

The man had diabetes. The high blood sugar was evidence of that. But he was also a heroin addict. His pupils were tiny, and he had track marks on both arms. Sometimes he used his syringes to inject himself with insulin; sometimes he used them to inject narcotics.

We gave him a shot of Narcan, the antidote for a heroin overdose. He didn’t wake up, but he did begin to cough—something he hadn’t done earlier. Then he vomited again. The stench in the back of the ambulance was overwhelming. Partially digested food and alcohol. In an enclosed space, it creates a potent aroma. Unfortunately, leaving isn’t an option. You must remain with the patient, breathing in the stench, all the way to the hospital.

Moments after leaving the man in the emergency department, we were sent to a home in the Back Bay. This patient, too, was diabetic. He had the opposite problem of our first patient. His blood sugar, which should have been between 70 and 110, had dropped to just 12.

A relative directed us into the man’s bedroom. Inside, the aroma was just as bad as the back of the ambulance had been during the previous call. The patient had lost control of his bowels, filling the bed with diarrhea.

It was an awful place to work. Breathing as shallowly as possible, I started an IV and gave the man an injection of dextrose. He soon opened his eyes. A minute later he was awake enough to talk. Earlier, he said, his stomach had been upset. Since morning, he had consumed just a single piece of toast. No wonder his sugar had dropped. He was lucky to be alive.

He insisted on going to the bathroom again before leaving for the hospital. I couldn’t let him go alone, because of the risk that he would pass out and get hurt. For the next ten minutes I stood at his side, standing guard while an eighty-six-year-old man defecated.

It’s funny, but I don’t ever recall any of my instructors in paramedic school talking about bad smells. They warn you about the sights you will encounter, about the mangled and bloodied bodies. People ask me all the time about the worst call I ever witnessed. Nobody ever asks me about the worst call I ever smelled.

There’s no sense in complaining about it. The odors are part of the job. Like rain, and snow, and heat, and cold, they make you uncomfortable, but you focus on the patient and try to ignore them.

Language

2008-06-29T00:00:00.000-04:00

In a city as big as Boston, where every language from Gaelic to Korean is spoken, communications frequently interfere with health care. That was the problem on our first call tonight. The patient, an 81-year-old man who indicated through hand gestures that he was experiencing chest pain, spoke only Spanish. And while a fair number of Boston EMS personnel speak more than one language, no one on this call could communicate with him.

As we were taking the man’s blood pressure, his son entered the room. The son spoke more English than his father, but not much. I asked if he would translate for us, and he shook his head yes. “Ask your father if he’s ever had this same kind of pain before,” I said.

The son did what nearly all amateur translators do—rather than posing my question to his father in Spanish, he answered the question himself. “Sometimes,” he told me.

“I need you to ask your father that question,” I said, making it clear that I appreciated his efforts and was not upset at him. “Please let him answer it himself. He’s the only one who knows what the pain feels like.”

The son grinned, but appeared somewhat embarrassed. “Yes, yes, I see,” he said. He posed my question in Spanish. The father responded, but the son couldn’t find the right words to covert the answer to English. He’d done his best, but we were getting nowhere.

We’d have to rely on physical findings. One of the EMTs took the man’s blood pressure. Meanwhile, my partner took an EKG. “Well, what do we have here?” he asked as graph paper scrolled out of the machine. He tore off the tracing and passed it to me.

The EKG told us everything we needed to know. Though he didn’t appear particularly sick, the man was suffering a massive heart attack. And to make matters worse, it was the bottom, or “inferior” wall of the heart that was struggling, causing his heartbeat to slow and blood pressure to drop.

I asked the son to explain what was about to happen: IV, medicine, ambulance, hospital. As the son spoke, I picked out a few familiar words. This time, he seemed to get the message across.

My partner started the IV. I gave the man some aspirin. We’d have to wait for his blood pressure to go back up before giving him any pain medication. The medicine normally used to treat cardiac pain, nitroglycerin, might kill someone in his condition.

We started for the hospital. I notified the emergency department by radio. His blood pressure remained low, but it came up enough to give him some narcotic pain medication.

The triage nurse didn’t stop us for a report. She waved us directly into the acute care area. Inside, a physician studied the EKG we’d performed. “Just like you said on the radio,” she told me. “There’s major inferior wall involvement. He needs to go straight into the cath lab, but unfortunately, we just sent somebody else up there. I’ll have to see if they can handle two patients at once. It all depends on their staffing.”

