Little Bodies

I sit on the floor of my living room. I make a circle with my legs and my dog finds his way there. He curls up and seems contented to be surrounded by "the boy." My hands find their way from his head to his hips and I feel his story along the way.

He is young, strong and fit. I can tell this from the shape of him. He is not a big dog, however. One of my hands covers his whole head. He's a burly boy but compact. If I reach, I can place my hands all the way around his chest. My thumbs meet in the middle.

Dogs are not people but, right away, I'm taken back.

My fingers meet between the shoulder blades and my thumbs are on the top of the sternum.

No person should be this small.

I squeeze and shove with my thumbs (We call this "chest compressions")

No person should be this small.

I am simultaneously squeezing and carrying this child.



We push air in. We move the blood around. We do it all perfectly.

We know.

It is still exquisitely painful....for everyone.

Nobody should be this small.



"Big truck...big truck...there you are"

(This one is for my friends, Elvis and Koehler......)

I'm rolling down the road.

I'm not driving a 16,000 lb ambulance. I'm driving my "compact" station wagon. I'm on my way home from work, not on my way to a call.

Big truck, big truck, there you are...

I see you. I rely on you. You move the way a professional (like me) should. You see ahead by 1/2 a mile and move your lane to make your exit.

I see that.

I drop back to let you in.

I know. I'm just a "four-wheeler." I'm part of the problem.

Last week, it was a "four-wheeler" who put herself between you and safety. You put on your brakes and grabbed that wheel like it was the end of the world.

You were in the berm. Soft grass and a gentle shoulder saved you. (along with your seatbelt).

The "four wheeler" had no idea of the chaos she caused with her thoughtlessness. I'm sure she/he was on the phone/checking email/texting. It doesn't matter. The end result is the same.

You, who's income is affected by your safety record, are in a ditch. You did that to save someone's life.

The driver of the "four wheeler?" She (he) had no idea. He did not even hang up the phone.

I check you out. YOU know you're ok. But I do my job (Heart rate, Blood Pressure, Breathing effort and a good sense of "what's wrong"). Your beloved rig is on its side next to the highway and there are things broken beyond what you and I can fix.

Yeah, You're OK. Shaken, angry and ready for a loooooooonnnngggg vacation but, to me, you're OK.

48 hours later, I'm driving my little station wagon home from work....

"...Big Truck, big truck...there you are...."

Yes, you can come into my lane.

Yes, I'll slow down to let you pass.

Yes, I'm not a "big truck" driver, but, somehow...I understand.

My car has four wheels but I'll never want to be a "four-wheeler."

"big truck....big truck....there you are...."




We get ANOTHER call for trouble breathing. This one is to an apartment complex that caters to people who are just barely this side of needing "assisted living."

We've gone there so much that we have a key to the front door on the ambulance as our standard equipment.

We arrive to the 3rd floor apartment to find a woman who is 84 years old, up on her feet, agitated and talking like this:


Get it?

I ask her about previous medical history (Heart disease, lung disease, diabetes, hypertension,etc.) and get a "no" at every single one.

She is house proud and wants to jump up out of her seat to open every door, move every piece of furniture, show us every thing every time we move. Over and over again, I ask her to, "Ma'am, PLEASE! Sit down and be still!!" after I've given her 15 liters per minute of oxygen.

Finally, while I'm struggling to fit our large cot into her tiny apartment, She jumps out of her seat! I have to use my 'Cop Voice',

"SIDDOWN! DO NOT MOVE STAY RIGHT THERE!!!" (I'm doing my best to scowl) "You! (I actually point at her) stay right there and let me do my work, OK??"

This earns me a meek nod from my patient as she hungrily sucks on the oxygen mask as if it were water and she was 5 days in the desert.

On the cot, out the door (keys, alarm, etc) into the elevator and into the back of the ambulance. Go, go, go!

I can't really figure out how an 84-year-old woman with NO previous medical history is having this problem just out of the blue at 3:00 am on a Saturday morning.

Until someone knocks on the door of my ambulance.

Now, you must understand that I get this all the time. Curious (Nosy) neighbors who are concerned for the welfare of their friends (Morbidly curious about who's dying before them) are always ready to ask me all kinds of impertinent questions.

I'm ready for this when I find my patient's daughter with a leather-bound book that contains all her mother's medications, medical history and allergies. It turns out our 84-year-old patient has had atrial fibrillation for the past 10 years, Hypertension (high blood pressure) and a whole bunch of other problems for just as long.

"Did you take all your pills today?" I later ask "Mom".

"Pills???" She replies.

Right! Ok! She gets the full work-up. Nowhere in the history I got from the daughter do I read anything about dementia or Alzheimer's disease but I'm trained to presume the worst.

Her Blood pressure is 200/104 (WOW!) and her 12-lead shows the early signs of an inferior MI (this means that the bottom part of the heart is sick and not getting enough blood/oxygen, etc and is not doing its job).

She's NOT complaining of any chest pain but the vague inferior MI signs lead a cautious medic to go above and beyond. We perform a 15-lead (for those of you who have been to a Bob Page seminar, it's V4R, V5-V8 and V6-V9) you all know that a right-sided MI (a sickness or oxygen/blood starvation of the RIGHT side of the heart) is a bad, bad thing. Even more so because we are not regularly taught to diagnose and treat this kind of sickness as a regular part of our training.

(Simply put, the right side of the heart takes blood from the body and pumps it to the lungs so it can dump all the Carbon Dioxide it acquired from the rest of you and trade it off for Oxygen the rest of you needs to keep doing whatever it is that you do!)

