Silent Siren, page 8
The senior paramedics that supervised us, Ken and his partner, often “buffed” calls. They listened in on calls being dispatched to another unit or even another service, and then attempted to beat them to the scene, steal the patient, and speed off to the hospital. A favorite was “pin jobs” or motor vehicle collisions in which someone was pinned inside a mangled wreckage and needed extrication. We responded with either FDNY’s ladder truck or with the NYPD emergency services squad, both of which carried “The Jaws of Life.”
Gear Geeks
The EMTs could be distinguished from the paramedics from the amount of gear they had on their belts. An EMT was expected to carry on his belt everything he could possibly need for an emergency. Multiple pairs of trauma scissors, hemostats, glove pouches, clanking oxygen keys, tourniquets, and flashlights festooned the belt-line of every EMT I met. I suppose it was good that many were overweight; they needed the extra room to accommodate enough gadgets to make a police officer jealous.
Once an employee made the transition to paramedic, or “near-Godlike status” as one supervisor put it, he dropped nearly everything from his belt, save a glove pouch and trauma shears, maybe a knife. The EMTs then were charged with the responsibility of carrying the paramedics’ gear. The “gear factor” is also the way we could tell the “newbies” from the “old-timers” on the west coast. The gadget geeks were almost always inexperienced, with only a year or two under their substantial belts. EMS supply companies cater to the newly initiated, hawking gear that proves to be not very useful in the majority of emergencies, such as hemostats, seizure bite blocks, and bandage scissors. The amount of gear an EMS’er carried seemed inversely proportional to his experience level. The same can be said for patches. Three first aid patches on the same shoulder does not equal one paramedic patch.
Ethel gets an Airway
We are called to a Jewish retirement home in our district for a report of a ninety-four-year-old woman with seizure activity. It’s a long response and I’m not sure if we have backup. Since I am unfamiliar with the system, I am not sure if I am to expect FDNY, Jamaica’s BLS unit, Hatzolah, or some other basic service to be on scene before us, providing care. Approximately thirty different agencies provided 911 services to downtown New York City. Depending on where the response was, we would either get an FDNY engine company to assist us, one of our own basic life support units, a private ambulance service or, in some cases, nobody at all. The FDNY fireman were tough and capable of assisting us with heavy lifting on scenes, though they the companies I worked with seemed to have little regard for emergency medical services.
As we arrive in the parking lot of the complex, Ken remarks, “Where is Hatzolah?”
The volunteer ambulance, Hatzolah, seemed to keep close tabs on all Jewish emergencies and would usually arrive with us or shortly behind us in such cases, sometimes transporting their Jewish brethren to the hospital.
We grab our kits and ascend the creaking stairs to the woman’s apartment. As is the case with every old person’s apartment, the temperature is sweltering and sauna-like, especially unpleasant after we had packed gear up several flights of stairs in a complex with no elevator. I had to wonder how anyone could find that kind of heat comfortable. How many lonely old people found dead in their apartments had actually died of heat stroke?
Ethel Rosenberg slumps in her beige recliner unconscious, mouse-colored wig askew, muscles twitching rhythmically in the throes of a grand mal seizure. Her apartment smells musty and is lit by a single yellowing light bulb. Her nursing aide stands near her recliner. The patient has a history of a stroke, Parkinson’s disease, and diabetes, we are told.
We place the patient on an oxygen mask and check her blood sugar. It is always best to test the most easily fixable hypothesis before moving on to those more dire. If her blood sugar is low, it would be an easy fix. We may even be able to leave her at home.
The blood sugar is not the problem. It is only slightly elevated—160—and we continue our assessment. Her blood pressure is normal also, though her pulse rate is 130—expected after a seizure. As we examine her pupils, I notice that her gaze is deviated to the right side.
I suspect the woman has suffered a stroke, which has led to the new onset of seizures. In very serious strokes, the eyes will at times be deviated to the side of the brain experiencing the effects of a clot or hemorrhage. For example, if someone is suffering a right-hemispheric stroke, her eyes may be turned to the right, and she will have weakness on the left side.
