Sunday, April 26, 2009

could you please stop breathing, please?

code 2 calls: no lights, no sirens, obeying all traffic laws. minor injury, minor illness, major drunkenness. not a big deal.

code 3 calls: lights, sirens, go through stops and reds and aging yellows. major injury, major illnesses, major drunkenness. probably not a big deal.

so one friday night around two a.m. or so, my partner and i were dispatched to a call for a code 2 police-requested evaluation for an assault. usually these are non-transports for someone who scuffled with another and now has a busted lip, a black eye, and a bruised ego. often these calls are a gift of an ice-pack, some sympathy, and having them sign a release so that they can go home and put a bag of frozen peas on their injury. this particular call was in a fairly rough area of the city, "the hood." we slowly drove to the call and saw about five police cars and some yellow tape... yellow police tape for the minor injury... weird.

it was my partner's turn to tech this call, so when i pulled up, he got out with nothing more than his patient care report. i saw him walk under the police tape and he took a look at the patient who was lying on the sidewalk about 25 feet from the ambulance. "dude... grab EVERYTHING," he yelled to me as I was walking toward them.

i gathered the jump bag, the monitor, the ecg, a backboard, and a collar. the patient was an asian male, about 25 years old, lying face-up on the sidewalk, with what looked to be about a quart of blood leaving his head. i called for more assistance. this job was bigger what the two of us could handle.

this patient, this victim... he was in a BAD way. he was lying face-up with his head cocked slightly right. his mouth was half open, his eyes... wide open. his forehead... man. his forehead had a hole in it above the left eye, and just to the right of that hole, and i'm not lying here, was brain matter about the size of a soggy crouton. if this wasn't bad enough, the guy was breathing. i couldn't believe this. brain matter outside of its house with signs of life is rare. and not only was he breathing, but he was making a good amount of noise with his groans. we were going to have to transport this guy who was gonna die at any moment. i wanted to just stand there for about twenty seconds or so and let that happen, but we really don't have that option.

the extra resources arrived on the scene and then everything got a little crazy. some people are pretty calm when shit goes down, and others simply are not. there was an engine emt who arrived... a short female about 30 years old or so who just started flipping out. my partner and i were being methodical. it's all an algorithm what we do out here, and it's best to follow that model calmly. you'll get more accomplished faster and more efficiently. but this emt didn't believe this philosophy, or perhaps never heard of it, and she began to flail around like like someone being startled on america's funniest home videos. "oh my god, we've got to get the fuck out of here! he's shot in the head!" yeah... no shit.

we loaded the patient in the ambulance and the engine paramedic, my partner, and this emt all went in the back. we told the emt that she didn't need to go, but she either didn't hear this or didn't care. it's hard to read a crazy person. i think she thought she could save this guy. because of this, i was able to get into the front seat and drive. i was pretty relieved as i really didn't want to deal with patient who i was sure was going to die on the way to the hospital.

and he did. about one minute into the transport i saw the emt starting chest compressions and my partner was attempting an intubation. the other paramedic was busy trying to get an iv, and it just looked frantic. i could hear them getting frustrated with eachother, "don't stop your compressions!," "did you get a tube yet? what's the problem!?," "CLEAR!" i felt lucky to be in the front.

we pulled up to the hospital and i opened the back door. all three of them were sweating, were irritated, and were doing their best to resuscitate someone who had no chance. as we were rolling the patient into the emergency room, we left a trail of blood that was leaking through the many layers of gauze that was on the back of the patient's head. this guy was shot through and through.

because this was my partner's call, he had to do all the charting for this patient, and because i drove, i had to do the clean-up. i definitely got the short end of stick on this round.

the back of the ambulance was the worst i have ever seen, and i've seen a lot of really bad ones. first of all, the equipment was all over the place, and they used a lot of it. the airway kit, suction, the ekg, a bag valve mask, gauze wrappers, it was like we crashed the ambulance and everything flew off the shelves. and not only were they all over the place, but they were bloody and some of the equipment was reusable. and speaking of blood, it was everywhere, on the floor, the bench seat, and worst of all, in the gurney tray. the gurney is loaded up into the ambulance in a metal cradle which is about seven feet long and a couple of feet wide which locks it so it doesn't roll around during transport. the tray has edging around it which is about an inch high. that gurney tray had a small lake of blood from the front to about two feet back, filling it about 1/2 inch high. i've never seen anything like it, and it was fucking gross. blood congeals extremely fast so this was like a crimson half-set jell-o.