The 15-lead shows a very slight deficit (infarct) there. Cardiologists look for at least 2mm of S to T wave segment elevation to tell them that the patient is really sick. I only see 1mm of S-T elevation but she's not hurting yet.

*In my head to myself: "do we have to wait until it's a FULL-ON heart attack before we decide to transport/treat them for a heart attack??*

We give her oxygen, aspirin and not much else as she's not complaining of any pain. Her trouble breathing is still there but she can now talk to us 5-8 words at a time between breaths. When I listen to her lungs, I can hear nothing but good, clean air moving back and forth. If I heard the sound of crackling cellphane or the crinkling of fine paper, that would tell me that her lungs are filling up with fluid, most likely due to congestive heart failure.

I was somewhat disappointed to hear clean/clear lung sounds. A case of pulmonary edema with congestive heart failure is one of those things we can treat really quickly and effectively if we catch it in time. However, things are never this easy!

We decide to go to a cardiac center (clearly, it's a cardiac event!) and we call 'em up by radio.

I've been spoiled. I'm used to talking to Emergency Medicine doctors. They value the opinions and judgement of Paramedics. They know when we speak of a patient who is "combative," for example, we actually mean, "She's drunk, bashed-up, possibly brain-injured but DEFINITELY beating me up and I'm ALL BY MYSELF in the back of this ambulance for the next 10-20 minutes so, PLEASE, give me permission to sedate them to a state of mutual happiness right NOW!

This time, I spoke to a cardiologist.

No fault on them. None at all. However, I think this cardiologist has become too accustomed to working in a hospital or Emergency Department where she has an unlimited number of ER techs, Phlebotomitst, Respiratory Techs, Nurses, Radiologists, Interns and other help at a moment's notice.

In the back of the box? It's me, the scared paramedic intern and the confident, capable EMT-B. And, THAT'S IT!!!

"Give your patient 0.4 to 1.2 milligrams of nitroglycerine (NTG) and monitor vitals" says the cardiologist.

I know. I know that if my patient is truly having a failure of the right side of her heart, she's deader than a doornail not 20 seconds after I give her this medication.

"Roger, [Cardiac Center], I understand your orders per [Doctor So-and-so] for 0.4 to 1.2mg of NTG, however, I must impress upon you that this Medic believes the patient may be suffering an inferior/right sided Myocardial Infarction and NTG may be detrimental to the patient outcome." is what I say over the (recorded) radio.

"understood, Medic XXX. Please administer 0.4 to 1.2mg of NTG, Sub-lingual and report any changes."

"Roger, [Cardiac Center]. 0.4 to 1.2mg NTG as per [Doctor So-and-So], please confirm spelling of doctor's name. "

"Medic XXX, [Doctor So-and-so (spelled out)] authorizes 0.4mg of NTG. Please consult and advise if any changes or if you need orders for further administration."

OK! Now the Cardiologist has had time to refer to her (his?) drug reference and brush up on the concepts of 'Pre-load' and 'After-load'. I think I covered my butt by pinning this on the doctor in question ("Pls confirm spelling...."). I have to say, with a blood pressure of 200/104, I'm not as cautious about giving her a medication that will open all her small arterioles and allow her blood pressure to drop a lot.

I'm also not so cavalier that I don't start two intravenous lines (ways to inject a blood-like fluid or medications into her bloodstream) with 1000ml bags of fluid (one of the most important things we need to revive someone) connected to each one.

We give her ONE dose of Nitroglycerine (0.4mg)

Her blood pressure DROPS!! from 200/104 to 128/60.

OH MY!!!

However, she's still awake and talking to us. All this time I have my hand around her wrist. I'm feeling the pulse of blood through her wrist. At first it was "bounding" or hitting back against my fingers pretty hard.

Unlike my compatriot, I'm not so freaked out by her drop in blood pressure. I can still feel her pulse in her wrist. My thinking is, if her heart is strong enough to push blood all the way out to her wrist, it's strong enough to push blood to her brain, into her lungs and to back-flow into the arteries of her heart. Yeah, we dropped her pressure HUGE but she's still going.

In the ER, the Cardiologist asks me if we gave her ANOTHER nitroglycerine dose.

"Hell, No!" I reply

"Why not?" She asks me with a cross look on her face.

I put my hand on her arm, "Doc, have you ever worked alone?"

She looks puzzled. This is a foreign concept to her.

Alive: Improved.




The call goes out as "Trouble Breathing"

CC-Rider and I are together again. Our driver, SmokeyJoe, is a recent Paramedic who's still getting his ride time in. He left the USMC and started paramedic school when he was 32. (Sound familiar?)

CC-Rider says to the both of us, "This is your call! I'm driving!" She clearly has much faith in us.

The "trouble breathing" is a woman sitting on the floor in the open front door of her house when we arrive. Her face, lips and neck are about twice the size they should be and she speaks to us in a pattern like this:

"I...GASP...ate...GASP...a...GASP...pistachio...GASP..." (you get the picture).

"Ma'am, are you allergic to anything?"


I look at SmokeyJoe over the top of my glasses and see his eyebrows do their best to meet his hairline.

Ooooookay! it's GO TIME!

I don't need my stethoscope to tell me that she's closing up. From a foot away I can hear a noise like "HeeeeEEEEEEP!" every time she breathes in. My stethoscope does tell me that she's not moving any air in her lungs other than the very center of her chest. Basically, this means that her allergic reaction is causing the muscles around her bronchioles (the smaller pipes that lead from your windpipe, or bronchia, to the business parts of your lungs) have all squeezed down really hard and are blocking any air from getting to the parts of her lungs that will enable her to get oxygen into her body and carbon dioxide out.

