The Heat of the Moment

It was one of those unseasonably hot Sundays in the valley. If you live out that way you might remember the actual day a couple years back. I had picked up a valley day car that was available earlier in the week as an overtime shift. I was thinking it would be a nice break from the Oakland grind completely unaware of the impending heat wave that was coming. The thermometer on the bank’s digital sign blinked 104F, but it felt even hotter.

We were spending the bulk of the day between calls looking for shade spots to park. It’s a kind of game you have to play in the summer if you are going to be out on the street all day. A large eucalyptus tree here, an overhang there; a bridge overpass will do nicely. Anything to escape the relentless heat that was building up and fuming off the asphalt. Our inadequate air conditioner in the ambulance was doing a poor job keeping up being an older model and probably mostly out of Freon. These poor ambulances get run so hard 24/7 we are lucky to get five years out of them.

The supervisors that day were tasked with chasing all the units around with coolers full of water and Gatorade. If they found us hiding in our shady corners, we had to drink a full water in front of them on demand. Dehydration was a serious concern and given the heat, the exercise was justified. They didn’t want us becoming patients too. To make matters worse, the call volume was up from heat related illnesses so we were working even harder. Hot days like this, especially in succession tend to thin the herd a bit.

Anyway, as I was saying, it was a blistering day. We had been run pretty hard. I remember noting that I had drank close to a gallon of water without having to go to the bathroom all shift. I was sweating it all out. We stopped into 7-11 for popsicles when the call came in. It was for chest pain. I had no trouble wolfing down the frozen treat by the time we got to the call. Nice to have some ice in my belly and the windows down on the way provided some relief.

My partner this day was an exceptionally laid back guy. Nothing seemed to faze him. We’ll call him Doug.

We pulled into the parking lot of a steakhouse up by the interstate to find a single car and the fire engine over in the corner of the lot under a shade tree. The restaurant would not be open for several hours and the parking lot was deserted.

The body language of the firefighters was that of uncertainty. They were standing around a brand new, glistening model of Mercedes that I was unaware even existed. It had to be an $80,000 car at least with gull wing doors; the driver’s side was open and fully extended up. I could not see what they were looking at, all I saw was a wall of turnout coats as the firefighters were circled around what I assumed had to be the patient with the chest pain.

“Wait on the gurney Doug, I’m gonna hop out and see what we have here”. I said to my partner.

“Sure” he said in a tone that really said “whatever, I’m hourly”.

As I approached the car, I thought maybe the heat was getting to me. I could see a pair of long legs with fishnet stocking terminating in stiletto heels sticking out to the side. “What was I getting myself into?” I wondered. I could hear the firefighters talking and a faint whimpering from the direction of the as yet faceless but leggy patient.

I rounded the wall of firefighter backs to a fairly shocking find. It was a young lady in her late twenties sitting sideways in the driver’s seat with those long legs sticking outside the car. She was wearing an impossibly short black mini-skirt and low-cut halter-top combo with plenty of silver accents. It was the kind of clothing you would expect a stripper or maybe a showgirl of some sort to wear. She had a large bouquet of long stemmed roses and baby’s breath bound together with tulle and cellophane draped over one of her forearms similar to the way you would expect Miss America to hold it. I half expected to see a tiara on her head and a “Miss Livermore” sash draped over her shoulder. If this wasn’t odd enough, one of her halter straps was undone and hanging freely and the other hand was cradling one of her naked oversized, obviously surgically enhanced breasts in a move of mock modesty. She was openly weeping and having trouble choking the words out through the tears. I sensed these were not tears of pain. Something else was going on here.

“What do we have?” Doug yelled over to me from the ambulance. This was more a “What do you need” kind of question. Once he knew the nature of the call, he would know what equipment to grab.

I shrugged back at him with the international sign of “I don’t know”. I really didn’t know what to make of this. Was this an assault of some sort? Was this a psych case? “You better get over here and check this out”.

“So what is the story?” I asked the Captain. He was a burly middle-aged guy. He had a balding head, walrus mustache, and the kind of belly that takes years of firehouse eating to develop. He was a little on the grumpy side today, probably the heat.

“I guess her breast hurts?” he said in a questioning tone. They must have arrived just before us and I don’t think they had gotten anywhere with her yet. I could tell this call was making him uncomfortable being that she was such an attractive young lady and looked like something out of a Calvin Klein ad. I took their uncertainty as a cue to jump in. I squatted down next to her and put on my best concerned look of authority.

“Ma’am, what seems to be the problem?” I asked trying not to choke on the fumes from her sickeningly sweet and quite liberally applied perfume.

“My breast is killing me” she said looking down at her breast. The body glitter on her chest was catching the sun and was distracting me. Making me squint.

“OK, do you have any chest pain or shortness of breath?” I asked. Had to stick with priorities even if I am talking to a human Barbie doll.

“No” she blurted and got back to sobbing.

“Any other medical conditions I need to know about?”

“No” again.

“Did you hurt it somehow?” I asked. “Did someone hurt you?” adding the next question with more emphasis before she could answer the first.

“No, nothing like that.” She said as she regained her composure for a moment. “I think it popped” she looked up at me with mascara streaking down her cheeks. This girl was wearing a lot of make up. Her hair and nails spoke of hours of expensive treatments. Her sculpted body told me she was concerned with appearance, this was hard for her to have a problem with a part of her body that she obviously held so dearly both figuratively and now literally.

“What popped?” I asked.

“My implant, I think it popped” she stated flatly.

That’s when the call took a turn to the bizarre.

“Look, see how different they are?”

She dropped her hands down and let both sides of the halter top drop exposing both of her enormous breasts. The Captain let out a strange noise that was half snort and half cough. I looked over at him and thought his head was going to explode.

“Jesus Christ!” he said, took two steps backwards, turned away and said to me, “this one is all you Jon”. He made a bee-line back to his rig. Something in him said “get out of here” and he was listening. I tried not to chuckle. A big, tough, grown man paralyzed by breasts was a sight to see.

I looked back at Doug and he was just standing there transfixed as were the other firefighters. Mouths slightly open. Everyone was just soaking it in and not sure how to proceed. This was definitely not in the training manual.

I had to do something. I was a bit uncomfortable with this scene. Five grown men, servants of the public no less, in a parking lot standing around an attractive young lady dressed, or should I say undressed, to the nines. This sideshow had run it's course, time to get back to business.

“OK, dear, let me help you” I pulled her straps back up and walked her over to the ambulance signaling to my partner with my eyes to head over that way. I had Doug help her step up into the back of the ambulance, which was no easy feat with those spikes she was walking on. He got started gathering info and taking vital signs for me freeing me up for a moment.

I walked over to the fire crew. They were all red-faced and quietly chatting with smug looks of humor in their eyes. This was a strange call for a bunch of young men to go on. Not in any way emergent and quite surprising. The heat was not making it better.

“You OK Cap?” I teased.

“What the hell was that?” he asked through his bushy firefighter mustache with his hands on his hips. He almost looked exhausted “I thought I was going to have a heart attack when she pulled those things out!” he said.

“I thought you were too” I joked. “You guys can clear, we got it from here”

“OK” he said and walked back over to the back of the ambulance with me. The shock was wearing off and he was getting back to his jovial self. The back of the ambulance was still open. The Captain popped his head in to say his goodbyes and wish her good luck as good Captains do to wrap up their portion of the contact.

Unfortunately he walked in on the wrong part of the conversation. Again she had bared her chest and was demonstrating to my partner the differences in how they moved, bounced, felt, etc… My partner did not seem to mind the demonstration.

“Will you stop that!” the Captain said to her gruffly and walked back to his rig shaking his head. “I am too old for this crap!” I couldn’t hold back the laughter anymore. I walked around the side of the rig. The whole fire crew was laughing now. Luckily the patient was out of earshot in the back of the ambulance with the A/C blasting.

In the end it was a non-emergent call and all went routine from there on out. We transported the patient to the emergency room at her request even though in our opinion she really did not need this level of care or transport. I am glad we did as it turned out that she had a good amount of alcohol and cocaine on board though we did not smell or detect anything. Perhaps our minds were distracted enough to dull our normal “Spidey-Senses” for things like alcohol. If we had let her go on her way, she could have really caused a horrible accident and injured herself or someone else. That would have been tragic.

The emergency room doctor concurred that she probably did have a rupture of an implant and prescribed her some mild pain-killers to hold her over until she could see her regular physician. She put on her little asymmetry demonstration for whomever at the hospital was willing to sit through it. Being mostly female nurses, there were not many takers.

After the call, my partner and I spent a good amount of time over popsicles speculating who she was and what her back-story was. This young lady was something of a mystery and it was fun to try and make something more out of her than she probably was.

Was she a beauty queen on her way home from a contest?