We start an IV and administer Valium to stop the seizure, the only prudent choice in this context. I push 5 milligrams of Valium and wait for Ethel’s seizure to subside. After a few seconds, the woman’s seizure ebbs, her face twitches a few times, and then smoothes out.
We load her into the ambulance and start for Jamaica Hospital. The woman has still not awoken from her post-seizure state. As we pull away, a twitch begins in the corner of her mouth and quickly spreads to the rest of her body. She will need more Valium, and I give her an additional 5 milligrams.
As the Valium hits her central nervous system, her seizure activity subsides, but so does her ability to breathe. I grab the bag-valve mask off the shelf and squeeze air into her fragile lungs, attempting to maintain a seal while 51-Victor careens through the poorly maintained city streets.
The woman doesn’t recover her respiratory effort after a couple minutes of bagging. We need to place a tube in her airway and breathe for her. In the irreverent parlance of our profession, she suffers from “Acute Plastic Deficiency.” Jamaica’s antiquated protocols do not allow the use of paralytic drugs to facilitate intubation, so if the woman had a gag reflex, we would be unable to pass a tube. The medical program director under whose license the Jamaica Hospital paramedics worked did not trust them to have the skill and judgment necessary to electively paralyze a patient in order to pass a tube.
The laryngoscope in my left hand and a 7.5-millimeter tube in my right, I sweep her tongue to the left and attempt to visualize her vocal cords. Once I get through the soft tissue, I visualize the gleaming white cartilage of her epiglottis and vocal cords. I pass the tube through the right corner of the woman’s mouth and attempt to pass it through the cords. As I near the glottis, they slam shut like a trap door.
I pull my scope out. “Bag,” I tell Ken. She needs to be re-oxygenated before I make another attempt. Heat rises in my cheeks, partly from stress, but mostly from embarrassment. Missing the tube on the first try didn’t carry with it many style points.
After thirty seconds or so, I re-attempt and once again ram my tube up against unyielding vocal cords. I’m playing the paramedic version of miniature golf. Every time I putt, the clown mouth shuts. My pulse throbs in my temples. I refuse to give up.
My partner, another paramedic student, looks at me with a gleam in his eye. “One more attempt,” he says, “and the tube is mine.”
Finally, on the third try, I am able to time the opening and closing of the glottis to my advantage. I pass the tube and attach the bag-valve mask. The patient is now the responsibility of Jamaica Hospital’s emergency room physician. Ken beams as he presents his student and his hard-won tube. We stow our equipment and ready ourselves for the next call.
AMR Northwest
My first job as a newly certified paramedic was with AMR Northwest in Portland, Oregon. A branch of the huge medical transportation conglomerate American Medical Response, our operation served both Clackamas and Multnomah Counties. In a sense, it was like coming home again. I had worked for AMR beginning in 1995, so I knew the company, big and impersonal though it was. Portland also held happy memories for me of visiting my grandmother in her house on Pine Street, walking in Laurelhurst Park, and feeding the plethora of geese that gathered in the reedy pond. I loved the fresh air and the slower pace of the West Coast. It was good to be home.
I was initially assigned to a night shift out of Milwaukie, Oregon and stayed the entire six months I was employed there. I liked the peace and quiet of nights and the fact I didn’t have to do inter-facility transports and deal with the traffic the days crews endured.
Like many AMR divisions in the country, we adhered to the System Status Management model. We roved all night from post to post, depending on where we were needed. We didn’t see the inside of the stations much, but it helped alleviate boredom and helped me learn the area.
Many a night we’d cruise the suburbs of Clackamas County in our mobile emergency room, the smell of hospital coffee wafting from my Styrofoam coffee cup, the acrid odor of chewing tobacco emanating from my partner, Ron, who habitually snorted nasal decongestant every few hours.