This is what we call, "bad."

Her husband hovers nervously in the foyer. SmokeyJoe and I waste no time. We practically fling her onto our cot, dash the 10 yards to the medic unit and load her up. CC-Rider is already there and bobs her eyebrows at me, asking what to do.

"Epi, IM." I tell her, indicating her to inject 0.3mg of epinephrine into my patient's arm muscle. This is a pretty cool drug. The paramedics in the UK accurately call this drug adrenaline. That's what it is. It's the thing that makes your lungs open up, heart race, blood vessels constrict and dries up any secretions in your mucous membranes. (Pseudo-ephedrine, or sinus medications is a form of this). The dose we give people having allergic reactions (anaphylaxis) is, for the human body, HUGE!

It works quickly and very well, however, it just buys us time. It'll probably wear off before she's done having an allergic reaction. SmokeyJoe tries and fails to get an IV line on twice. I tell him to start a neb of albuterol. This is a drug that acts directly on the aforementioned bronchioles and cause them to open up. We deliver it by nebulizing it so the patient breathes it directly into the lungs (quickest way to get it where it's needed).

Meanwhile, I drop the IV perfectly into the patient's left arm. This is significant in that it's my first successful IV in over a year (not a lot of chances to start one when you're a teacher) and I was nervous that I had "lost" my skills. CC-Rider jumps in the driver's seat and we roll. Our patient is breathing easily and has the hyper, nervous laugh that comes with getting jacked up with more adrenaline than your body can make in an hour.

She's not the only one breathing easier. SmokeyJoe and I are already confident in the fact we had a "save."

What I mean is, had we not arrived (or arrived late) this one would have closed up and suffocated. She'd be dead at age 33 and her husband would be a lost and confused man, having watched his young wife die before his eyes.

We turn her over to the friendly staff at the local hospital and in the part of my paperwork that says, "Condition of Patient Upon Arrival at Destination:" I gladly choose "Alive:Improved."

Life? It's good.


Epiloge: I saw her a few hours later when we brought another patient at the same hospital. The sight of her happy (normally sized) face made up for the "died-despite-all-we-did-and-we-did-it-right" condition of my current patient.


Second Guessing.

I'm in a unique place.

One of my students is also a member at my volunteer firehouse (where I am the EMS Sergeant). She has another four months until she becomes my student (begins field clinicals) but she's still "one of mine."

She came to me with a rather prescient question today. She had been the primary provider on an accident. She was riding the ambulance and the fire engine (with our station officer on board) had been dispatched on the call too.

It was an auto accident with very minimal car damage. There was a "star" on the windshield but not in the typical place for head impact. Relevant too, was the fact that the driver (my student's patient) was seatbelted. No airbags installed on his car.

He was also "altered." This means the person driving the car was in an altered mental status, or was so out of it that he did not remember the question that was asked of him 2 minutes before.

My student said, "Off to the trauma center you go!!!" In fact, as she arrived on scene, she asked for the status of the local trauma center.

The officer, however (someone who is primarily involved in fire suppression), said, "No, you should go to XXX hospital" (the closest but NOT a Trauma center).

60 hours later, she catches me in the Chief's office and asks me if she made the right decision.

Now, understand that these "questions" are never asked. They are always prefaced by a story. She's telling me the story and when she gets to the part about "star on the windshield + altered mental status" I interrupt and say, "Trauma Center!"

She counters with, "What if it's a seizure or EToH?"

I respond with, "Look, If its a seizure, EToH or a stroke, the local trauma center can handle that. If it's an altered mental status due to a stroke or an epidural bleed, for example, then the local "community" hospital is going to transfer them to the trauma or the stroke center (both in the same place) and that will delay care.

I tell her, "I would have made the same decision. Fire donkeys and cranky nurses be damned."

She sighs her relief.

I asked her if that's where her patient went. (To the Trauma Center) Yes, but she feels bad about "second guessing" the officer on the call.

I ask her, "Who's in charge of patient care?"

Her shoulders drop and I can visibly see the stress fall away...."Me!"

"Then it's your call and you made the right one."

"Thanks, Sarge!" A flip of a wave and a spring in her step and she's gone.

She's ready for the next one.



Please don't eat before you die!!!

Well, yes, I told you "More to Come" and here it is!

We get called to a townhouse for one having trouble breathing. Dispatch has done a great job of getting information and we know that, even though she's 42 years old, she's already had a heart attack, suffered from congestive heart failure (CHF), and has an extensive history with a LOT of drugs.

In the door & up one flight of carpeted stairs.

This place smells horrible.

There are a lot of concerned people standing around who, I assume, are family.

Another flight of stairs. (Why is this so common!???)

Into the bedroom where she's lived for the past couple years (we can tell that walking in).

She's on a big recliner. She's got all the signs of a lifetime of being unkind to her heart. I see all this and I see her chin on her chest (not natural). Right away, I can see that "trouble breathing" is now "NO breathing!"

ZIP! I slide in and check a pulse while moving her head up to open her airway.

"I got nuthin!"

This galvanizes the other two medics I'm working with. Mind you, this is my second shift with them. The last one was exciting as well.

It's game time!

CC-Rider and I quickly move our patient from the recliner to the floor. MedicToMyRight (who, strangely enough, is again to my right) dives in to help. We also have some well-meaning, enthusiastic volunteer firefighters too.

The room is suddenly crowded.

As my patient's head is wedged between the recliner and the wall, I can't immediately get a quick assessment of her airway other than getting a basic airway (OPA, or OroPharengyalAirway) in her mouth.