Was she a high-priced call girl on her way to service a celebrity?

Was she some kind of secret agent on a mission undercover as a stripper?

Was she just some superficial gal who had landed a rich sugar daddy?

We will never know, but that call will go down in my memory as one of the more unusual and entertaining calls I have ever been on, and probably ever will.

He works in mysterious ways

It was a nice sunny afternoon in Oakland when the call came in for “man down”. I love that description, seems so sinister, yet rarely is. We pulled up at the same time as the fire department to a boxy, two story apartment complex that had the look of a converted cheap hotel. This one was badly in need of a new roof and paint. The external stairways and walkways were framed with rusty wrought iron railings and a decent amount of trash to navigate through. There were several older large black women dressed as if coming straight from church waving to us from the top step. Wool dresses, matching hats, purses and pumps. Color coordinated to the max.

We made our way up the rickety steps. They were center supported concrete slabs with spidery cracks veining the cement. The corners of most of them were chipped off, one was only two-thirds of a step. The center steel beam that held up the steps from below creaked and groaned under the stress of three firefighters, my partner and I plus all of our equipment trudging up the steps. I tried not to think about it. Much the way you don’t look at the cheap cotter pins that hold together a Farris wheel when you are stopped at the top.

At the door on the second floor, the church women met us. They were excited, sweaty and all talking at once.

“We just got home and she aint right” one said.

“I don’t know what happened, she was fine this morning” said another.

“Oh Lord don’t take her like this!” pleaded another one at the sky above.

We were calmly led to the back bedroom by the woman who seemed to have the most control over her emotions. On the bed we found an obese younger woman, approximately forty years old dressed in an old fashioned pale pink dress lying face up on the bed. Next to her was an empty bottle of opiate-based pain-killers. Another empty one was sitting on the nightstand. Just clues. Gotta keep your eyes and ears open and let the scene talk to you.

The woman was breathing maybe four times a minute and shallow. She did not respond to our shouts or when we shook her. I could tell she was not getting enough oxygen without testing her pulse oximetry.

“Let’s bag her” I said to the firefighter. “one every five seconds” I added.

As the firefighter repositioned her airway and began to assist her with her respirations, I continued with my assessment. Her radial pulses were weak and she was sweaty. Her pupils were pinpoint and she had some frothy sputum around her mouth. I noted it and moved on.

The engineer was just finishing getting the blood pressure.

“It’s really low and hard to hear…maybe sixty over palp?” he more asked than stated.

I could hear my partner asking questions in the background of the family.

“What medicines does she take? Does she have any medical problems? Any allergies to medications? Does she drink or take any illegal drugs? When did you last see her normal? Has she been sick lately?” All the right questions. Nothing obvious was sticking out. I kept thinking about the empty pill bottles, our only clue thus far.

“Let’s get a line going. Can you spike me a bag?” I asked the engineer.

“Sure” he said and got to it.

“Can you put her feet up please?” I asked the Captain who was standing at her feet.

“Copy” He got right on it.

“I’ll check her sugar.”

When you anticipate a patient needing medications or fluids and it seems as if they are going to be a stat patient, we will often start an IV on scene to get it going before we move. In the case of this patient, she was not only hypotensive, but I was suspecting an overdose. We would not be playing around too much here, it would be a stat transport as she was not doing well.

“I’m going to try some Narcan” I told the captain. I spun around and grabbed the box of Naloxone, better known as Narcan. Narcan is a wonderful drug that is a competitive opiate receptor inhibitor. It will bind to the opiate receptors and prevent the opiates, such as heroin, morphine, or methadone from having the effect of slowing down the breathing and ultimately killing the patient. The drawbacks are that it will not remove the opiates in the system, just block them so when the Narcan wears off, they will OD all over again if enough opiates are still in their system. Narcan also will take away the high instantly sending an addicted patient into acute withdrawal syndrome which could including seizure, profuse sweating, explosive diarrhea, abdominal pain and vomiting, heart attack to name a few, so we are careful with it. Only enough to get the respirations normal.

Just as I was preparing the Narcan, in walks a mousy woman in all black wearing a matching black hat with black roses and a short veil pinned up. She had thick glasses from the 80s that magnified her eyes. She was holding an old leather bible. It was clear by the way the rest of the family was acting that this was someone to be respected. Possibly an elder of the family or a holy person.

“Excuse me” she said in a meek voice. “Do you mind if I say a prayer?”

“Well ma’am we are working real hard here to save this young lady, pray if you need to it certainly can’t hurt”. The Captain reassured.

“Thank you” she said quietly and jockeyed for a good position at the patient’s feet.

I don’t understand what happened in the next few seconds, but this meek and mild old woman suddenly became aflame with the holy spirit. She turned into the shouting preacher complete with throwing her hands up in the air and punctuating the pertinent syllables in her sentences like she belonged in a travelling revival tent in the turn of the century south.

“Lord!” she started with a dramatic pause letting all the air leave her before springing back up “It is not time to take this humble servant!” she said impossibly loud with an elongated “ssssssss” on the “this”. “She has so much more of your work to do! Do not take her today, I beg of you. Give us more time. Do not take her. Not like this. Not like this! Not like this!” The repeated part got louder and more dramatic with each pass. The other women were starting to grunt and nod in agreement getting more involved in this impromptu prayer meeting.

She was throwing her body onto the legs of our patient and wailing. She was throwing elbows to keep us back. The prayer was much more than we had expected. Her arms ran from the tops of the patient’s thighs down her legs and she chanted and pleaded with her maker to reconsider what surely must be a mistake.

It got to the point where we were not able to get to the patient to do our job anymore. The little prayer had turned into a full-on sermon complete with theatrics, call and answer, and singing. It was time to shut this down, or at the very least get some room to work.

“Ma’am please, I understand you need to pray, but we need to work here” the captain reasoned. “If you don’t let us help your friend here, she will die. And soon.”

“You can’t save her, only the Holy Spirit can make that decision” she retorted sternly in the captains face “Do you hear me boy?” she redirected her eyes up “You can save her! Only you!” she shouted at the cracked ceiling with the old fashioned fixture on it before swinging her hips to block the path of the captain the way a defensive guard does underneath the basket. We gave her another ten seconds of sermon time before we shut it down. This was getting ridiculous.

“Let’s go” the Capt said nicely as he forcibly removed her, pinning her arms to her sides.

“I’m not done! I’m not done! Hear me Lord!” she yelled over her shoulder as she was lifted out of the work zone.

“Well you can finish from over there” the now-miffed Captain stated gruffly.

With the would-be prophet out of the way, we got back to work. I quickly started a line and pushed 2 mg of Narcan and stood back to witness the chemical miracle that Narcan is, from a distance. Sometimes people come out of this violently or start projectile vomiting. I didn’t need that.

Nothing.

I looked over at my partner. “Get the stair chair, we need to roll”.

By the time the chair was there, I pushed an additional 2 mg and had delivered a 500 ml bolus of normal saline. Still nothing.

We all looked at each other, this wasn’t right. “Come on!” I thought. “Everything is pointing to overdose, accidental or otherwise. What the hell is going on here?” I thought silently in my head. Protocols were flashing before my eyes, but no answers.

“Suggestions? Ideas? Anything?” I asked my fellow rescuers. They were as dumbfounded as I. We all at once decided to get her out of here. At least do something we know how to do that will benefit the patient.

We managed to get her lifeless, slumped over body strapped onto the stair chair and get her down from the second floor and into the ambulance. It took all five of us and we were pretty shot by the time we got her down.

I grabbed the fire medic to ride with me and we took off code three to the hospital. It was just a short hop, maybe three minutes total transport time. I was grateful for that. This would soon be over and she would have a higher level of care available to her.

Once at the hospital, we told the doctor the whole deal and how we suspected narcotic overdose but the Narcan wasn’t working. Of course he ordered up another 2 mg of Narcan, guess he thought I must have done it wrong. I wasn’t offended, he needed to see it for himself. It didn’t work any better than the previous two doses. I left the patient with the team who was now aggressively searching for a cause. Younger people don’t usually just present like this. There has to be something.

About five hours later I returned to the hospital and they told me she had passed. I was a bit confused. The doctor filled me in. She had had a major vessel in her brain spontaneously rupture. This caused enough brain herniation to pinpoint her pupils and reduce her respirations which ultimately killed her. He told me there was nothing we could have done differently.

The lesson I walked away from on this call was two fold. The first is obviously to keep an open mind and think outside the box. Everything is not always as it seems. The second is that there is no end to people’s arrogance to think that if they just say one more prayer or shout louder, their God will hear them and reverse a medical situation. Prayer is a powerful tool and provides comfort for many in times of need, but when it gets in the way of saving someone’s life, it is another thing all together.

I am reminded of a joke I once heard in a sermon. Here it is modified to fit the scene.

