November 2003 Archives

I find it somewhat embarassing but feel like, in the interest of full disclosure and to keep myself from feeling guilty about it happening I should "enter it into the record" so to speak.

I have said it here before, I generally do not sleep while I am at work, even when I am able to. I have gotten to that point where you are neither totally alseep nor totally awake but haven't really fallen asleep to the point of dreaming very often.

Last night I got sent on my one cover assignment around 0530 and parked in the parking lot of one of the churches. I was listening to Handel's Water Music, a nice classical peice that I enjoy quite a bit. I remember opening my book and the next thing I realize is that the preist is knocking on the window of the truck asking of I am OK. It was 0615.

I wasn't just drowsy, I wasn't just dozing, I was deeply asleep and dreaming. Not a good thing. Sheepishly I called the dispatch center on the radio and inquired as to the status of the other units and was told that they were still tied up. At least I didn't miss anything.

That was a weird experience. When I work Medic 6 and am allowed to sleep, I can't, yet this morning a drifted off much to easily. The only comfort I get from this episode (aside from 45 minutes of really good sleep) is that it happens to everyone at least once in a while. It just hadn't happened to me in well over 10 years.

It appears that the day shift medic was responsible for some of the chaos. There are no calls logged and no paperwork done. A sure sign of a busy day. We've just finished counting the narcotics and I am off for the first call of the night. Three calls in back to back. Nothing serious, but all stuff that needed attention of some kind.

The weather is cold already, in the mid thirties (F) and there are high clouds. Cold is bad news but clear skies are a good thing meaning that should I need to air evac anyone out I will at least be able to do that. Low cloud cover or ground fog keeps the helicopter on the ground and can leave me with some very long transport times even with critical trauma. Eventually I'm hoping that the helicopter program will come up with the funding to get their aircraft instrument rated so that they are not forced to ground or abort missions as often as they are now.

At the moment I am parked near the river and I'm startiung to see small sheets of ice forming at the edges. Winter is here and it's almost time for the Coast Guard to relocate one of their icebreakers to our part of the river. During the winter we can get very think ice which is a hazard to the barges that traverse the river daily delivering fuel oil and coal to various power plants and oil depots as far north as Hartford. I am fascinated by these vessels when they work and could watch them for hours. Last year I went down to the dock and met the crew and was very surprised that the entire crew was comprised of enlisted personnel, most of them around 20. The captain was an older, more senior petty officer who looked like he couldn't have been more than 28. Very interesting to know just how young the crew was. It was also a little odd because, even wihile on icebreaking duty, the ship sails with .50 cal machine guns mounted and manned or at least they were that day. The crew said that post 9-11 their entire operating guidelines had changed.

Medic 1 tonight with no student scheduled. If history is any guide things should be slow to moderate and I should have some time free after the usual chores. Of course many of you can see that I am only trying to rationalize the extra book I threw into my brief case and clearly the random nature of the work comes into play. I truly have no idea what tonight will bring except temperatures in the mid 30's and possibly some snow.

I got a reasonably good days sleep only waking up a couple of times but going back to sleep pretty quickly. I am concerned that I keep waking up, something I never used to do. But I am pretty well rested and ready for another night.

End of the month tonight so I will have a number of small chores to do at midnight. Change out the log book, check the packs for expired meds, milage from both of the trucks at the hospital, inventory of our supplies on hand. Nothing difficult, just time consuming and somewhat tedious...and part of the job.

It doesn't really matter what the night brings since I will have to deal with it no matter what. However, since it never hurts to ask; Hello G_d? If you're listening, please don't make me go to WalMart again tonight. I thought I was going to get trampled last night. Thanks.

I stayed home and have been working the entire time. Work at night, sleep during the day. At home, it's just me and the cat and he's not much company. The first day or two were actually quite nice. It was nice to enjoy the quiet house and sleep undisturbed. But now it'sgetting to be a little rough. I haven't seen my family in three days, it's been two days since I have had a chancee to have my normal contacts with my friends via ICQ and AIM, even making contact with the other paramedics who were working has been difficult because of the amount of activity that has been happening. Alone at home, alone at work has started to become rather unpleasant.

This kind of reminds me of the time I spent alone after my divorce. I hated that time, it was full of anxiety and loneliness. I know some people who thrive on being alone. I am not one of them. Clearly, I am not meant to spend this much time without the contact of family and friends. I need to get back into the patterns of contact that I had. They were comforting and downright enjoyable.