I roll it in and she doesn't gag. This means that the airway is "tolerated." This also means that the patient is in a bad way. The control of the gag reflex comes off the brain directly and if there is no gag reflex, that can be pretty bad.

At this point, Volunteer Firefigthers are "bagging" (pushing oxygen via a special bag) into this woman. There's a lot of gurgling. We're having a tough time getting air into her lungs versus her stomach. (Can't breath through your stomach so, that's bad.)

I check again for a pulse and find none. I start chest compressions. All my paramedic training and the most important thing I can do for this woman (Really!!!) is something I learned about 12 years ago (CPR!).

Now, let me take a moment to tell you about OPAs. They are merely a piece of plastic curved in a way to keep your tongue from falling back in your throat. The more modern ones are very much like a curve plastic stick that does the job while allowing air to move around it. The older ones, however, are more like curved TUBES that, essentially do the same thing but are a pipe going into the back of the throat.

Neither one, however, does a dang thing to keep air from going into the stomach, versus the lungs. (two pipes down there, remember!)

The OPA that I grabbed from the bag was the old style. As I started to slam down on her chest with all my might, the pressure of the air in her stomach, combined with the full meal she just ate contrived to make a geyser.

Each time I pumped on her chest, we got a bit of vomit shooting 12 to 18 inches up in the air.

The Vomit Comet rides again!!!!

It's at this point that CC-Rider and MedicToMyRight look at me. They shake their heads. Last shift we had a code and this is looking to be the same way.

Down 2 flights of narrow stairs, through the living room and into the medic unit we go.

We intubate, hook her up to a monitor and give her a TON of ACLS drugs.

All the while we're being driven by a volunteer firefighter who's wearing a full stetson hat, a torn t-shirt and his bunker pants.

He hits every bump and curve at 65MPH.

We all get puked on as we bounce around the back of the ambulance like ping-pong balls in a tornado.

...and he gets lost on his way to the hospital.

Basically, he exemplifies every un-professional characteristic of our volunteer service (keep in mind that I'm a volunteer and riding as one during this call).

What a donkey!!!!

After the call, as we're cleaning up, I pull him aside.

"Hey, man, Howareya?"


"Great..thanks..listen,...can I ask you a favor????"


"Yeah,....great...Listen, Um...Don't ever drive a medic unit agin..Ok?"

He's gettign defensive at this point...."What?"

We've walked away, out of earshot of everyone else, by this point. I put both hands on his shoulders.

I look him right in the eye.

With the most firm and benevolent, fatherly look I can put on my face. I say:

"It would be bad."

I keep looking at him.

He's thinking this is some kind of man-fight and gives me a defiant look.

I keep looking at him.


I keep looking at him.

His shoulders hunch and I can feel him getting tense. He tries again to be tough...

I keep looking at him.

"F*** you!"

I keep looking at him.

"F*** it, I hate the ambulance!" He says with a flame in his eye.





38 year old male. Bleeding from the head after an assault. We arrive about 2 minutes after the engine crew does. We were all called here by the police. They've got the scene safe enough for me to enter the house.

I find a guy sitting on the couch, holding a bloody towel to his head. He looks right at me as I come in the door and answers all my questions appropriately.

He's got a 3-5 inch gash on the side of his head.

"Sir, what happened?" I like open-ended questions sometimes, I can get a lot more information that way.

"I come in 'da house. 'Dat ***** went upside my head wiv a smoova!"

Now, being from where I'm from, I know what "upside the head" means. I can see it in my mind's eye. Someone took a big wide swing and hit him in the temporal area (above the ear between the forehead and the back of the skull).

But what the heck is a "smoova?" So I ask him.

"A 'Smoova'?"

"Yeah! A Smoova!"

I look to the firefighters standing around me. They look as puzzled as I do.

"Sir? What's a 'Smoova'?"

"A Smoova!! Y'know! For you clothes!" he makes an arm gesture like he's ironing a shirt.

A "smoother." An iron.

Ok! OW! That must have hurt!

I love my work!



Pacemaker + Fail = Pump and Blow, Load and Go!

The call is for "trouble breathing" but by the time we get there, it's something else. A community swimming pool and it's a guy in his late 60s. He started having trouble catching his breath in the pool.

The BLS (Basic Life Support) crew is strapping him to their cot. I have the luxury of doing nothing but looking at him (many hands).

"Um...I don't see breathing." I feel like the kid who said the emperor has no clothes. My words galvanize a group of people into action.

BVM, Cot to the medic unit, IV, EKG. Go go go go.

Nope, he's not breathing and his pulse is fading fast. I'm on his chest so I look to my right and say to the medic I just met 3 hours before, "You've got airway and breathing. Get me a good tube. you're second line for ACLS drugs. Got it?"

I'm the new guy but she nods at me as if I was there every day for 20 years.

I look to my left where CC-Rider, my new pal and best friend, has already pulled out the combi-pads (sticky things that allow us to shock someone's heart) and EKG leads (more sticky things that allow us to analyze what the heart is doing).

"IV and meds, Please."

That earns me a wink and a nod.

I dial up the EKG and see that this guy is in a ventricular escape rhythm (the lower 2/3 of his heart is trying to beat) but it's way too fast (about 70/minute). CC-Rider and I realize that we can't put the combi-pads in the usual place because he's got a big, metal square under his skin just inside his left shoulder.

Can you say "Pacemaker?"

I can...and i did.

OOOKay. Well. pacemaker or not we treat this patient. I see no pacemaker "spikes" on the monitor.

Can you say, "Pacemaker FAIL?"

I can and do.