A woman’s friend is dying in a bed and she calls 911. She yells out to God to save the friend. The paramedic tries to save the friend but she jumps in and says “No, God will save her.” Then the fire captain picks up the gear and tries, and she likewise beats him back citing God will save her. Finally an EMT jumps in and tries but is again beaten back similar to the other two. The friend dies right in front of them despite her pleas to God and she is distraught.

Many years later when the woman dies she goes to heaven and meets God and asks “Why didn’t you save my friend when I pleaded for your help? Have I not always been your humble servant?” God took a deep breath and said “What more did you want, I sent you a Paramedic, a fire Captain and an EMT!!”

Milk it does a body good

It was a pleasant day on the east side of Oakland. The sun was shining, the birds were chirping. All of the gang-bangers and drug dealers were still asleep. All was well. I was working with one of my best paramedic friends on the ambulance, Joe. Joe is a tall and lanky guy with a crooked smile who lives for intelligent humor. He and I have very similar backgrounds, though raised on opposite coasts. It always amazes me how two people can be raised three thousand miles apart and still have unbelievably similar experiences. It was Joe’s tech, meaning that he would be the one to do the patient care and I was driving.

The call came in for a particularly run down area of Oakland by the Coliseum. This neighborhood was one of those that had been forgotten. A large overpass was built several years ago creating a monstrosity that overshadowed the rows of tiny bungalow houses. The elevated road made it so that you could not even access it from the main roads, further isolating the neighborhood. Good for those that want to be able to go about their illegal dealings without the hassles of the police and general public, not so good for the average citizens who make up the bulk of the people.

The call was for accidental poisoning/overdose. This is a generic complaint that could mean anything from taking three aspirin when you were supposed to take two all the way to drinking bleach or a heroin overdose. Who knows. We pulled up to the multi-unit house, which was actually in pretty good shape given the neighborhood. The street was littered with trash and beer bottles. The ever-present faint smell of urine, the trademark of these neighborhoods, provided a quick shock to the senses as we exited the ambulance. Nothing new here.

The fire department had beat us to the call, but were just unpacking their medical gear from the engine so we walked in behind them.

“Fire department!” The captain announced as he knocked on the slightly ajar door causing it to swing open a little more.

“In here! In here!” replied our soon-to-be patient.

We entered the house. We navigated around the scattered laundry of unknown cleanliness that littered the floor. The art on the walls was modern African tribal art. The house reeked of marijuana and a haze hung in the air. We were going to get a contact high if we spent too much time here. In the back of the house in the kitchen, we found a forty-something woman wearing a bad wig, a leopard print tank top and Apple Bottom jeans that were easily two sizes too small for her obese frame. She was in the middle of her kitchen talking on the phone standing barefoot in approximately a half an inch of milk, much of it curdled. She was loudly gabbing away on the phone apparently unaware of the partially digested, lumpy dairy product that now covered her linoleum floor. Her brightly painted toenails and dark brown toes stood out in stark contrast to the white milk. In her other hand she was holding a mostly empty gallon jug of milk that she was waving around to punctuate here sentences. The milk sloshed and hit hard against the sides of the plastic container making an unusual sound. Not the weirdest thing we have ever walked in on, but definitely up there.

“Ma’am, we need you to hang up the phone” the captain said.

“Just a second” she said with a defiant finger up and a wild-eyed look that warned us to not come any closer.

“Ma’am, please, tell them you will call them back,” the captain persisted.

“OK, Ima have ta call you back, this RUDE MAN in MY kitchen needs to talk to me” she told the caller in a passive aggressive move. She hit the “end” button with much more force than was necessary and looked at us with a look that said “…..AND?”

“Ma’am, did you call 9-1-1?”

“Well, there’s no one else here is there?” she snapped back.

“No there isn’t ma’am.” The captain said calmly, rethinking his approach. “Do you have a medical emergency?”

“Yeah, I threw up all this milk and I can’t stop throwing up” she quickly raised the gallon jug to her lips and chugged what was left which quickly came back up and added to the sea of smelly milk she was standing in.

“Maybe you should stop drinking it if it is making you vomit” he said.

“But I have to, I was poisoned” she said as if we were idiots.

Red flag. OK, this had potential to be a little more than we thought at first glance.

“Please sit down on the couch over here” Joe directed.

She complied, bringing the phone and the now empty milk jug with her.

We started immediately checking her vital signs. She looked fine overall, but her eyes were dilated and very bloodshot and she was talking very quickly. We needed to gather some information before moving on.

“My partner here is going to take your vital signs and we need you to answer a couple of quick questions. What leads you to believe you have been poisoned? Did you take something?” Joe asked.

“OK, so here it is. Today is my birthday.” She started her story. “So I decided that today I am going to stay home and smoke a whole lot of weed”. OK, that wasn’t so strange, plenty of people take their birthdays off to kill brain cells.

“How much weed are we talking about?” Joe asked.

“All of it” she answered. “That whole baggy was full.”

If this was true, this would explain a lot as far as her actions were concerned. She was high as a kite. That would be a lot of marijuana for one person to smoke in one sitting. I couldn’t believe her lungs would tolerate such an onslaught, but the body is a resilient thing.

“So what’s with the milk?” Joe dug deeper.

“I was afraid I was poisoned and I know that you should drink milk if you are poisoned” she said.

“But you didn’t actually ingest anything you smoked it!” One of the firefighters interjected, obviously irritated at this point.

“You know what guys, you can clear, we can handle this” Joe said to the firefighters. They happily left in a hurry shaking their heads in disbelief as they went.

We continued our assessment and found nothing unusual with the patient. All vital signs were normal and the longer we sat with her, the more she seemed to be relaxing and becoming lucid.

“Do you want to go to the hospital?” Joe finally asked, after all, taking people to the hospital is what we do.

“No no no, I just wanted to get checked out. If I’m OK I’d rather stay home”.

We agreed, she was not technically mentally altered, just really high. She was still able to make decisions for herself and certainly was hemo-dynamically stable. We tried a few more times to get her to go, probably not as aggressively as we should have, but nonetheless, in a few minutes I was running back to the rig to get the “Against Medical Advice” paperwork for her to sign. This would release us from any legal liability.

“Now you have someone you can call who can come over and stay with you for a while until you fully sober up, right?” Joe asked.

“Oh yeah, I can call my cousin, she’ll come right over.” She said.

She made the phone call, the cousin was on the way, and she signed our paperwork. That little voice in our head was saying this was not a good idea, but I think the selfish motives of being rid of this patient and the promise of a good cup of coffee were too alluring to pass up.

Approximately fifteen minutes had passed since we had cleared that last call. We were happy to be moving on. We had received a new post that was not too far from where the call was.

“Five one two, five one two, copy code three” the radio said. It was us.

“Five one two, go ahead” Joe said, he was driving now.

The dispatcher gave us the exact address and the same basic demographics as the lady we just had, but added a nice little tag on the end: “CPR in progress”

All of the color drained out of Joe’s face. I actually felt a cardiovascular response similar to the one you feel when you get news a relative just died or find out your lover is cheating on you. I could feel a slimy sweat forming on my brow.

“Dude, we just signed her out” Joe said in a tone that spoke half disbelief and half resignation. He flipped on the lights and siren and floored the gas.

“I know.” I said reaching for some way to make this messed up situation better. “Do you still have the number to that truck driving school?” I asked, quoting the famous line from “Top Gun” when they were getting chewed out for buzzing the tower and were pretty sure they were going to get fired.

“We are so fired” Joe said.

“Just get there. Fast.” I said.

We could not have been in a worse area to drive fast. This was an overly-crowded street with rows of shops. There were hundreds of people out walking up and down the sidewalks and in and out of the various markets and shops. To make matters worse, traffic was basically at a standstill due to people slowing to allow jaywalkers to jump from one side to the other. Many others were trolling for a good parking spot.

Joe was laying on the horn and the siren, I was half out the window waving people to the side. They seemed to not even notice the big white and red van behind them with the flashing red lights and impossibly loud siren. Sometimes I wonder about people. Finally we threaded our way through the busy area, not without several close calls.

We pulled up at the same time as the fire department and the police. The police come out any time there is a death and this was a CPR in progress call so they came. We jumped out of the ambulance eager to find out what the heck happened when the lady came walking out with her hands over her head waving us back.

“AHHHHHH…..I’m just playin’ with yall!” she laughed.

“Ma’am, we got a call of CPR in progress, what’s going on?” The fire captain asked.

“Nobody, dyin’ here” she said with a laugh. “I’m just messin’ with you”.

I could see the rage building up in the firefighter, but he maintained good customer service.

“So you have no medical complaint?” he asked.

“Nah, I’m just playin’” she responded.