Go figure, me, the guy who likes working alone so much, not enjoying being THIS much alone. Heh.

It was indeed a quiet night. Only three responses all night both early in the shift. Patient load in the ED was light and acuity was minimal. I was able to catch up on some project work and actually sit down to do some reading. It's nice to have one of these nights every once in a while. Although, in all honesty, Friday night was great and I wouldn't mind a few more of those nights either.

Total calls for the night: 3
1 Cancelled upon arrival
1 ALS transport
1 Cover Assignment

Total Milage: 44

CD for the night: Water Music by Handel

It was one of those arrests where nothing really goes right for you and the student was obviously distressed. They were not able to get an IV, the student had been unable to intubate the patient, none of their treatment was having any effect and it was very clear that all efforts would be stopped soon after he was moved over to the hospital stretcher. Which was exactly what happened.

One of the difficult things when dealing with students is that they way they are trained that every action results in some kind of reaction, at least in the practical teaching scenario. In real life there are many ocassions where there are no results or results that you don't expect. One just needs to be ready for these things to happen.

The reality of our situation is that we successfully resuscitate very few cardiac arrest victims that don't go into arrest in front of us. It's a function of time, and when you are dealing with primarily volunteer EMS providers time is something that is often the deciding factor. The ideal goal is to have BLS on scene within 4 minutes with a defibrillator and a paramedic within 7. This is great in theory and we would love to make these goals.

In the real world, however, it may to 10 minutes for a crew to be assembled to even get the ambulance on the road. Paramedic response times can be as long as 25-30 minutes to some of the more remote parts of our service area. This is just a fact of life when you live in rural areas. It's a fine line that we have to tread when we try to balance the need for rapid response times against the need for economical operations and against the need to keep the EMS crews busy enough to keep their skills up but not so busy that they become burned out. There are many, many factors that feed into all of these and the system, such as it is, struggles to find the right balance.

I understand the frustration of the student but also recognize that this is something that he needs to learn to accept. It's a hard lesson but one that, once learned, will serve him well throughout his career. Some people will live and some people will die in spite of everything that we do.

It took me a good 20 minutes to restock after their call. Technically it was the day medics job to restock but it never made sense to me for the day medic, with all the paperwork hanging over her head to also have to take the time to clean and restock the equipment while the oncoming paramedic is left to essentially twiddle his thumbs. It is just as easy for me to restock since I need to check the equipment anyway at the beginning of the shift. So I check the equipment while restocking, that actually makes more sense to me.

Cold and windy tonight, when I went out I actually had to stop at Wal-Mart and buy a $9 set of gloves because mine were so old and so full of holes that they were not doing much to keep my hands warm. We'll see how the night goes.

I came home this morning pretty tired and fell into bed after throwing a load of laundry in so I'd have trousers for tonight and feeding the cat. I fell asleep quickly and slept very well all day, actually waking up a few minutes before my alarm was set to go off.

I am so happy that I had a student last night. I wish I could do that more often. It is probably the only thing that I miss from my time as a Paramedic Field Instructor with the large AMR division in one of the nearby cities. There I would have students or graduate paramedics precepting for medical control frequently.

It is, at least to me, and I know paramedics who feel differently, one of the benefits of being one of the "old goats" of EMS, the opportunity to pass along some of your knowledge and experience. Paramedics students are trained pretty well in the didactic portions learning much more of the skull work than I ever had to when I was trained. Where they are lacking is frequently the practical application of what they have learned and some of the more subtle skills such as scene management, interpersonal skills, how to quickly find your "rhythm" for a call, and frequently have no development of that "sixth sense" that means so much to an experienced field provider.

What do I mean by "sixth sense"? It's the ability to come on a scene and know that something is just not right. It's the ability to breifly look at a patient who appears to be stable and get just a feeling in your gut that something is amiss, you can't out your finger on it right away, but something requires you to act NOW, not 5 minutes from now. It's the ability to listen to activity on the radio and figure out where you are going to be needed before you are needed. It's the ability to work with a crew for the first time and make a decent determination of the skill level and comfort they have with their skills. It's a lot of the intangible stuff that we deal with every day. It's a lot of stuff that you can't put your finger on but is necessary for your safety and the well being of the patient.