MedicToMyRight drops a perfect tube and we get a capnography wave that is good but the CO2 level does not get above 17 mm of Hg and is dropping (this tells us how much air is getting through the lungs into the blood by measuring the return Carbon Dioxide). I'm looking for a nice wave and a level above 28.

That's when I see pink foam surging up the airway tube on every exhale.

Pulmonary edema.

Deep suction takes out a LOT of the "juice" and we get a capnography reading of 30. Lovely!

I'm doing chest compressions by this point because there is no pulse that any of us can feel anywhere.

IV is in.

Pump and blow

Epinepherine, 1mg. BAM!

Pump and blow.

Check the monitor:

Asystole. (flatline) No heart activity.

I'm not giving up!

Pump and blow.

Capnography says 15mm of Hg and dropping.

Crap! Suction again!! It climbs to 25. Good enough!

Atropine: 1mg

Pump and blow.

Epinepherine: 1mg

Pump and blow

EKG is a flat line with occasional, weak attempts by the heart to do something.

Diesel Thereapy!! (Drive fast!)

Perhaps a bit too fast. The firefighter who jumped in the driver's seat of our Medic unit made a traffic decision that lead us onto a Hella-bumpy road.

Only my experience in the Coast Guard on small boats in high seas keeps me upright. CC-Rider and MedicToMyRight are both on their butts on the floor.

We arrive at the hospital a bit frazzled but with a completely worked patient. I'm standing on the carriage of the cot so I can continue chest compressions without having to walk. All the while, I'm directing the 3rd round of ACLS drugs and getting the BLS provider to work with MedicToMyRight to check that we haven't lost the tube and we're still suctioning the HUGE amount of fluid infiltrating this guy's lungs.

Like usual, we seamlessly merge with the resuscitation team and I find myself moving to airway with bagging and then drawing up more drugs.

By the time I have a chance to step back and wash my hands. It's over.

The doctor declares this one dead. Ah, fooey.

Not that we didn't see that one coming. This guy had a pacemaker that kept his heart beating well. He also was doing all he could to keep that working right. According to the staff at the fitness center, he was a regular. Swam a mile every day.

Unfortunately, his pacemaker failed. It failed while he was in the middle of his swim. As a result, his heart was not able to crank out enough pressure to his body and then the pressure in the blood going to his lungs began to rise. It got to the point where the pressure of the blood going to his lungs started to push the water in his blood into the breathing space of his lungs.

Pulmonary edema.

Acute congestive heart failure.

CC-Rider, MedicToMyRight and I were cleaning up and getting ready to talk about the call. In my head, I'm thinking about what went well, what went wrong and what I could have done better.

We all agree that by the time we got to the patient, there was not much more we could do. His heart had stopped working properly and he had stopped breathing. We did what we were trained to do and, we did it exeedingly well. We all worked together as if we were the same person.

As this was the first time I worked with CC-Rider and MedicToMyRight (the first call, in fact), I asked how I did.

"Maddog, You're in charge!"

"That was awesome. You knew exactly what to do and you told us when to do it."

"You 'da man!"

Golly! *cue maddog blushing*

But wait! We did this again and again!!!

...more to come...




I got "pinged" by a reader. She's a regular and she hadn't seen me post in a while. So she sent me an email asking how I was doing.

Somehow, coming from a stranger, that meant a lot to me.

I've been busy with family death and my own non-blogging obligations. Yet, there's more than that.

You see, I'm a fundamentally broken man. I feel that I don't fit into where I am. There are parts of me that don't fit into how the rest of the world lives. I'm working really hard to make myself fit but I see the reminders of how I don't and it's a powerful thing. I'm reminded all the time of what an outsider I am.

I try and I try but, really, I'm not like anyone around me. We all live as if we will never die, or, if we do, it'll be a thing we're all ready for. We will all die. Many of us will do so unexpectedly.

That sucks. Big Time.

I'm aware of that all the time.

(Here's the really scary part:)

I know my father will die. I'll likely be there

I know my mother will die, I hope I will be there.

I know Herself will surely die and I will surely be there.

EVERYONE will die (even me!!!).

But many of us live comfortably because the frailty of life is not in our face. We assume that so-and-so will be there tomorrow. We operate under the assumption that we will all have friends and family around us tomorrow as we did today.

Am I the only one who feels in his guts that this is SO not true?

I'm scared all the time.

Am I allowed to be scared?



What would YOU do???

We, who do what we do, live with the persistent knowledge of what we have done.

It's so very easy for those who have not done what we have done to dissect our actions.

"Yeah, maddog, but I would have done THIS. "

All I know is that I came on scene and there were people, and blood, and gunk, and a big mess.

I put tubes where they should go. I pushed on the things that needed pushing and I gave the drugs that needed giving.

The whole time I'm sweating how well or how poorly I'm doing. It's not about me, It's about my patient.

You can sit back in your "armchair" all you want but, it was ME that was doing CPR, Intubating, pushing the drugs and otherwise making the decisions that helped the family know we had done all we could.

You will never be the medic that I was at that exact moment.

Me? I'll spend the rest of my life thinking about what I could have done. I don't need you to ask me stupid questions.


EDIT: This post was written in response to the casual comments by a less-than-professional jerk after a particularly difficult call. It is NOT directed at you, my dear and loyal readers! Thanks for reading.


Cocktail Parties

An earnest young student asks me a serious question:

"What's the hardest part about being a paramedic?"

I look her right in the eye.

"Cocktail parties."

I say this with all seriousness.

She leans back in her chair, blinking her disbelief.

It's the social that's the most difficult.

Here I am, out with a bunch of people who have no idea what they'd do if someone died right in front of them.