“I’ve got this” I stepped in. I didn’t want her to get punched regardless of how much she deserved it. The fire crew cleared.

I called the police officer over. “Ma’am, I’d like you to meet my friend here.” I said in my most authoritative tone I could muster. “He would like nothing better than to cuff and stuff you and take you in. Calling 9-1-1 for a joke is a crime. You have wasted all of these city and county resources that could have helped you. So you now have two choices the way I see it, go with us, or go with your new police friend.”

“Well I aint going to no hospital” she said.

“Perfect” I responded “hook her up” I said to the cop.

“No no no no I’ll go to the hospital” she recanted. “I don’t need to go to no jail on my birthday. I am short of breath, my chest hurts” she knew what to say.

We took her to the hospital so she could be monitored while detoxing from her excessive marijuana smoking. I would have liked to have seen her arrested not only for wasting our time and resources, but also for endangering the community and practically giving Joe and I a heart attack.

After we cleared from the hospital we popped over to a local bakery and picked up a small cake and brought it to the fire house. We felt bad for signing her out in the first place and wanted to make amends. We went in and had coffee and cake with the firefighters and laughed about the call. Everyone had cooled down by now and it was comical in retro-spect. I think the thought of us driving code 3 with our hair on fire entertained the guys.

In the end, I think we probably did the right thing not sending her off to jail. She wasn't a criminal, just really stoned. If only we had done the right thing the first time and not signed her out, we could have saved everyone a lot of stress. But that is really the way EMS goes. You start out with a base amount of knowledge and you learn day by day, making mistakes as you go along. Some of them more entertaining than others. But in the end, you never stop learning and refining your judgment. And to this day, whenever I see a plastic gallon milk container, I think of our crazy old patient in the crooked wig standing toe deep in milk waving it around.

copyright 2010 Jon Kuppinger

The Bleeder

It was the first night without my regular partner in a while. She had transferred over to critical care transport on the day shift leaving me with what we affectionately call “mystery meat”. Mystery meat is when you don’t know who your partner is going to be. It is a bit of a gamble really. If you roll a seven you get a great partner who knows their job and can hold a conversation. If you roll snake eyes you get a lazy partner or maybe a dead fish that doesn’t speak for the entire twelve hours of the shift. This night I was lucky and rolled a seven.

Nadine was a tall, well-mannered young lady who obviously was a bit classier than the typical EMS worker. Her soft-spoken confidence spoke to someone who knew her job, but wouldn’t tell you so. We were having a good night of conversation between calls with the new Sade album playing softly in the background when a call came in for the west side. It was a shunt bleed.

When a patient’s kidneys fail, they are often offered dialysis as a way to prolong their lives. Three times a week they go a dialysis facility and a machine is hooked up to a port, usually on their arm. Their blood is cycled out of their body and through a machine that cleans their blood and removes excess toxins and volume. The machine serves as a form of artificial kidney for the patient. The port is called a “shunt” and is the direct line into their major veins and arteries. If this port breaks open, they will bleed out in a short time. It is a true life-threatening emergency.

“Have you ever had one of these?” I asked.

“Yeah, a couple, they can get real messy” she replied as we sped through the abandoned and darkened streets of downtown.

“I had one a couple months back and she almost bled out. The room was like a murder scene, blood everywhere”. I ran through my bleeding control protocol in my head quickly. There would not be any time for fooling around, we would have to go as soon as we arrived.

We pulled up in front of the run-down apartment complex at the same time as the fire department was arriving. There was a thirty-something woman standing in her pajamas waving to us frantically.

“Please hurry! Please hurry!” she pleaded. “We can’t stop the bleeding”.

“I’ll grab the trauma dressings and wrap” I yelled to the fire captain, ”You guys check it out”.

The captain nodded to me and they headed in with the frantic woman. I often worry about taking control like that, after all, technically it is the fire captain’s scene but it was clear the fire crew had just woke up and were in no mood to be leaders.

“Nadine, not sure what we are going to need, jus bring the gurney to the bottom of the stairs please, get some extra sheets, I’m going to run ahead with the trauma dressings”. She gave me a look that told me she understood. We were all in work mode now.

I walked into the apartment and was surprised at how many people were there. There were at least six adult women in this house not counting myself or the fire department. One was sound asleep on the couch. Sleeping through all this commotion. Interesting. I made a note.

As I poked my head into the back bedroom that everyone was pointing to, I saw our patient lying on the bed. The contrast of the bright red blood against the white sheets was startling. There was a steady stream flowing from her upper right arm and her middle-aged daughter was trying to hold pressure with a towel. I ripped open all the dressing packages and asked the firefighter to cut off her nightgown sleeve. It was completely blood-soaked anyway and was ruined. I asked the daughter to carefully pull away the towel and when I did a pulsing stream of fresh blood shot through the deep-red coagulated jelly that had collected around the site of the shunt due to the towel being on her arm. I quickly pressed a trauma dressing on her arm and began wrapping it as tightly as possible.

Around and around and around we wrapped the dressings until her now-oversized upper arm looked like that of a bodybuilder. Blood was still streaming out of the end of the dressing at her elbow.

“Squeeze here, and here, and lift it up” I directed the firefighter. “And get comfortable, you can’t let go until we get to the hospital”.

“Are you kidding me?” He asked. He was just a kid.

“Congrats buddy, you just got the worst job in EMS. Holding a bleed” I smiled at him. His captain winked at me, he thought it was funny. They love to see the new guys squirm.

The patient’s daughter was pacing around the room. She was worried and needed a job to do.

“Can you grab me a robe, some slippers, and her medical card” I asked. Having a task is very helpful for people who feel helpless. She disappeared into the other room, the tears stopped temporarily replaced by determination.

“Gurneys at the steps, need a stair chair?” my partner Nadine shouted from the front room.

“Awww crap” I thought to myself. Of course we would need one, I had forgotten we were on the third floor and there was no elevator.

“Yeah, good idea” I said a bit embarrassed I didn’t think of it myself.

“Good thing I brought one up” she teased. I love partners like this that think proactively.

We loaded the patient into the chair and buckled her in for safety. I got on the bottom and one of the firefighters took the top. The patient only weighed about one-fifty. We could easily handle that. We decided to just carry her down instead of going step by step. I find it easier on the back with lighter patients than the up and down of dropping on each step. That way you only have to bend over once, not at each step.

Once in the ambulance I threw another dressing around the existing one and began the bizarre dance of working on the back of an ambulance around a fully necessary firefighter who was stopping the bleeding, but now serving as a roadblock to the front half of the ambulance. The patient was getting pale now and her eyes were starting to swim the way they do before you pass out.

Right out of the blue she vomited. And I don’t mean just a little vomit, more like the projectile kind you see little kids do.

“Don’t let go!” I coached the firefighter really holding back a giggle, after all this was a serious call. But it was funny to see this kid getting assaulted from every side. He was getting covered. His arms were already soaked up to the elbows in blood and now his chest and hair had vomit in them. Good thing he had a long sleeve pull-over on. That thing was going in the garbage when the call was over.

“What do you need?” It was Nadine. She had slipped in the side door and was going to help from the other side of the firefighter.

“Suction. She just puked all over.”

“OK, got it” she said as she turned on the electronic suction and began clearing the patient’s airway. Aspiration can be very serious and lead to life-threatening pneumonia. Nadine would try and clear as much as she could from her mouth.

As soon as her airway was clear and it looked like she wasn’t going to vomit anymore, we all knew it was time to go.

Our patient’s daughter who had waved us in was now standing at the back of the ambulance watching us work and coaching her mother to “Keep on living” and to “fight”. She was fighting tears and trying her best to bury her own fears and give all her strength to her mother.

“Where are you taking her?” she asked.

“The closest, it’s just around the corner.” I said.

“No don’t take here there, she’ll wait forever!” She pleaded. The hospital in question was a busy one and you could wait there for hours as it is often overrun with patients.

“Don’t worry, they won’t make her wait this time” I promised. The back doors closed. Bleeds don’t wait.

“Code three, shunt bleed, hypovolemia, approx 500-1000 mls.” I shouted up to the cab.

“B/P is 90/P, tachy at 128 bpm, pale and cool, starting IV now, GCS 14” I added.

“Copy” Nadine yelled back, signaling she understood.

The sirens came on and we bounced along down the pothole-ridden streets. Being that the firefighter couldn’t free up a hand to reach for anything on his end of the ambulance or risk spraying more blood on the walls and floor of the ambulance than there already was I had to get creative and contort myself around him. It was becoming like a disgusting game of Twister.

I got my vital signs, started and IV flowing wide open and put the patient on oxygen just in time to pull in. It was only a mile or so, felt longer.

We wheeled in fast with the firefighter in tow. His forearms had to be burning by now. Blood was streaming off his elbows and leaving a trail from the back of the ambulance, through the triage plenum, past registration and into the trauma room. We wouldn’t be hard to find.