I like to cite the example of a call I did several years ago when I responded to a motor vehicle crash in a church parking lot where an elderly man had driven his car into a pole at low speed. He really wasn't complaining of anything but some back pain and the BLS crew wanted to cancel me when I pulled up. Just looking at the scene and taking a quick glance at the patient gave me a creepy feeling, the hair stood up on the back of my neck and I told the crew that I woudl be setting up in the back of the bus. They looked at me with a really weird look and started to protest but I had gone already. I have no idea what made me so uncomfortable. This patient was oriented to person, place, time, and event and was not complaining about anything that sounded like it needed a paramedic. The BLS crew did a standing longboard application that was quite well done and loaded him into the ambulance. Routine ALS on the fly enroute to the hospital. About 5 minutes out the patient started to act strangely, thought the FDR was president and that it was 1938 and during my reassessment started to seize. He stopped seizing after 12mg of Valium but, understandably, remained obtunded for the rest of the trip. When we arrived at the ED the patient went rapidly to CT scan and was found to be having an evolving ischemic stroke.

Looking back I can find a couple of small things that made me uncomfortable about the call but only two. First, I found out early on that this gentleman was a retired truck driver who had driven trucks for over 40 years. That raised my suspicion that this was not just a case of the elderly driver getting confused as to which pedal was which. The other thing was just a small abrasion on the tip of his tongue. Nothing that was rememndously bad, nothing that was an obvious tip that something was amiss. That "sixth sense" was just telling me that something was not right.

When the crew asked me why I chose to transport with them my answer wasn't very satisfying to them. All I could say was "something wasn't right". Sometimes I think our patient care reports should have a check box for "Something not right" on them.

The outcome for this patient was, unfortunately, not very good. He had some lasting neuro deficits but I feel like these could have been worse if he had been forced to seize for a longer period of time and remained hypoxic.

Unfortunately there is no distilling this sense into an elixer or a simple 30 minute lesson to give to students and candidates. All that can be done is to have expereinced field personnel lead and teach by example and trying to do their best to show the new class what makes their skin crawl and their stomachs knot even when everything outwardly looks fine.

Field internships are great for passing along tips and tricks, and showing how the field differs from the classroom but trying to get the student and candidate to understand and look for the unexpected and to be prepared for it is, I believe, the true purpose of their time in the field.

Round three tonight. Down to Medic 2. It should be an ugly night with temperatures in the 20's already and a very stiff wind. I haven't been outside yet but the roads look dark so I suspect that they are either wet or starting to ice. That should make life interesting.

This was the busiest night I have had in a while and for a change I had a student with me for the entire shift. We ran almost start to finish which was great for the student who needed 28 more ALS calls to complete her internship. We managed to get her 7 more calls during the night.

I really enjoy working with students, it gives me an opportunity to teach but also to learn what they are learning and their take on the EMS world. This night was a little different. The paramedic student that was with me was already well acquainted with our service through her work as a Flight Respiratory Therapist with the area helicopter service. It was quite interesting to get her views on what was going on, how our service compared to others that they interface with and some of the things they have been learning.

With her background we spent quite a bit of time talking about airway management and respiratory care in the out of hospital setting and think it is safe to say that I probably learned as much as she did.

I am out of work almost 2 hours late after finally finishing all the paperwork and am really looking forward to getting some sleep as I have to be back in as Medic 2 at 1900.

Total Calls for the night: 12
5 ALS transports
2 ALS turned over to the ALS ambulance
1 Cancelled upon arrival
4 cover assignments

Total Milage: 187 miles

CD for the night: "Buffett Live: Tuesdays, Thursdays, and Saturdays" by Jimmy Buffett

Today was that day. When I got home this morning, late as usual after my last call coming in at 0645, I finished some housework and then crashed. Now I will admit some Benadryl did help me sleep but what can you do? I really needed it. The house was absolutley quite with the rest of the family gone.

7 hours later my alarm clock started going off. I feel reasonably refreshed and ready to face the day.

First order of business is washing some shirts so I have one to wear tonight and a spare. I made the mistake of not taking the holiday into account when I dropped my shirts at the cleaners and ended up wearing my last clean shirt for my shift last night. My shirts will be ready in the morning but that leaves me having to be domestic today so I have something to wear. Wash, dry, and iron, reminds me of all the reasons I spend the buck a shirt to have the done at the cleaners.