We wheeled the man into a treatment room. Just as we transferred him to the hospital bed, the physician came in. “They can take him,” she said. Then, to the nurse, she said, “Let’s get him up there right now.”

Not every call goes as smoothly as this one did. All of the pieces fell into place. The emergency department staff believed our diagnosis—something that doesn’t always happen—and they acted on it, getting him upstairs immediately to have his coronary arteries unplugged.

What really made this call unusual, however, was that everything happened without any input from the patient. Thanks to an abnormal EKG, he received prompt, efficient care—without even being able to tell us what was wrong.

The Nature of Doctors and Paramedics

2008-06-25T22:11:00.009-04:00

It's not easy to remain a paramedic.

Every two years, you have to renew your license or certificate. This means taking a CPR test, sitting through a month-long "refresher course," finding forty-eight hours' worth of continuing education seminars, and completing an Advanced Cardiac Life Support (ACLS) course that tests your knowledge of resuscitation drugs and techniques.

To get an idea of how rigorous these requirements are, compare them to the renewal process for Massachusetts lawyers. They don't have to take any continuing education classes at all. They simply mail the Bar Association a check with their application for renewal.

During my recent hiatus, my ACLS certification lapsed. And so today, at eight o'clock in the morning, I reported to the Boston Medical Center to take the course and get a new card.

The class was small. There were just eight of us in all, and everyone was a physician but me. I was nervous going in, because I assumed that everyone would know more than I did. I've been a paramedic for a long time, but they were doctors. And besides, I haven't worked on an ambulance in about five months. Even before that, I hadn't looked at a medical text in years, because I've been too busy studying law.

It struck me as odd, then, that the first question posed by the instructor met with silence. Even a brand-new paramedic would have known the answer--Adenosine is the first medications to be given for supraventricular tachycardia. But nobody in the room spoke up. And it wasn't because the doctors weren't paying attention. An oncology fellow to my left frantically scanned a workbook, looking for the answer, while a psychiatrist to my right reluctantly hazarded a guess.

"Metroprolol?" he asked tentatively.

The instructor responded charitably. "You could try metoprolol eventually," he said. "But that's not generally the first thing we use."

Everybody else appeared stumped. "Adenosine," I finally said quietly, trying not to sound like a know-it-all.

"Adenosine," the instructor echoed. "That's right. And how about a patient in ventricular tachycardia? What's the first-line drug for that?"

Again there was silence. This time I didn't wait so long--otherwise, the class would have gone on forever. "You could give amiodarone," I said, "although some health care providers still prefer lidocaine. But depending on the clinical presentation, you might have to consider synchronized cardioversion before pharmacological intevention."

And so it went. The instructor posed a question, and I would answer it, again and again. I kept looking at the doctors, wondering if I was making any enemies, but they were clearly relieved that I had taken the pressure off of them.

Later, as the instructor had each of us talk our way through a hypothetical resuscitation, the psychiatrist approached me. "I don't understand why we need to know this stuff," he said. "I mean, it's not as if I'm going to treat any cardiac arrests in my office. I'm never going to use this stuff."

It surprised me that a physician could be so short-sighted. "I work downtown," I told him, "in the section of the city that includes the airport. You'd never believe how often flights are diverted to Boston with a medical emergency. It happens probably two or three times every week. And what's the first thing that happens when somebody gets sick on an aircraft? They ask if there are any doctors on board. If you happen to be on that flight, wouldn't it be good to know what you're doing?"

"Yeah, I suppose so," the psychiatrist said. "I never thought of it like that."

I did not leave the course thinking that I was smarter than a doctor. That would have been ridiculous. The field of medicine has become so complex that nobody can master it all--not even someone with thirteen years of medical-school education. Paramedics have it much easier. They only have to focus on a single narrow area of medicine.

Even so, it was gratifying to know that in some circumstances, paramedics can hold their own. We might not have the training of doctors, but when it comes to life-threatening emergencies, we can handle this aspect of medicine as well as anyone.

Loss of an Ally

2008-06-23T20:44:00.007-04:00

"What's taking so long? He should be in the operating room already."

That was my introduction to Dr. Erwin Hirsch, longtime chief of trauma surgery at Boston Medical Center. It was two o'clock in the morning, and I was a brand-new paramedic who'd just come into the emergency department with the victim of a collision. Dr. Hirsch was berating one of his residents--something he did frequently, but never without good reason.