For some reason, the resident doctor doing his rotations at the hospital kept hearing “shot” instead of “shunt”. Perhaps it was because he has seen so many gunshot victims. In any event, it provided a moment of levity as we did this round of Abbott and Costello.

“Where was she shot?”

“Shunt not shot”

“What? Yeah, shot”

“Shunt”

“I know, WHERE was she shot?” he emphasized.

Funny stuff. But this was serious, we just bowled through him to the room where they take all the stat patients.

The code team at the hospital was ready for us. We quickly transferred her to the bed, the firefighter was still holding her arm through this exercise. Most of the team had gloves, gown, and face shields on now.

“OK you can let go now.” The doc said. He was ready to resume control.

“You sure, it’s gonna blow if I do” the firefighter said. He knew, he was holding it.

“Let go, we need to see what we have”

My partner, myself and anyone else in the room who had seen this kind of thing before faded back. I actually left the room to the other side of the glass. The new doc leaned in.

As soon as the firefighter let go and the bandage was off, the doc got covered with blood. So did the bed, the equipment, the floor, pretty much anything within three feet.

I laughed to myself. So did an number of the senior nurses. They saw it coming.

“Clamp it down clamp it down! “ the new doc shouted.

A quick thinking nurse put a B/P cuff above the shunt and pumped it up. It stopped. Half the people left the room. This emergency was over.

Over the next few hours this patient would receive as much fluid and blood products as she could take to replace the volume she had lost. The emergency was over and she would live to see another day.

I cleaned myself up, finished my report and went out to the ambulance bay. Nadine was out there scrubbing the back of the ambulance.

“We better go delayed” I said, meaning that dispatch would be told we were out of service for a while to clean up.

“Already on it” she said with a smile. Again, a step ahead of me. When the little details are taken care of, it really takes a lot of stress off a paramedic, especially on stat calls.

“You hungry?”

“Starved, let’s go eat.”

Ed the Killer

Tonight I met a killer.

He was sitting in handcuffs in the back of a police cruiser with no shirt on. He was wearing nothing but baggy jean shorts, tattoos, and a fresh coat of sweat. This was peculiar because it was a cold and damp January night. There was steam rising off his slick shaved, scarred scalp and blood trickling down from the corner of his eye into his carefully manicured pencil thin moustache. He had a split eye the way you see boxers get when they are punched too many times in the eye area. He was mess, but determined to control the situation.

“Hey man,” I opened with, “I’m not a cop, I’m a paramedic and I don’t care what the hell happened, I just want to check you out and make sure you are not hurt. Is that OK with you?”

“Whatever, I aint sayin’ shit.” He replied with a dead forward stare.

I questioned him over and over again and he just kept throwing out inappropriate answers to common questions. Name. Date of birth. Address. All came back with non-sense answers, just as the police had told me when I first rolled up. I sensed he was not actually mentally altered, but more enjoying this game of cat and mouse with the police and now me. He wanted us to think he was crazy and give up, which would land him in the hospital and ultimately the psych ward instead of jail. But he was different from the typical nut, his eyes were too sharp and calculating, not vacant. This was a ruse.

“Look buddy, I’m not trying to come down on you, but if you don’t start answering these questions appropriately, I am going to have to assume you have brain damage and you are going on a backboard and getting an IV. When we get to the hospital they are going to have to go through all kinds of tests and scans for possible brain bleeds or concussions. They usually start with a finger up the butt. That’s the best part. It gets worse from there.” I was lying, but he straightened up and from that point forward answered all questions appropriately. Of course he still wouldn’t budge on why he was bleeding or what circumstances led up to us meeting this chilly winter night.

I approached the police officer, leaving the patient in the patrol car.

“So why is this guy being written up on a 5150 again and what do you know about him?” A 5150 is a psychiatric hold you place a patient on when you feel they are a threat to themselves or others. Usually the person needs to make suicidal or homicidal statements or attempts to qualify. In this case, the police didn’t want to deal with him so they were throwing him over the fence to the ambulance crew to take away instead of taking him to jail. Probably because they had nothing to hold him on and he knew it.

“Says his name is Ed, no ID. Neighbor called saying they found him sitting on the curb all sweaty and bloody so they called. He’s going on a 5150. He’s a danger to himself” the cop stated in that bravado way cops talk.

“Did he say anything to make you think that?” I dug a bit deeper.

“He’s just not making sense so he’s going with you guys,” the cop replied, punctuating the sentence by ripping off the duplicate of the form and handing it to me with a smile. He was obviously irritated with where I was going with this and the conversation was over.

“OK, I’ll take him,” I conceded, as if I had a choice. It wasn’t worth the battle. It wouldn’t be the first time I have taken a healthy, mentally sane person to the hospital on a 5150 hold and Lord knows it won’t be the last.

En route, the patient did not talk to me much but was generally cooperative. I kept prying. His body told a rough story of life lived hard. He had gang tattoos all over him and obvious scars from bullet and knife wounds of various ages. I wanted to hear the story from his mouth.

“Can you run the siren?” He broke his silence in an almost a childlike tone. “I like the siren” he smiled through bloody gold teeth.

“Sorry Ed, it’s not that kind of emergency”.

“Well then take me out of these restraints.” He tugged at the leather restraints on his wrists and ankles.

“Sorry again man. It’s procedure. Just go with the flow and it’ll be over soon. You’ll be out in no time.” I half lied. I knew there was no way this guy was going to be a treat and release. They would hold him to run warrants and photograph his tats and try and get some info out of him. They would try. If he was lucky, he could slip through on the psychiatric path and the law would forget about him Seventy two hours later, if he could prove to doctor he was sane, he would be free. In the meantime he would have a safe place to sleep and eat. Not a bad deal. Beats jail.

Once at the hospital, we were stuck in the triage plenum, a room with locking doors on either side where the ambulance crew waits while the ER staff are preparing a bed for the patient, or in this case, when they don’t have one available. You can wait there for hours on a busy night. Tonight was a busy night. The ER was buzzing; people were swarming in every direction with equipment, clipboards, and gurneys. A triple shooting had just come in and two of the victims didn’t make it. The third was in critical condition and all hands were on him so I had to wait. I was fine with the wait until Ed started talking.

“Man, you like this job?”

“Sure, it’s fun.” I replied into the screen of the laptop I was writing my report on.

“So you like tying up people and being the cops’ bitch?”

“It has its good days and bad days.” I replied flatly. I knew where this was going. I was not taking the bait and addressing the slur.

“Do you ever think about this stuff at home? I mean do you have nightmares about all the people you kill?” He asked. I think he was serious so I bit.

“Come again?”

“All the muthas who get smoked because of you askin’ all these questions. Trying to get people to talk. When someone talks, someone dies. Fat Face is a killer and didn’t even know it.” He chuckled. “That’s OK, I am too. We are a lot more alike than you thought, huh….”

I stopped typing. Ed had my undivided attention. This was the kind of perspective I was looking for. I just wasn’t sure why he was turning the tables on me as a perpetrator. I don’t wear a badge. I don’t wear a gun. I don’t chase the bad guys, I just patch them up after the excitement is over. He continued, now aware that I was listening.

“Man you are out here in this game and completely unaware of the game you are a player in. How is that possible?” His tone and cadence were now ratcheting up. He was feeling it. We both were. “I know, I know, just doing your job. Right? WRONG! Your job is getting people killed. And not just killers like me…mothers, kids, brothers, we get the family if we can’t get the guy. I do it with a gun, and you do it too with your bullshit snitch questions.”

He was rolling now, and I was not going to stop him. Morbid curiosity assured that much. The bulging veins on his forehead and neck backed up his harsh words.

“You have no fucking idea what you are doing out there. Every day I smoke mutha fuckas and you come pick up their almost-dead asses and drag them here. But you never see me on that gurney, do you? Look at this tattoo. Look at it and read it!”

“1 8 7 – Fuck a ho, kill a bitch.” I read. Charming. “That’s nice work, where did you get it done? San Quentin?” It wasn’t nice; I was trying to change the subject and feign interest in his ink. Maybe we could stop talking about “smokin’ bitches”.

“It’s professional, this aint no jailhouse gank.” He was more amused than offended. “You stupid. Now you look at this scar from where I got shot.” It was a dull red scar from the bottom of his rib cage to below his belly button. He wore it like a badge. “Every time, you see. Every time. Ev-A-Ree time I get shot but I keep living and the other mutha fucka dies. That’s what happens. You can’t kill me. I do the killing. I end up here and they sew me up. I don’t die but the other guy does. Every time. Just like those guys in there.” He was pointing towards the direction of the trauma rooms where the dead gunshot victims were lying. He knew this place.