like i said, the back of the ambulance was really bad, but the gurney itself was worse.

not only did we leave a trail of blood while we entered the hospital, but even as i rolled the empty gurney back outside to the ambulance, it was still leaving it's mark. i took the bloody sheet off, tossed it in the biohazard can, and then took off the pads so that i could hose them and the gurney down. the gurney was a wreck, from the bed to the wheels. i took a rag and began to wipe down all the obvious bits. i started at the head of the gurney which was the worst. i was wiping the blood off the head of the gurney and saw a small piece of flesh. as i wiped over it there was a scraping sound like fingernails on a chalkboard and it raised the hair on my forearms. the scraping came from a small skull fragment. i threw the rag into the biohazard can and shaking my head i wondered how i ever got into this profession.

i realized that feeling lucky for not having to tech this call was premature... the clean-up of this mess was far worse. on a regular call you can get an ambulance ready to go in about five to ten minutes, 20 if it's pretty messy. this took me a little over an hour to clean and a couple days to clear out of my head.

turns out this was some sort gang-related execution. someone took a pistol, put it right up to this guy's head, and blasted him. how he was breathing and making noise with a piece of brain matter on his forehead and falling skull fragments i'll never know... but i hope i never see that again. it's just too messy.

Monday, April 20, 2009


a lot of what i've written so far deals with the gritty aspects of this profession. guy kills himself, guy get's his arm ripped off, kitten eats a face. but there's a bit more to this work that probably isn't all that obvious to those curious about paramedicine. here are a few things...

one of the weirdest aspects of this job isn't seeing crazy shit or dealing with a lunatic partner. i think some of the most bizarre experiences i have is intimately viewing the various ways in which people live. i can go to one call in a beautiful 10 million dollar mansion with 100,000 dollar paintings with someone asking me to take off my boots before entering. everyone so polite, thankful, and gentle. everything so clean and in its place. and i have to speak to these people in their language so as to put them at the greatest ease and so to get my best diagnosis of the problem. i speak softly, i smile. i posit information this way. i take them to their favorite hospital and then i clear this call and immediately go to the most desperate part of the city inside of a residential hotel room literally full of shit and piss and creepy videos.

and that's what's weird. i have to immediately change gears from a clean and pure and nice environment. now i'm watching where i step and there's no amount of money you can pay me to take off these boots because i'm avoiding needles and human excrement. my language has to change, and my demeanor has to change, because i need this same information so as to get my best diagnosis of the problem. these residential hotels all have one thing in common: they're putrid... cigarette smoke and urine and unshowered 1/2 dead, drug-filled bodies. it's the mangy cat and the negelected litter box. it's the piles of newspapers from '87 and onwards. it's bizarre, it's real. but you have to adapt. adaptation with a good dose of common sense are the keys to doing this job well. the person living in the mansion and the person living in the hotel room... they're both people, but their lives are so different that you'd think they'd be living in two different continents speaking very different languages. thing is, they are literally 1.5 miles away from eachother, but they've never seen eachother. the neighborhoods are named differently, but you wouldn't know it by distance. the romantics would say that we are all the same, that we have so much in common just by being people, living the human experience. but i disagree. these two people are worlds apart.


i've heard that when you are in a romantic relationship you can test its longevity by taking a long road trip. if you can sit next to eachother for hours on end in this tiny car and still love eachother, well, then you've got a good thing. on the ambulance, you are on the longest road trip of your life.