I would hear him utter this same phrase dozens of times in the years to come. He was always in a rush to get people into surgery--not so much because he was naturally impatient, but because he knew it would save lives. As a Navy physician in Vietnam, Dr. Hirsch had developed a no-nonsense approach to trauma care that went something like this: "Don't waste time with fancy tests and procedures. Trauma patients need surgery. Get in, fix the problem, and get out. Fast."

Erwin Hirsch didn't save lives only in the operating theater. He saved lives outside of the hospital, as well. Back in 1974, when ambulances in many parts of the country were still operated by funeral homes, he advocated a sophisticated EMS system for Boston--one in which highly-trained personnel called "paramedics" would start IVs and perform other procedures traditionally done only by physicians. While other members of the Boston medical establishment felt it was good enough to have "ambulance drivers" rush patients to the nearest hospital, Dr. Hirsch envisioned something infinitely better.

Over time, this plan became reality. Boston became one of the first cities in the nation to send IV fluids, cardiac monitors, and medications to scenes of accident and illness. Dr. Hirsch never did sever his ties with Boston EMS. Long after he'd relinquished control of the city's ambulance service to other physicians, he remained a fixture at "paramedic rounds," a weekly educational conference where unusual calls and patients were analyzed. It was a nerve-wracking experience to present a case before Dr. Hirsch, because you knew that he would grill you on every aspect of your treatment--and he didn't care whether he embarrassed you in front of your colleagues. Paramedics occasionally grumbled about this behavior, but those who did missed a crucial point: Dr. Hirsch was treating us just like he treated his residents in the hospital. He did this because he respected us. To him, we were not "ambulance drivers," but professionals held to nearly the same standard as physicians.

When he wasn't saving trauma victims, Erwin Hirsch loved to sail. A couple of Fridays ago, as he traversed a Maine harbor in his sailboat's dinghy, the craft suddenly capsized, tossing him into the 48-degree water. Rescuers couldn't locate him immediately. That afternoon, he was pronounced dead.

He leaves behind a remarkable legacy. Countless Bostonians owe their lives to him, not only because of his surgical skills, but because of the EMS system he helped to create.

By those who were saved by him or learned from him, he will be missed.

A Politically Incorrect Observation

2008-06-20T09:32:00.004-04:00

You'll have to forgive me for not writing about EMS today. Or for writing about EMS only in a peripheral way. I don't return to work until next week, and so I don't have any new incidents to discuss.

Yesterday, though, as I leafed through the Boston Globe for the first time in five months, I saw a column that reminded me of work, even though it had little to do with health care or EMS. Written by Yvonne Abraham, and entitled "Squeezing the Homeless," it demonized a group of citizens who live on Upton Street, in Boston's South End, for objecting to a plan by a local homeless shelter to establish transitional housing in their neighborhood.

Ms. Abraham is entitled to her opinion, of course. And to be honest, it doesn't sound as if the plan will do very much harm. It calls for thirty-seven people--most of them older, some of whom hold jobs--to move into an apartment building under the supervision of the sponsoring shelter, The Pine Street Inn.

Ms. Abraham doesn't just make a case for the plan, however; throughout her column she belittles the neighborhood residents for objecting to it. She portrays them as paranoid hypocrites who "bristled at the suggestion that they don't like the homeless, when they really do like them, a lot."

I don't have a dog in this fight, as the saying goes. (Or, perhaps, in light of Michael Vick's misfortunes and the spirit of political correctness, I should say that "I don't have a horse in this race.") It make no difference to me whether the apartment building on Upton Street is turned over to the Pine Street homeless or not. I don't live anywhere near that street, and if I respond to a 911 call there, it won't make any difference to me whether the patient previously lived in a homeless shelter or not.

I can't say that I blame the residents of Upton Street, though, for objecting to the plan. Upton Street--and, indeed, the entire South End--has undergone tremendous gentrification during the past two decades. When I first responded to calls there, hookers stood beneath the elevated Orange Line and drunks slumbered in many of the doorways. Half of the buildings were either abandoned or falling down. The South End was, more or less, a ghetto.

Recently, though, it has become one of the more desirable locations in the city. Renovated brownstones routinely sell for two or three million dollars. It's not a bad place to live, if you can afford it.

It doesn't sound to me as if the plan proposed by the Pine Street Inn will have much of a negative impact on Upton Street. But then again, I'm not the one who lives there. I'm not the one who laid out millions of dollars for a condo on that street. Yvonne Abraham pokes fun at the Union Park Neighborhood Association because it is worried about the effect of homeless people on their property values. If I'd invested all of my money on a home in that area, then to be honest, I think I'd worry about property values, too.