“Mmmmhmmm,” I was now looking through the little window out to the rest of the world. The world that was not in this box with this maniac.

“You listening to me fat face?” Apparently I had a new nickname. “I will fuck you in the ass and kill you if I want to. It’s the way it is. I decide! Let me outta these restraints and we’ll see what’s what.”

“Whatever you say.” He was getting overly agitated now, I didn’t want to probe further. I was done with my little foray into his world. I wanted back into mine.

“We have a bed for you” The nurse popped in not a second too soon.

“Hear that Ed the Killer?” I teased. Two could play at the nickname game. “You have a bed.” I had a new sense of confidence. I was back in a routine I was comfortable with and had the support of the staff there. It would be OK form here on out.

“Haven’t you been listening to me?” he snorted. “I don’t need a bed, I need to get outta here so I can get back to work. I have mouths to feed and people to smoke.”

I left Ed the Killer with the nurses in the psych section of the emergency room. Ed was not a psych case, he was a killer. A triple shooting had taken place 3 blocks from where he was found about 15 minutes prior to finding him. It was likely he was involved somehow. I didn’t understand how the connection was not made, but police work is not my job. I take patients to the hospital regardless of their indiscretions.

Some hours later, I was at the psychiatric hospital talking with another crew as we waited to unload our patients. The psych center only takes one at a time and the lengthy admissions process ensure we have plenty of time to chew the fat with the other ambulance crews. One of the other guys was telling me about their patient they had just brought in. A transfer from the hospital psych unit. Apparently they had a live one.

I told them about my deceptive killer I had earlier and said the name Ed.

“What a coincidence, our guy is Ed too” said the EMT.

“No way!” I looked at my partner. We had to look. We went around to the back of the ambulance and peeked in the window. Sure enough it was Ed. He was smiling back at me. With those gold teeth. He had convinced the hospital that he was in need of psychiatric care and was going to be able to hide out at the psych center. He had succeeded in his plan.

After that shift I was driving home. The commute offers me a bit of solitude to decompress and prepare to enter what I call “the real world”. This day I was rehashing what Ed had said to me earlier. It was sticking with me for some reason and I had to work through it. In his insane ramblings there was a bit of truth. Newton’s law states that for every action there is an equal and opposite reaction. I believe that law can also apply to social situations. There were actual consequences to all of my actions, as clearly as there were to Ed’s. I sometimes take the job lightly, not considering the world I am operating in, where a moment of weakness can mean your untimely death or someone else’s. Is it possible that in our zeal to do what is right, to tell the truth, to try and help people we could actually be making it worse?

Not a chance, I decided. I didn’t choose the life Ed or his targets chose. They chose that life and understand the consequences of that choice. Likewise I chose my path and it is a path that leads me to the other side of the fence from Ed and his pals, the fence that separates us from the killers.

copyright 2010 Jon Kuppinger

Life in the Minutiae

It was a Sunday morning in Oakland. The sun was coming up over the mountains and was blinding to the bloodshot eyes of vampires like me that work the night shift in the city. The rising sun often came as a welcome reminder that the night was over and our shift was coming to an end. A kind of new beginnings signifying the end of a rough night of weekend calls. I work from 9:30 PM until 9:30 AM. Getting off shift at that hour of the morning is challenging because the morning is a time when the call volume is very dense. In a matter of a few short hours our system quickly becomes depleted of available resources. It makes sense when you think about it. Early morning is when you have people first arising and realizing that their loved ones (or themselves) have a problem. Compound this with the large amount of people who get up and pass out in the bathroom or just get up to fast and have strokes or heart attacks and you have a busy timeframe. My partner and I have learned to anticipate that we will get a call too close to our OD (short for off-duty) time and will get held over. It’s OK if you learn to embrace the extra overtime money you will receive.

Today was such a day.

The call came in for a particularly affluent portion of the Oakland Hills called Piedmont. Piedmont is where the doctors and lawyers and anyone else who has done well in Oakland lives. Most of the houses are multi-million dollar, three-thousand square foot plus houses that are built into the mountainside with outstanding views of the San Francisco Bay and all of it’s well known landmarks. The Golden Gate, Alcatraz and the Trans-America pyramid are all clearly visible from this perch, when the famous fog gives you a break. Since the more affluent types of people rarely call unless it is a good reason, your guard is generally up a notch when you head up the hill.

We arrived at a well-kept, modern house on a very narrow canyon street that the ambulance fit down, but blocked traffic both ways. The house was built vertically so that you had to go up two flights of outdoor stone steps before you even got to the front door on the ground floor. From there the house went up another three stories. It was a code 2 call, which means that the dispatcher had determined that the patient was a “less urgent” patient and we would be responding alone without the fire department as is customary on most medical calls.

Our patient was found lying on the upstairs bathroom floor in good spirits. He was an approximately fifty year-old man in good physical condition. Apparently he had passed out earlier when going to the bathroom, but was feeling much better right now. His spouse was a MD and had fully assessed him and did not find any pertinent findings but had a gut feeling that he should go with us as a precaution. She would follow in her personal car. We were fine with that. All of his vital signs were near textbook perfect and the patient was not orthostatic, meaning that there was no drop in blood pressure with changes in position from lying down to sitting to standing. This would be a finding we would expect for a patient who passed out due to a lack of adequate blood flow to the brain. Also his blood sugar was at a perfect level. We were stumped, and our guard was down. After all, it was probably nothing and this would be an easy call. Good way to end the shift.

We assisted the patient down the several flights of stairs. He did fine and did not complain of any dizziness or pain at any time. His color was good and his coordination was normal. I was walking down backwards in front of him in anticipation of him falling. He found this odd.

“Jon, you don’t need to do that, I’m perfectly fine”.

“Steve…”not his name, but we’ll call him Steve to protect his identity “I have had people fall out on me that seem right as rain. I’m not taking any chances on these steps”.

Steve shrugged me off and continued his descent from the castle to the ambulance.

Once in the ambulance we talked about football, his job, and the neighborhood. All small talk to pass the time and make the best of an awkward situation. After all it is a bit unusual for one grown man to be poking and prodding another in the back of a van. I did all the checks I do on everyone and everything checked out. My partner Megan started the slow roll to the hospital through the windy canyon streets.

When it came time to start an IV, he was very nervous about the needle.

“I hate needles” he said.

“Nobody has ever told me they like them” I joked back at him “but most people are surprised by how quick and painless I make it. So who are you calling for the Super Bowl?” I kept him talking about things to keep his mind busy and off what I was doing.

He bore down hard when the needle broke his skin. I was a little surprised at how intolerant to pain he was. Most guys in his condition don’t even flinch. His teeth were gritting and his face was turning red. He was starting to slow his own heart rate down from the internal pressure and I wasn’t too excited about that, but a guy like him would recover fine.

“Aww come on, it’s not that bad Steve, just breath in through your nose and out through your mouth.” I coached. “Steve? STEVE?! STEVE!!!”

He was staring straight at me when the lights went out in his eyes.

I looked at the monitor and saw his heart rate drop by tens. I heard a sports announcer from the seventies in my head:

“Sixty… Fifty… Forty… Thirty… he… could… go… all… the… way! Twenty, Ten, Five, TOUCHDOWN!”

Steve was now gurgling with no cardiac activity on the monitor. His face was turning purple and the lights were out in his eyes. He began to sweat a profuse sweat we call diaphoresis. This was really bad.

“Shit!!! Megan! GO! GO! GO! GO! GO! CODE 3! GO!”

My partner Megan lit ‘em up and hit the gas. Getting back down to civilization on these windy, narrow streets, and doing so with a quickness, was going to be a trick. A trick she was up for, but none-the-less a trick.

“What do you have?” She yelled back, part morbid curiosity, part need to know, trying not to take her eyes off the road.

“No pulse, asystole, not breathing” I was really yelling now more in disbelief than anything. “Just go! PLEASE LET’S GO!”

“We are going” she said. We were going, I was whipping a horse that was already charging. It was time to stop yelling and start working. I couldn’t figure out how to communicate how quickly I wanted to be at the hospital now. Working a code blue alone was a nightmare. It’s a hassle even with a team.

“Steve! Come on man, wake up!” I gave him a brisk sternal rub that would have woken the dead. Nothing.

I don’t know what made me look out the back window. Maybe it was that feeling you get when someone is watching you. I saw his wife in the car behind us trying to keep up and straining to see what was going on with all the commotion in the back of the ambulance. I was like a tornado bouncing from cabinet to cabinet pulling out equipment thanking God I had done my rig checkout that day. There was so much to do. I pulled out my shears and cut his shirt from the neck to the belly button in one fast motion. I slapped the defibrillator pads on him and passing by his head to grab the BVM I instinctively bumped his O2 to high flow. CPR was going to start in a second and I wanted everything out that I would need. My mind was reeling, my heart was pounding in my ears, and I was a bit stunned. I was alone back there, but I could do this. I had no choice. Of course I could do it.