I, on the other hand, know exacttly what I'd do!!!.......Pump and blow, Load and go!!!

(If the preceding phrase has no meaning for you, then you're definitely not an EMT. )

We, who do what I do, live with the persistent knowledge of how easily and how frequently people die.

We also live with the constant assurance of our role in that process. We know what we are to do and when we are to do it.

I find that I alternate between the responsibility of being guardian of all life around me and the honor of being the shepherd of the passing of life around me.

At times, it makes me dizzy.

At cocktail parties, it's awkward.



How to make a nurse laugh....

Roll into the ER at 0500?


Have a perfectly healthy, whiny patient with abdominal pains?


Tape a "falling hazard" warning sign to your shirt and stagger around the ER saying "Coffeeeee.....""




Sometimes, we win.

I did an amazing thing, apparently.

Duty Night. Chillin' in the lounge chairs, watching a movie I've seen before and don't mind seeing again. Earlier that day, I had played in a kickball game with some other folks from the Firehouse. Good times. No beer for me as I was heading directly to the Firehouse afterwards.

Roswell pops his head into the lounge, "Hey, maddog, can I see you?" He tilts his head in a way that tells me he need to talk to me RIGHT NOW.

"Sure!" Off I go. He leads me back to one of the dorm rooms where his girlfriend, JLB, who's also a firefighter/EMT, is lying on the bed. They've been drinking steadily for the previous 7 hours (they started at the kickball game). She's lying on her side, breathing at a rate of 60 breaths per minute.

OoooooooKay! Pulse is 92, BP is 130/82 and her blood is 99% saturated with oxygen (SpO2=99). These are all good. Oh, yeah. She also smells boozy to the max!!! The thing is, I can't rouse her at all. I do exceedingly painful things to her but she doesn't respond. That is bad. However, considering her blood pressure and pulse are reasonably OK, I'm willing to adopt a "wait and see" attitude and see how long it takes her to sleep off her drunk. Roswell and I roll her onto her left side and make sure she's got a clear "vomit path" in case she barfs. We're trying to ensure she doesn't breathe in, or aspirate, anything she pukes up.

I'm standing next to the bed, discussing with Roswell what we should do. We were just deciding to check on her ever hour when her noisy breathing stops.

We look at each other.

We look at her.

We look at each other again.

This is the first time I've ever seen Roswell scared. Strangely enough, and totally out of context, I realize that, despite the ups and downs of their relationship over the past 2 years, Roswell really loves JLB!!

I roll JLB on her back. I move her head back to ensure her airway is open.

She's still not breathing.

I check her pulses on her neck (carotid) and her arm (radial). What had earlier been a steady "THUMPTHUMPTHUMP" is now a, "THumpthumpth...tu..th.......th......t...t....p....p................"

Everything is now bad.

"Hey, Roswell?" I say in my calmest voice, "I think we need to start a medic unit, OK?"

In a flash, he's gone.

I try again to get JLB's airway open and, again, try to rouse her with painful stimulus.

Still no breathing.

Check the pulse again. I can barely feel it. It's beginning to dawn on me that I may have to do CPR on a woman who I consider a family member. I guess I better get her off the bed and onto the floor!

I cradle her like a child and move her to the floor. She's as limp as a rag doll (or the newly dead). By this time RockSteady has shown up. He was a Paramedic back in "Joisey" before he came down here to be a financial planner. He runs at the Firehouse because, deep down inside, he misses it.

"What do you need?" he asks me. As calm as could be.

"AED, O2, BVM, a medic unit and wake everyone up." I reply in a tone that I hope sounds as calm as RockSteady.

Brooklyn shows up with the "Go" bag and the O2 Kit. This kid has learned much from the maddog. I drop a 22fr Nasopharengeal airway in JLB. Her jaw's pretty tightly clenched so I know I'm not getting anything in her mouth. At least I can help a bit with a flexible tube down her nose to help get oxygen into her lungs. I get out the Bag-Valve-Mask (BVM). This is a device that allows me to put a mask over your nose and mouth and squeeze air, via a specially built bag, into your lungs. I'm trying to breathe for JLB. By this time, Brooklyn has left to go get the stretcher. I check JLB's pulse again.


I check it AGAIN!

No, Really, I mean NOTHING!

"Crapcrapcrapcrapcrapcrap!" I'm saying to myself.

Weed has slid into the room at this time. She's still half asleep. I've never worked a bad patient with her but she and I work together as one.

"I got nothing" She says to me. She's feeling for a pulse too.

"Right!" I say. Weed hands me the scissors and In about 1 second, I've got JLB's shirt and bra cut off. Weed takes over the ventilations.

At this point, part of my mind is remembering how many times JLB and I have joked about getting "Trauma Naked" by cutting someone's clothes off. We say that this is a real possibility when someone dates a paramedic. Now, here she is, "trauma naked."

I start shoving on her chest with all my weight. I'm forcibly and mechanically taking over for her heart. I'm slamming it flat to force the blood in it to go out to her body and lungs and then springing up suddenly to allow it to fill up with blood to, again, be forced out to her body by the next compression of my body weight on her chest. It's not elegant but it IS effective.

I do about 2 rounds of 30 compressions when the AED arrives with Brooklyn, Ninja and RockSteady. We slap the pads on her and stop CPR long enough to have the machine tell me that no shock is advised. I go right back to CPR.

Here's the freaky bit:

I finish my 3rd or 4th cycle of chest compressions when JLB's eyes snap open and she takes a deep, ragged breath.


Did I just do that?