If Thy Hand Offends Thee
On a slate-gray day in April, I respond to one of the most horrifying calls I can remember. Still early in my field training period, I’m riding with two experienced paramedics, one of whom serves as my FTO, or Field Training Officer. Todd had been a paramedic for at least twenty years. Bald, bespectacled, and mild-mannered, he puts me at ease in my new role as a medical practitioner. His partner, Matt, is rotund, friendly, and somewhat younger than me. He had been a paramedic for a year or so in the Portland system.
We’ve just settled in at one of our posts when a call comes in for a possible stroke—elderly male found on the floor. Todd has the AMR radio and Matt has the fire radio. Both of them chirp to life on different frequencies, alerting us to the emergency. Both the fire and the EMS dispatcher had to be acknowledged individually. In addition to the clanging radios, my alphanumeric pager tones and displays the call information on its screen. As if that isn’t enough symphonics for one call, a mobile data terminal in the ambulance squawks incessantly until we push a button to silence it. With four different methods of communication, it is nearly impossible to miss a call.
Upon arriving at a middle-class residential neighborhood, we are met by a neighbor who says she had seen, through a glass sliding door, a man lying on the floor, but that the door seemed to be locked and she was unable to gain access. Todd, Matt, and I grab our medical kit, airway bag, and heart monitor and head down the slight incline to the residence. The door slides open easily, but, upon entering, we see no trace of a patient.
What we do see is a large blood stain on the carpet just inside and blood sprayed on the walls and ceilings of the daylight basement. A glass of whiskey is overturned on the rug beside it and a half-empty container of prescription drugs lies nearby. The house is utterly silent and mostly dark. I can feel my pulse in my throat.
By all rights, at this point we should have backed out to a safe position and called for police. After all, we could have just walked into a crime scene. Against our better judgment, we hesitatingly make our way through the basement, shouting, “Sir! Paramedics!”
No answer comes. A light shines from a back room, in which carpentry equipment is illuminated.
Todd shouts, his voice rising an octave, “We’ve got a hand!” and I turn in the direction he points to see a disembodied hand lying on the floor beside a blood-spattered table saw.
Shit! The guy’s cut off his own hand and is nowhere to be found!
I follow a trail of blood droplets to a closed door in the corner of the main living room. The doorknob is smeared with what appears to be fresh blood. With trepidation (as well as foolishness) I open the door and squint up the dark and steep stairway to see a slumped form at the top of the stairs.
“He’s up here!” I shout, and charge up the stairs. As I approach the crumpled and still form, I yell back towards my partners, “I think he’s exsanguinated.”
The man is face down, though I can see that his hair is gray and sparse. He is clad in a blood-soaked bathrobe and lying with his left wrist in the air. His left hand is conspicuously missing. No blood flows from the wound and I suspect the man has already died of massive blood loss. I reach down to his neck to check for a pulse. The skin is cold and damp. He lets out a low groan. Still alive!
“He’s got a pulse!” I yell down to the two paramedics charging up the stairs, banging equipment along the walls as they go.
As luck would have it, the best access out of the house is through the upper story and several police officers begin to filter into the residence and help me to lift the limp and barely alive man onto the stretcher.
“Grab the hand and the meds!” I shout down to Todd. I think it’s safe to say this is the first and the last time I will ever utter these words.
Matt places the man’s amputated left hand into a red biohazard bag and places it between his legs for the trip to the hospital. His muscles remain flaccid as his blood-soaked robe is cut off him with trauma shears, a high-flow oxygen mask is placed on his gray, sallow face, and large bore IVs are jammed aggressively into the veins of both arms.
Someone has gotten more of the story from the neighbor. The man had struggled with alcoholism and, when drunk, would beat his wife. She had just left that morning for a safe house and our patient, in a fog of alcohol and drug-induced self-hate, had intentionally removed his left hand, presumably the one he used to beat his wife.
I don’t remember his name and I’m not even sure if he lived. I do remember a swarm of doctors and nurses surrounding him at the hospital, placing an endotracheal tube into his lungs and ordering O-negative blood from the blood bank. Likely, irreversible shock had already set in and his body had begun shutting down. Unable to maintain consciousness with the blood loss, he had begun to slip into a coma.