“What do I tell them? What do we have?” Megan broke my trance with a solid question. You don’t just fly into a hospital, you need to tell them you are coming and what kind of a mess you are about to drop in their lap so they can gather the appropriate resources.

“He just coded” I gasped, “I don’t know if this a seizure or a code or what” I felt for his carotid pulse on his neck. Nothing. No pulse. The gurgling had stopped and he was in a blank, dilated, motionless stare.

I ripped open a nasal pharangeal airway (or NPA as we call it) and lubed it up. He was going to need a secure airway and did not have one. I glanced over at the monitor and saw a ripple here and there. IVR. This was not good. This guy was healthy. We were just talking. He was a walking and talking guy with no complaints thirty seconds ago. What the hell was going on? My mind raced for answers as my body automatically ran through the well-rehearsed algorithms on autopilot.

Just as I was sliding the NPA into his nose he popped awake.

It was just like a light switch had been thrown on. His eyes suddenly became animated and his facial muscles regained the composure that makes Steve look like Steve. This is the oddest thing to see. It’s like the return of somebody’s soul to their body. Like a robot that had been switched on.

“Kaiser Oakland, go ahead” I heard the radio crackle from the front. It was time for the report.

“He’s back, we got him back!” I yelled into the cab. His heart rate did the reverse run like an end zone interception. “Zero, Ten, Twenty, Thirty”

Steve opened his eyes and took a deep yawning breath like a little kid just waking up from a nap.

“That was weird” Steve said in a dry, even tone. That was weird? This was his response from the grave? He really looked like a guy waking up from a refreshing snooze.

“Steve, you scared the hell out of me” I was reaching for his neck to check his pulse. It was back and strong. He was breathing normally. All his vitals quickly returned to normal.

“What happened? I felt like I was drifting off to sleep. Did I pass out again?” He was curious, but not concerned.

Meagan was eavesdropping on this exchange. “What do I tell them?” We were getting close to the hospital.

“Crap I don’t know, he just had two minutes of asystole with no breathing and now he’s back like nothing ever happened.” I was stabbing at the dark “I don’t know. Give me a second to get a blood pressure and take a sugar.”

His vitals were back to textbook levels again. What was going on? Did that just really happen?

“Steve, what did you see?” I asked. “Was there anything peculiar or different?”

“Not at all. I just felt sleepy.”

This gave me a huge sigh of relief. Perhaps death was not this awful thing to fear? I thought about my relatives who had recently died. Maybe it was as peaceful for them too. That would be nice.

Megan’s chaotic ring-down was an accurate description of how baffled we were I don’t fault her a bit. What do you tell someone when you don’t know what the heck is happening? The situation was radically changing even as she was talking into the mic. She ended it with a cringe anticipating the eventual laughs and jabs from everyone who heard it.

When we arrived in the ER we were quickly brought into a room with a team waiting. I had to tell and retell the story of what happened to no less than five different doctors. They all wanted to hear it straight from me because something must have been lost in translation. Healthy people don’t just die for a few minutes and come back unaware that anything had transpired. I talked with the ER doc, a cardiologist, the ICU doctor and his resident, and the patient’s family doctor who just arrived with Steve’s wife the doctor. I printed out EKG trend strips and re-enacted it over and over. They all were hunting for an obvious flaw in the assessment, but I had been diligent with this one and left no stones unturned.

Steve seemed to be doing fine in the hospital bed. A little anxious and confused about all the hub-bub but overall doing well considering a few minutes ago he was dead for all intents and purposes. I was another story. All this insanity on the tail end of a busy night had my nerves shot. I had already run a freeway accident, a “hot stroke”, and a near arrest patient on a ventilator. I was feeling the sting in my limbs and chest that you get when you go through repeated adrenalin cycles without rest in between. It feels as if your bones were replaced with metal. That’s the only way I can explain it. I was happy that Steve was alive, but still completely confused about what had just transpired. I was curious from a clinical standpoint but I was also personally invested being that this happened to a patient in my care. Was there something I could have seen or noticed to arouse my index of suspicion? More importantly, how do I make sure this doesn’t happen again?

I debriefed with my partner and retold the story about ten more times to curious hospital staff and fellow EMS workers we ran into. We were done for the day and ready for some much earned rack time. On the way back to the barn Meagan and I laughed, cranked the stereo, and talked about who was going to beat whom to bed first. We were shot. Later that day I couldn’t sleep so I called a senior medic friend who related to me a similar story. It sometimes feels good to hear a common story. He also reiterated the mantras from medic school regarding that this is exactly why we take every call seriously and perform due diligence on every patient. If I had not been careful with this patient and gathered all my information first and eggressed from the residence without the proper precautions this could have been a very different call. What if he coded and stayed dead and I had no line or no baseline vital signs? What if I had talked him into staying at home?

I know this call will change the way I look at patients, if only for a while. The hum-drum day-to-day grind will eventually again deviate my sense of normalcy, but in the meantime, I need to find that balance between paranoia and being slack. Living life in the minutiae.

Copyright 2010 Jon Kuppinger

Turkey and Pumpkin Pie

It was an unseasonably warm late afternoon for the time of year. Being just past Thanksgiving, you would expect the air to have more of a nip to it. Instead the still air had a comfortably warm heaviness to it, like an old comforter. Though it was only four o’clock, the shadows were stretched long across the Starbuck’s parking lot the way they do in early December. Perry and I were not complaining. We were having a nice slow shift that almost felt like a day off. Almost. The conversation turned to how it had been a long time since either of us had a “real call” meaning the kind of “stat” stuff you see on TV or the movies.

“Man, over the summer I was the grim reaper, but the past month has been nothing but bogus calls.” I joked.

“I know bro, you have a reputation for that. Everyone has a ‘Kup story’ about a crazy call they ran with you this year.”

The way the call deck gets shuffled is beyond approach. I stopped trying to figure it out a long time ago. Some nights you will get murdered. Critical call after critical call in a steady stream like a chain-smoker lighting one off the last. Then for the next two weeks you wont have anything above a sprained ankle or headache. There is no rhyme or reason to it. I’ve tried tracking the day, time of day, the lunar cycles, the times of year, you just can’t put a finger on it. The only thing you can count on in Oakland is that the dragon will eventually find you. It lurks and waits in the belly of the city until your guard is down and strikes with extreme prejudice.

“You know, I could go for a code.” I said, meaning working up someone who has just died. I didn’t mean at all that I wanted someone to die, just that if someone’s time was up, (and in a big city, somewhere, somehow, somebody’s number is up right now, it’s just statistics) I wanted to be there to help and to sharpen my skills as they were getting soft in this current slump.

“Dude, I totally feel you. I haven’t had a code in months.” Perry replied.

This form of small talk has a lot more behind it than seems on the surface. A couple of things are going on here. First off, we were trying to gauge our respective critical call volume as compared to the other guy’s. We always futilely try and make sense of it all, if not just for sport. Secondly, you are trying to see if your partner is “due”. This is silly superstition. Nobody is ever due, just like a blackjack table is never “hot”, but often enough it seems like it, so you still ask the questions. When you are due, you know it and walk around with the specter of death just a few steps behind you. You know it’s coming, just not when and are relieved when it comes.

The third part of this silly little verbal dance, and this is important, is we need to talk about what we do. We need to hear about each other’s calls and relay our information to them about what happened, how we responded, and lessons learned. This is part learning and part therapy. To recount a crazy and stressful situation is to revisit it using the front seat of the ambulance as a psychiatrist’s couch. When this is done to sympathetic ear that really understands the job, you get to chip away at a little piece of the burden we carry around in memories and bad dreams. That is the therapeutic component. The learning side is also important given that most patients do not fit into the neat little boxes in our protocol book or in our training session in school. You may go your whole career and only get one opportunity to see one odd presentation or unusual set of circumstances. If your partner has already hit the jackpot, you want to know about it and store it away in that little dark corner of the mind that paramedics hide all these heinous stories for retrieval later. Then when you get your chance to shine, you access that dark place and dig it out. Turn a negative into a positive.

This unseasonably warm evening in that Starbuck’s parking lot my door was opened and my feet were propped up in a position that shouldn’t have been comfortable, but somehow was. I was in deep relaxation. Shooting the breeze with one of my buddies and sipping on an iced coffee. It had been over an hour since there had been any traffic at all on the radio. It was quiet out there, but the dragon was lurking.

“Can you believe we get paid to do this?” I asked Perry.

“For real” Perry is kind of a hippie/surfer type from Santa Cruz and has the lingo and longish locks of black hair to prove it. Well, long for the public service sector anyway. His boyish looks cause many to mistake him for a student, which is the source of much razzing. All in good fun.