"Hey, darlin'! Glad you've decided to come back and join us!" I say in a voice I hope sounds lighthearted and calm. Her eyes orient towards me and she makes eye contact. Well! This is Very Good!!!

She fades in and out. Her respiratory rate never gets above about 6-8 per minute so, I keep assisting her ventilations with the BVM and a full dose of Oxygen.

Brooklyn, Ninja, Weed, RockSteady and I get JLB moved out on a Reeves stretcher. This is a nice tool for getting people out of tight spots without jerking them around too much. As we load her onto the stretcher/cot in the engine bay, we hear the Medic unit pulling up out front.

Smooth and easy we move her into the medic unit. Weed and I stay in the back to help out and Ninja jumps in the driver's seat. Off we go. The medics hook JLB up to the EKG, check her Carbon Dioxide output (Capnography), her blood pressure and other vitals as well as starting an IV in her left arm (after an attempt in her right arm and her external jugular vein with no success). All the while, JLB is alternating between lucid periods where she's looking at me and asking where Roswell is and complete unconsciousness with a respiratory rate of around 4-6 breaths per minute.

The two medics, Weed and I work together like we were cogs made for the same machine. Medic #1 calls the hospital on her cellpone and gives them a good, solid report so they know exactly what's coming in the door when we arrive. It pays off too. We roll right into a critical care resuscitation room and are swamped by nurses, techs and doctors.

As soon as we arrive at the hospital, we're swarmed by other firefighters, JLB's family and a few cops too. It's a circus. I hand off ventilations to a tech and clear out of there. I wash my hands and find a spot out of the way to wait and see what happens.

20 minutes and 2 liters of intravenous fluid later, JLB is answering questions and completely alert. 1 Hour later, all of the people involved are having a CISM debrief in a conference room in the hospital. 2 hours later, JLB is going through a battery of tests, EKG, 12 lead, Blood work, etc., etc.. I'm back at the station, filling out my reports and restocking my gear.

They keep JLB at the hospital for a while to do a full workup. By the time she slides into CAT scan, I'm dead to the world asleep.

I did everything as I should and made no mistakes. Clinically, I'm pleased and satisfied. 14 hours later, telling the story to someone who's not a firefighter, I can't stop myself from crying. No sobbing of loss of control. I simply cannot stop the tears from flowing out of my eyes.

She woke up. Her eyes opened and she looked right at me. I'm beating on her little body hoping to push enough blood around to keep her brain from dying and she opens her eyes and looks AT ME.

Somehow, this is the part the overwhelms me.



Indy 500.

Yes, I was there.

Every year, my brothers and I go somewhere awesome with our father for Father's day. Though it was a bit early, we went to the Indy 500 this year.

This pretty much sums it up:




Nothin' Doin'

It's a fill-in night at the firehouse. I've asked Helga to cover for me in the past and I'm paying her back now.

There's this kid. Her mom and my Mom went to Nursing school together. Her older sister is a doctor and she's thinking the same thing.

In the interim, she's decided that being an EMT-B is a good idea as a start on her road to her MD. An application, background check and a physical exam (Ironic?) later, she's a member.

Now, she's my problem.

The only time we roll the ambulance tonight is to go get ice cream at 11:00 at night.

Exciting times, no?

She fits in so well that I feel she's been here all along. This is one of those cases where someone is well suited to be here contrary to all assumptions.

I don't have a blog-name for her yet. She plays it too close to the vest for that at this point. For now, we shall call her, "Sis." She is more like a sister to me than anyone I've ever known at the firehouse. She's beautiful, confident and capable.

I have great hopes for her.

Tonight, she joked with us, commented on bad movies with us, made a senior member blush and was first on the engine when it got toned out for a fire. I watch this person for 4 hours and realize that nothing will stop her and she will do well in all she puts her mind to.

That's some powerful stuff.

'Go, Sis, GO!'



Sunny Day

It's the first beautiful day of Spring. temperatures creeping into the 80s. Lovely.

Around 11 am, he puts his favorite lawn chair in a sunny spot, grabs a cup of coffee and has a seat in the sun. He's 93 years old.

It's a beautiful day.

Nine and a half hours later, we find him. Still sitting in the char, still holding his (now empty) coffee cup. From a distance, it looks like he just rested his chin on his chest and went to sleep. Up close, I see the signs.

For him, I think this beautiful day never ended.

For us on the engine and ambulance crews, we smile quietly and look inward. Passing is sad but, somehow, this one seems to fit.

Not a bad way to go.



There are smells...

I am driving south on a major highway. An interstate, in fact.

There are smells leaking in to the confines of the vehicle I drive. They are smells like any other.

It all comes down to context.

There is a smell I call "vaporized rubber." Its the smell of locked wheels sliding across tar pavement. Some of that black tire material becomes a vapor and gets into my nose. I have smelled the remnants of this as I pull up and survey the scene of someone's bad decisions

"Diesel urgency" is a smell that exists in many areas. Chemically, it's the smell of insufficiently burned diesel fuel. This can happen when a diesel engine is accelerating excessively (Go faster! She's fading fast!)or when one is desperately trying do decelerate(Oh Crap! Oh Crap! Oh Crap! *BANG*). It is also the smell equated with spilt diesel fuel hitting a hot surface (Get 'em out now!!).

This, too, is a smell I equate with highway calamity.

I, however, am not driving an ambulance tonight. I'm merely driving home from work. These smells leach into my nose and brain via the ventilation system of my car.

Around me, the day to day catastrophe of an interstate occurs. I am just another commuter.

The smells remind me.



Testing, testing, 1, 2, 3...