What really bothered me about Ms. Abraham's column, though, was an attack she leveled on the current president of the UPNA, a guy named Jerry Frank. Now, let me be clear about something: I don't even know Jerry Frank. I don't know whether he's a good guy or a jerk. I couldn't care less who heads the Union Park Neighborhood Association.

In Ms. Abraham's eyes, Jerry Frank is a bad man because he once called the Pine Street Inn a "very, very nasty place." She seems to suggest that the wealthy and homeless would be living side-by-side in perfect harmony right now, if only an anti-homeless man like Jerry Frank hadn't been elected to the board of the UPNA.

And so I can't help wondering--has Yvonne Abraham ever been inside the Pine Street Inn? Even once?

Because the truth is--whether you're a homeless advocate or a homeless hater--the Pine Street Inn is a very, very nasty place. The whole facility stinks of urine and body odor. The belongings of the residents are filthy. In fact, most of the residents are filthy.

Night is the worst time. The snoring of 400 people in varying degrees of health makes an incredible racket. Arguments break out. Residents sneak into the rest rooms to shoot up heroin. Others get drunk. They steal from one another. Violence is not unusual.

The staff is extremely dedicated. I give them a world of credit, because they try extremely hard to set rules that will give the homeless a decent place to sleep. But it's an uphill battle. Residents sneak needles and syringes into the shelter. And bottles of booze. And occasionally knives.

In fact, the Pine Street Inn is so dangerous that many of the city's homeless people refuse to go there. More times than I can recall, after being called to check on the welfare of a homeless man on a sidewalk, I've been told, "I don't want to go to the Pine, or any other shelter. Those places are too dangerous. Whenever I sleep there, somebody steals my stuff."

So, like I said in the beginning, Yvonne Abraham is entitled to her opinion about the wisdom of establishing a transitional house for the homeless on Upton Street.

But, please, Ms. Abraham, don't try to tell us that Mr. Frank is wrong for calling the Pine Street a "nasty place."

Truth is, it's one of the nastiest places in all of Boston.

Back to Boston

2008-06-18T09:02:00.003-04:00

I'm back.

My initial military training complete, I have returned--for now, at least--to life as a paramedic.

I've learned a lot during the past few months. A lot about military law, and a lot about being a soldier. The process was much more demanding than I'd anticipated. It was, in fact, the most challenging thing I've ever done. More challenging, even, than becoming a paramedic.

The days were long. We started most mornings at 5:00, and sometimes as early as 3:00. Ninety minutes of physical training, or "PT," came first. Sometimes we ran six miles. We did push ups and sit ups to exhaustion. The sergeants conjured up devilishly creative exercises. One morning, they ran us to a steep incline known as "Cardiac Hill," where they ran us down and up, three times. Then, with our legs feeling like rubber, they ran us up the hill one final time--carrying another soldier on our backs.

Still, I enjoyed most of it. We rappelled from a fifty-foot tower--something I hadn't done since paramedic school. That was fun. The "confidence course"--an obstacle course of 16 towers, some extremely high--was fun, too. I really enjoyed the week we spent at the firing range. We even had an opportunity to throw hand grenades--something I never imagined I'd do.

One thing I didn't enjoy was the weather. At Fort Lee, Virginia, we assembled each morning in pitch darkness, shivering without jackets in sub-freezing air. At Fort Benning, Georgia, we had the opposite problem. There, the temperature hovered around 100 degrees. For twelve hours each day, and sometimes longer, we trudged and crawled along dirt paths in the direct sunlight, loaded down with weapons, rucksacks, first-aid kits, and ammunition pouches, practicing land navigation, ambush tactics, and patrolling techniques. In one exercise, four soldiers had to be removed from the course for heat exhaustion. Those were miserable days, and I couldn't wait for them to end. Still, it could have been worse. On the other side of the world, I reminded myself, soldiers are doing the same thing, in actual combat against real enemies, in temperatures twenty or thirty degrees higher.

But now that's behind me. In exactly one week, I'll return to the ambulance. I have mixed feelings as I do this. Work as a paramedic is stressful, of course, and physically demanding, with unusual hours.

But at least nobody gets you up at three in the morning to do push ups.

Being a Soldier Is a Little Like Being a Paramedic

2008-05-02T22:12:00.004-04:00

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

2008-03-31T21:15:00.003-04:00

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

2008-03-21T22:08:00.002-04:00

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

2008-02-08T09:09:00.001-05:00

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.