In a haze of alcohol and self-loathing, our elderly patient had taken literally the biblical verse from Mark 9:43: “If thy hand offend thee, cut it off.”
Skinny Dip
It is early spring in Sandy, Oregon, an outlying community in our district, and still too cold for a reasonable person to attempt creek swimming. However, this afternoon, a woman not overly burdened with brainpower decides to try, aided by a sense of adventure, liquid courage, and the camaraderie of a new friend.
My partner Ron and I are called to a deep ravine for a woman who had been in the water, now out, possibly intoxicated. It sounds simple enough, simply a matter of getting the woman out of her wet clothes, wrapping a blanket around her, and cranking the heat in the ambulance.
I forget, of course, that working with Ron means I get half his “Bad Call Karma” by proxy. For some months now, Ron has been considered a “Black Cloud.” Dreadful things happen when he’s on shift—ATV riders plunge to their deaths off steep, inaccessible cliffs, obese drunks are thrown through windshields of exploding cars, cardiac arrests occur in most inconvenient locations.
Ron maneuvers the ambulance down a gravel path off the main road. As the path narrows, he slows until he can drive no more without bashing the mirrors on trees. We park at a trailhead. Alder trees dripping with recent rain form a canopy that allows only small vehicles to travel further down the rutted dirt trail. We grab a few pieces of essential gear and clamber into the bed of a volunteer firefighter’s pickup, like some third-world rescue team.
We get to a place in the trail where even the small pickup cannot navigate. We grab our gear and begin to weave our way between trees and over moss-covered logs, through spiders’ webs and down a steep embankment towards the creek. We walk for about a mile, trundling our heavy kits. The muscles in my shoulders and arms are getting fatigued. Who’s leading this expedition? Does anyone know where we’re going?
Tromping out from behind a stand of firs, we spot our patient. Alone, half-in and half-out of the cold, rushing water, atop a bed of pebbles lies three hundred pounds of wet and naked female humanity. I reach down to her neck to check her carotid pulse. It’s present but slow and her skin is ice-cold. She doesn’t move as I gently shake her—an early spring skinny-dipping adventure gone terribly wrong.
Ron places the unconscious woman on an oxygen mask and I apply EKG patches to her chest. They aren’t sticking. Her breath comes slowly and shallowly but her blood vessels have constricted tightly to preserve warmth to her internal organs, so I am unable to obtain either a peripheral pulse or a blood pressure. The woman is so severely hypothermic that she has stopped shivering—a very bad sign. We haven’t brought any blankets with us down the embankment, so a couple of firefighters doff their jackets and place them on the woman’s ample body. I stop short of skin-to-skin contact. Sorry, not in my job description.
Now that we have gotten to her and initiated treatment, the problem remains of how to get her back out again. At three hundred pounds and deep into a ravine, this would be no easy task. Search and Rescue is notified at some point, but it would take them a long time to get assembled, make it to our location, and pack the woman out. We decide to call the Navy and have them send a rescue helicopter to lower a basket to us.
Meanwhile, Ron, being the good Boy Scout that he is, decides to make a campfire to warm the woman up. This proves to be an excellent idea, as we are given an ETA of an hour for the helicopter.
The sun begins to descend behind the trees and our only sources of light are a couple of dim flashlights and the glow of the campfire. On the positive side, however, our patient is now warmed enough to begin shivering. Although she is still unable to speak intelligibly, she mumbles in response to questions and is able to move her limbs.
Her new friend and former skinny-dipping partner, a skinny, chain-smoking, shady-looking character, saunters down from a thicket of trees, bearing beer. Oh, this is helpful. Buy some beer, then call 911.
The thudding rotors of the SH-60 Seahawk twin engine rescue helicopter cut through the night air and spotlights shine down on our makeshift field hospital. Getting the helicopter positioned safely above us will be a challenge for any pilot. As the chopper descends into the canyon, its powerful rotor wash whips the jackets off the woman’s chest and threatens to spread the campfire in our direction. Hastily, the sandy volunteer firefighters and I lift the woman’s heavy, limp body alongside the creek bed and away from the fire.