Yes, I have an iPhone. I'm testing to see how well blogger works with it. So far, I'm having a bit of difficulty getting blogger and Safari to play nice. The only way I can enter text is via the HTML only window.




Death and I...

I'm dead asleep and it's the address coming over the dispatch radio that wakes me before the bell rings. Somehow I'm attuned to the addresses and street names in my home town. 

"One not breathing" is an ominous call for early in the morning. 

During our run to the scene, dispatch updates us that CPR is in progress. I've got 2 trainees, Babygirl and Fireplug. They wear stern faces and follow my instructions with immediacy and exactitude. Babygirl is about to go into the military and Fireplug has been active duty army for about 12 years. 

We roll into the house to see the daughter doing chest compressions on her father in a hospital bed in the living room. Grizzly is my partner on this one and, in his 30 years at the firehouse, he's seen enough of this. We work without speaking. No pulse, no breathing, nothing. 

We grab the top and bottom of the sheet and move the patient to the floor. Stiff. 

"Cot and backboard, into the house." I say. Without looking, I know that Babygirl and Fireplug are on it. 

Grizzly gets the monitor ready as I try to secure the airway. I can't even open the jaw to get a oral airway in. The chest is crunched in from the CPR and the stomach is distended. We slap the pads on his chest as the Medic unit arrives. 

"When did you last see your dad?" I ask the daughter. 

"Last night, when I gave him his morphine."

We logroll her dad and see the dark purple blotches of pooled blood on his back. This is called "dependent lividity." He also moves like a board. I can't unbend his arm to look for a vein, nor can I move his head at all. Rigor Mortis. The Stiffness of Death. 

The two other medics bustle in the front door, just ahead of the cot and backboard. I give the lead medic "the eyebrow" and say, 

"Lividity and rigor."

The medic hands me the leads for the EKG and plugs my pads into his monitor. We see a flat line (asystole) on all leads. 

Dad is cold. 

"He's dead, isn't he?" says the daughter. She works for the recreation department and is CPR certified. She's been all business since we walked in the door but this is the first time I've heard a quaver in her voice. 

"I'll call it." says the medic. 

"I'll talk to her." I tell him. 

"You sure?" he asks. He's looking me in the eye. I look him back. 

"Yeah, She's a neighbor." He nods and pats my shoulder and calls in for the police and coroner. 

She's already on the phone with her sister in California. 

"He's dead, isn't he?" She's got her hand over the phone receiver. 

"Yes he is. He seems to have been for a while." I look right at her. I will not shy away from this. Her eyes now start to fill up. 

"Here, tell my sister, will you?" She hands me the phone and sobs. 

"Hello? This is "maddog", I'm with the Fire department."

"Is my father dead?" says a scared voice from 2800 miles away. 

"Yes he is. He died last night, it seems. I'm sorry." This is the point where it hits me. I was expecting this but it always hits hard. My face is getting hot and I feel the welling of tears in my eyes. "Your father is dead."

"Thank you so much for being there. Thank you so much for what you do" She says. That's the hammer-blow. My cheeks are now wet. "May I speak to my sister now?"

"Sure." I croak as I hand the phone back. The daughter sees my tears as she takes the phone. I will not shy away from this. This is what I do.  She mourns with her sister on the phone. 

As we put away our gear and my eyes dry up I see the leering face of the full moon as it dips behind the trees to the West. It looks like the skull of death to me this night. I can imagine it nodding at me as if I've done my job and been in the place I'm meant to be for this one life. 

This is what I do. 


I can't FEEL anything!!!

I'm now a Sergeant at my volunteer Firehouse and, this particular duty night, I'm in charge. 

1900, Assign housework, apparatus checks and get dinner ordered. We eat, run some training and then get ready for a long night. 

You see, the moon is full and the night is one of the warmer ones as spring starts to seep its way into our area. I'm ready for stabbings, shootings, fights, drunken silliness and more. 

First call: car vs. car at an intersection. I have the most cooperative and mellow patient in the world. She's in the driver's seat and got t-boned (side impact) she's got no complaints other than a painful hand and head. The arriving crew before us has already put a collar on her and we arrive in time to extricate her. 

Both cars are sitting where they stopped and I have to crawl over the hood of one car to get into the passenger door of the one my patient is in. The plan is to pull her out, feet first, from the driver's side door onto a long backboard. My job is to guide her head and shoulders down into the passenger seat and to keep her head in line with the rest of her spine. It's not as elegant as it would seem. Cars these days are built in a way that they seem to wrap around a person and make it difficult to just turn them 90 degrees and lay them down. I have to negotiate the parking brake, gearshift, armrest/console and the bucket seats. All the while we're bouncing this girl around a bit. She's not complaining, wincing, or crying at all. 

This is not normal. 

We get her onto the backboard, into the ambulance and YoungJim and I work her up. Rapid trauma assessment reveals no obvious injuries or pain other than her left hand. Ok. I ask her if she hurts anywhere other than her hand (NO) and if she feels different or funny. 

"I can't feel anything." She says calmly. 

UH OH! I'm thinking she can't FEEL anything!!! Quickly, I check that she has motor, sensory and a pulse in each of her legs and hands. I pinch the top of each foot, "Wiggle the toes of this foot."

"Ow! Ok." she says. 

Same with the other foot and both hands. Good. Apparently she meant that she didn't feel ANYTHING as in she wasn't hurting anywhere. YoungJim and I take the tension down a few notches and calm down. 

Grandma's going to ride with us. 

"Do you mind if I take your grandma for a drive?" I ask the patient. 

"Please do." She replies. "She needs to get out more." I install Grandma in the front passenger seat and drive easy and smooth to the hospital.