you probably get a glimpse of working partnerships from tv shows glorifying police work. ponch and john... great partners. you spend ten hours a day, four days a week with one person. that's way more time than anyone spends with their family. and this person, you have to depend on them, sometimes with your life. and sometimes you fight. and sometimes you can't stop laughing. and the stories you tell while you're posting up waiting for a call... they can get deep. you learn things about this person you never wanted to know... and you never asked. and after a while, you get pretty damn close to this person. or, after a while, you may want to murder this person. but there's always compromise, there's always love, there's always dispute... you're in a full-blown relationship with your partner. you can get to be pretty tight.

in personal relationships what can bond people is going through tough times together and coming out okay, you can be bonded by commonalities, you can be bonded with your sense of humor, or perhaps you're bonded by knowing that when you need it, you can depend on this person. in ambulance work, this happens all the time every day... these bonding moments. when you are both on scene on some crazy bat-shit call where people are shot and the scene is out of control but you both manage to get things back in order, well, you did it together and maybe one of you did an impressive job and you admire that and, well, you bond. you're both interested in the same shit, you have the same career, you bond. you're waiting for a call, you're shooting the shit, you are both being particularily funny, and you bond. your partner may be the most important facet of the job. it can make the job great, and it can make you want to quit. many people have over this... a good friend of mine changed departments because of his asshole partner.


the last aspect of this job that might not be so apparrent to those outside of this work is that everyone seems to assume that this career must give you instant satisfaction because everyone must be so happy to see you, as you are there to help them. while this does happen from time to time, it is actually rare. the job itself is actually a bit thankless. and this isn't any sort of criticism on the manners or kindness of our patients, but the reality is that pretty much everytime we deal with someone, they are having a really bad day. it's not going to be in their nature to be incredibly miserable, and then be gracious about the help rendered. and i don't blame them. it's hard to imagine being shot in the arm and then saying, "hey, thanks guys, you really helped me out!" or someone with really bad asthma who had thoughts of dying for the last ten minutes... it's not going to run through their head that they should shake our hand and say, "hey, thanks for the albuterol, buddy!" so what you do is take the thankful people, the one's who probably weren't that bad off to begin with and blow up their appreciation and remember it for a day or two, because the next thank you might not be for another couple of weeks.

the job... it's pretty rad. but it's not packed full of gratification like you may think. you can get people swinging at you from drugs, alcohol, or low blood sugar, you can get people coughing in your face after you've told them to cover their mouth five times, you can be cleaning vomit out of your ambulance because someone didn't ask for a basin. i just figure that if i work hard, i'll get my own satisfaction out of that.

anyway, the next post will involve brain matter if this one bored you.

Tuesday, April 14, 2009

so gross

"what's the grossest thing you ever saw?"

i think that's every paramedic's most popular question. it does get annoying, but i've asked that same question before i got into this field. i get it. whenever people ask me that a rolodex of images start snapping through my head like a thumb on the corner of a book. i don't even know what the answer is to that.

back when i was an emt i had to transfer patients from one facility to another. they didn't need anything medically advanced, but they also couldn't go by personal vehicle as they may have had an iv hanging, or perhaps they had to lay flat... maybe they just needed monitoring. so i get a call to pick up a 10 year old boy, transfer him from one children's hospital to another. that's all the info i had.

i went up to to the pediatric floor at this hospital, grabbed the patient's paperwork from the nurse, and entered the room. inside was a 13 year-old boy lying in bed watching cartoons. he was laughing. he was happy. he was infantile. he was wearing a diaper.

i spoke to the mom, she only spoke spanish. my spanish is good enough for simple conversation so we started to small talk. she was young, positive. we transferred the patient onto the gurney and rolled him downstairs and into the ambulance. it was my partner's turn to tech this call, so i drove the 25 miles to the other hospital and had the mom sit up in the passenger seat next to me.

along the way we were chatting, me in my almost capable spanish. i asked her what happened to her son. she told me that on cinco de mayo her son and his friend went out roller blading. her son came back around 7pm telling his mom that he had fallen and struck his head on the street. she felt a large bump and gave her son some ice to put on his head. pretty much a good choice of treatment, i'd say. he felt tired and went to bed. during his sleep he started making some odd noises.