“So tell me about what would be your worst call right now if we got one.” I asked with my eyes lazily closed behind my sunglasses, basking in the sun like a lizard on a rock. I love to chew the fat about the job.

“I hate the kid calls” he said.

“Not me, for me it’s breathing calls. I can’t stand the anxiety and panic the patient goes through when they can’t breath. It’s as if some of their anxiety gets transferred to me”. I wasn’t kidding, I hate those calls, but I am learning to embrace them since they are a bread and butter call for us.

“I feel ya bro.”

Just then a call came in for a familiar SNF. A SNF is short for a Skilled Nursing Facility or as we call them SNIFFs. Perry was very familiar with this particular SNF and had run several calls recently on the same guy who says he is “short of breath” but really isn’t. To make matters worse, this guy weighs in at a portly three hundred plus pounds and doesn’t really help you out much so you have to carry his dead weight. Ahhh people.

As we pulled up Perry was telling me about the guy we were about to run on and I was mentally preparing how I was going to deal with it. The whole day had been a day at the beach and neither of us were going to break that vibe. We sauntered up the front door and were let in by a very anxious Filipino nurse. She was like a rabbit running around, talking too fast for us to understand and pointing us down the hall. She was standing next to an oversized and gaudily decorated Christmas Tree with various presents under. Empty cardboard boxes with festive wrap and bows on them, no doubt. It’s always weird running calls in the presence of all these icons of happy days and good spirits. That spell was broken by the familiar stench of the SNF, which is a combination of urine, feces, vomit, and rotting decubitus ulcers. How people work an eight-hour shift in these places I will never understand.

“She down there. She can’t breath. She have asthma.” The Nervous-Nelly nurse shot-gunned at us in a constant loop until we responded. Already our gears were turning. Asthma was an easy one. We deal with it all the time and can often times fix it in the field. She was awfully high-strung for an asthma call.

As we walked down the corridor decorated with cheap dollar-store Santa cut-outs, gold and red garland, and generic greetings for a joyous season, we could see some of the fire departments medical gear boxes and bags sticking out of the doorway of a room down the hall. Perry looked at me with a puzzled look.

“Dude, that’s not his room” he stated with just a hint of surprise. I just shrugged. A call is a call, I could certainly go another day without meeting our frequent caller. Besides, this was an asthma call. Easy as pie.

I was at the front of the gurney and was the first to pop my head in the room.

“Crap Perry, they’re intubating her!”

I snapped the cool breeze vibe we had been riding. It was too good to be true anyway. The reality was that firefighter was not actually intubating her, he was looking down her throat with the laryngoscope. The patient was a fifty year-old grey haired lady lying face up on the tile floor. She was pale, unconscious and struggling to breathe. The captain was busy writing down the patient’s medications and trying to get some information out of another nervous nurse The engineer was preparing an IV bag of saline.

We left the gurney in the hall and quickly entered the room, it was time to get our heads in the game.

“What do you need?” asked Perry. It was his call after all. Since we trade off every other call, I was functioning as the EMT on this dual medic bus, an assistant of sorts.

“Get me a line, she’s really tight. Not moving any air at all. I’m trying to see if I can see any blockages.” the firefighter responded. He quickly turned to setting up the BVM with an albuterol nebulizer in-line. He was going to try and force some albuterol into her lungs, maybe it would free her up a little.

Perry went straight to the patient’s head. I stayed at the feet. It was obvious the engineer was not going to get an IV. He had already tried three times with no success. I went straight for the bone drill. This patient was going to be critical, possibly a code blue. I didn’t want to waste any more time with IV needles.

“So what’s the deal?” Perry asked in an even, laid back tone. What does it take to fire this guy up? I was happy he was here.

“She’s sat-ing really low” reported the firefighter referring to her oxygen saturation in her blood. “and when I try and bag her, I don’t hear any lung sounds. It’s really weird” the firefighter was understating the gravity of the situation, which we sometimes do to cut the tension. Without oxygenation to the lungs this patient had minutes or even seconds to live depending on how long she had been down.

I had the ears near me so I put them on and listened as he tried to bag her. He was right, you couldn’t hear any of the air movement you were accustomed to hearing and I found this creepy, like nails on a chalkboard. Was she tight from her asthma or was it something more sinister? The patient was struggling to breath. Her inter-costal muscles around her ribs and collarbone were contracting around the bones outlining her rib cage. Her heaving abdomen was jerking and working overtime to try and draw in even a squeak of air. She was getting tired. She would give up soon. For now she was compensating and maintaining a pulse and cardiac rhythm, so at least we had that for the time being. We just needed a bit of time to figure this out. Just a few more seconds.

“Hang on lady, we’ll get you fixed up” I thought to myself.

Meanwhile, I got back on task and drilled her leg for IV access. It went in easily and smoothly. I could overhear Perry and the firefighter talking at the head.

“Let me take a look” he said grabbing the laryngoscope. “Hmmmmm, pass me the Magill’s” he was referring to the Magill’s forceps. An unusual set of forceps that have an angle to them that allows them to be placed deeply down a patient’s throat.

Perry retracted the forceps quickly and they were empty. Like when you play that game with the big glass enclosure and the claw that tries to pick up stuffed animals; the one nobody ever wins.

“Dammit, I almost had it”. Now we were all intrigued. We were still performing our tasks, but looking up to Perry to see what “it” was that he almost had. This was getting interesting.

“Perry, you’ve gotta hustle bro, she is brady-ing down” I said with more than a little stress in my voice.

The patient was brady-ing down, which means that her heart rate was slowly decreasing at a steady pace. It was at thirty and on it’s way down. She would be dead in moments. Her oxygenation level was also dropping and now had hit the lowest the meter will read, <50%. She was turning that color they turn just before they die. Not good.

“She’s going to code, get ready for CPR!” It was time to rally the troops. This call was about to change radically for the worse.

“I just need a sec….hold on……there!” he said and with one smooth move pulled “it” out.

We were all stunned.

“It” was an unbelievably large piece of turkey the size of a cell phone. Nobody in the room could believe it. It was coated in an orangey-brown substance that instantly grossed everyone out. Well, almost everyone. You could smell the aroma of the puree on the chunk of meat and it was decidedly pumpkin pie. They say that smell is the most potent memory recall device of all the senses. This was a festive smell that one associates with the best times of the year and childhood memories of Grandma’s house not this horrible situation we were in. Why were these two now juxtaposed images being thrust together? Better yet, why was I getting hungry in the face of this crazy call?

I broke my little mental trip to see Perry at the head holding up the piece of turkey. He was pretty damned happy with himself and experiencing a bit of disbelief in the face of this surreal situation. How did this giant piece of meat end up in this woman’s trachea? Nobody would ever eat a piece that big. What exactly was going on here?

Anyway, it was time to get back to business. As soon as that piece of turkey cleared her windpipe, the wonders of homeostasis took effect. She took a big deep breath, and then about fifty more. Her heart rate jumped back up over one hundred and her oxygen saturation crept up by twos until it was over 90%. Was this really happening? Was my little surfer buddy truly saving a life just like they do on ER?

Back to reality, there was still much work to be done. Now that she was breathing she would need a secure airway and to be transported urgently code 3 to the nearest hospital. She was not out of the woods yet. Her air had been cut off for quite a few minutes and that means her brain was not being oxygenated. Brain damage to some level was certainly possible and recovery was not guaranteed. The firefighter rode with us to support Perry and I drove as fast as possible.

Once we had turned over the patient at the hospital we popped outside and started talking about the call. We all had to metabolize what had just happened. Perry was beaming.

“Dude, that was a career call!” He kept saying over and over. “Some guys go their whole career and don’t get to do that!”

Perry was right, it was a career call and one to be proud of. One that will certainly go into heavy rotation on the story wheel when we sit around and talk about our craziest calls. I couldn’t help but start to get a little private eye on this one. There were a few odd circumstances.

For one, why was the patient fed such a large piece of meat? In reading over the patient’s file at the hospital she needed to be fed. Secondly, why were the nurses trying to sell us on asthma? Someone had to have been feeding her at the time it happened. It’s not like she swallowed a six-ounce piece of meat and coughed it up and aspirated it again. I made sure that my concerns were heard at the ER. This is always a sticky situation when you suspect a fellow health-care worker of foul play or more likely incompetence. The way I usually handle it is to present the facts in an order that allows people to see the inference without making it for them. If they feel it is worth pursuing, they will. The ER is really good about that.

So Perry and I did what most people do after a big call. We went delayed and ate a big old dinner. Food always helps. Sharing a meal with someone else is a great way to de-stress and get your energy level back to normal. Sharing it with a hero I call partner is even better.

Copyright 2010 Jon Kuppinger