his mom went into his room to find him convulsing. she called 911 and the child was rushed to the hospital. while in the hospital the medical staff had found after a ct scan that the child had a bleed in his brain which stopped the flow of oxygen to critical areas, causing him to seize, and causing permanent brain damage.

the patient's mom's spirits were good. she was telling me how she felt that her son was going to get better and that this would all be in the past. i nodded, smiled, and wished her good luck. thing is, that patient was never going to be the same. one night he's out with his buddy, doing kid stuff, roller blading, falling, getting hurt. the next day, he's in diapers, cooing at cartoons, and acting like a two year old.

acting like a two year old for life is pretty gross.

going back to my emt days... we spent a lot of time in convalescent homes transferring patients from there to dialysis, or from the er to there. very basic life support, just a bus with a gurney on it taking patients to appointments or wherever else they needed to go.

these places, for the most part, are atrocious. there's often the smell of shit from dirty linens or diapers, the nurses are often cold with thick accents, and the patients are invariably depressed and hoping to die. it's an incredibly unhealthy place to spend any time in as you begin to fear your last days. every emt in this capacity always talks about how they're going to off themselves with a pistol before they spend any days in a place like this.

the food... it comes on plastic trays with plastic bowls and plastic cups. plastic plates, plastic food. and some of these people have soft food requirements so that their beef is now pureed beef, and their carrots are carrot mush surpise. and food could be the only pleasure that these people might have and these fucking places do nothing to insure that for them. that is, if you are fortunate to be able to eat with your mouth. many of these patients are tube fed with this sweet white viscous liquid. very satisfying, i'm sure.

family? no... family is somewhere else tending to their healthy children at their soccer games in another city. maybe they stop by on holidays, maybe they don't. who would know? it's sincerely the most depressing situation one could spend their last days in.

convalescent homes are pretty gross.

okay okay... now you want a gross story... one with blood and shit and piss and vomit. i'll give you the first three fluids.

i ride a motorcycle. a lot of people ask if i'm insane because i'm a paramedic and i must be crazy to ride one after seeing so many accidents. well, to answer that one, i've seen a lot of respiratory therapists smoke, so what's worse?

so i get a call for a motorcycle vs. auto in a tunnel that we have here in our city. i enter the tunnel and have to turn around to get to the westbound section to get to my patient. when we arrive on scene the leutenant from the engine comes up to me and says, "this guy's arm is torn off."

"do i need a biohazard bag?," i asked. he told me to take a look. i approached the patient... he was sitting against the wall of the tunnel, dazed look, sweaty. i looked at his right arm and it was completely ripped off at the shoulder, save for about five inches of skin at his back which was keeping it barely attached. there's really no protocol on how to deal with this so you just have to make do with what you have. i cut his shirt and leather jacket off and grabbed a few rolls of kerlix. i essentially wrapped this kerlix around his shoulder and arm, securing it to his torso, wrapping it around his entire upper body like a tight, white sleeping bag with reddish designs at the shoulder. he kept asking me if he was okay, and i said, "oh yeah, you're fine buddy." he said, "my hand really hurts."

"yeah, man, you did a little damage to your hand, but you'll be fine." his hand was perfectly okay.

after securing his arm to his torso, we loaded him up and went code three to the trauma center. this guy was getting really shocky... sweaty, nervous, cool and clammy, and his blood pressure was fairly low... he needed fluids. so my partner and i were looking for some veins, and there weren't any. i think that his body was beginning to shunt blood to keep as much as it could for his heart and brain. his extremities were a not a concern for his survival, and his veins were collapsing.

no iv access on his left arm, so i go to his feet and legs to see if i could find anything there. i pull off his boots, and as i'm fishing for a foot vein, the patient shits and pisses his pants. so if you can imagine, im basically right there, at his feet, and he takes a crap. it was such an awful smell. i was pretty sure that the guy wasn't all that health conscious.

so we arrive at the hospital, i tell the guy that he's going to be okay and not to worry. i never did follow up on this patient... i don't follow up on most of them. i assume that with today's technology that his arm was reattached just fine and that maybe he's back on a motorcycle.

having your arm ripped off is only kind of gross. having your arm ripped off and shitting your pants... now THAT'S gross.