Second order of business is going to be finding something for dinner. The big problem here is the fact that I can barely cook and none of the stuff I know how to cook is in the house (since my wife helped me move out of my apartment 11 years ago the few things that were in my refridgerator have been banned from our house). Everything I am finding that I might be able to make is either going to take too long or not something that I want to be eating. I am heavily leaning towards heading to the hospital early and eating there.

After dinner it's back to work. According to The Weather Underground it's going to be foggy and rainy until at least midnight before it starts to get colder and clear up. Dense fog warning is in effect until late evening and the rain is expected to be heavy at times. Sure, lets see if we can get the river to flood some more streets.

It's a Friday night and I am hoping for a more exciting night than last night was. The few inetersting calls that were done were done my Medic 2 and Medic 3 so I figure I am probably due for something soon. We'll see what the night brings.

In truth, I couldn't give ALS away. I spent a lot of time on the road but aside from the beginning of shift equipment check never opened the gear again. Medic 2 and Medic 3 were busy doing ALS but all I did was cover for them while they were out.

Total assignments for the night: 9
1 ALS turned of to the ALS ambulance
1 no medical emergency
1 BLS downgrade
1 canceled upon arrival
5 cover assignments

Total milage: 128

CD for the night: "Mirrorball" by Sarah McLachlan (I know I have been listening to this one a lot. She has a fantastic voice that really captivates me.)

Tonights winner is a 35 year old man who was, well for lack of a better word, I'll say mugged. Problem is he was mugged in a neighbourhood where the dominant business is the drug trade. When I arrived on scene with the Engine Company in front of me and the ambulance behind me the police were already on the scene. Our friend was telling the police that he was driving home from the next town over and heading to an address on the other side of town when he was attacked, dragged out of the car, and the car stolen (story #1). That story started to fall apart when one of the police officers pointed out that to get from Point A to Point B did not require coming 4 miles out of the way and driving through a not so great neighbourhood.

Story #2, OK, OK, he was driving home from work and decided to meet his brother at a bar for a drink. After they tossed back a few he went to get in the car and was viciously attacked and the car stolen. No? OK lets try...

Story #3, OK, it's like this, he knew he had had one to many so he was going to walk around outside the bar and clear his head before he drove home. As he walked around the parking lot of the bar he was savagely attacked and beaten. Oh, how did he get the 4 blocks from the bar to where he was found? Uh, well, this is what happened...

Story #4, see, like I was finished at the bar and knew that I had had a couple too many and decided to go to the diner for a cup of coffee and some breakfast until I could sober up. Oh, the diner is almost 3 miles away? Uh, lets see...

Story #5, see I parked the car in the parking lot down by the river and walked up to the bar. On my way back I was attacked. OK, so he parked the car in the middle of a parking lot that is under 18 inches of water? Oh, well....uh...

Story #6, Hey where am I? Who am I? Who are you? (Did he really expect that to work after 10 minutes of story telling?) That one was clearly not working so we moved on to...

Story #7, well, you see, it was like this... Right about then one of the police officers returned and interrupted. It seems that, after finding some witnesses the truth was now known and was contained in...

Story #8. It seems that a couple of the neighbours watched this young man walk down the street and met with another man and entered into some type of negotiation. Money changed hands, product of some kind changed hands, and when the other man checked the money her became very angry, hit the patient on the head with a stick and took his "product" back.

As it turns out the man he was negotiating with was a known drug dealer, on the ground several yards away they found a "pad" of money with a ten dollar bill on the outside and blank paper on the inside, a large stick with blood on it, and a small puddle of blood on the ground. Oh, and this guys empty wallet was found in a bush a few doors up the street

So the truth comes out, he wanted to buy some "product" (probably crack according to the police), tried to rip off his dealer, the dealer whacked him with a stick and took off with the drugs after he rolled the guy who was trying to cheat him. What a moron.

With the truth finally known the patient decides that he is deathly ill and needs to go to the hospital right away. Of course the police were only too happy to oblige since this made their paperwork much easier. So now he's here in the ED, with an alcohol level three times the legal limit, causing difficulties for the staff, and trying to make phone call after phone call to try and get someone to come sign him out and bring him back to his car.

You know, we might have bought the idea that he had someone coming to pick him up and bring him home and may have actually gone along with it if his ride was sober. Now he's pissed off, and fighting with the staff. Security is restraining him in four points restraints as I type. No trip home for him until he's sober now no matter who comes to get him.

The terrible thing? If he had just told the police "Hey, I tried to do something stupid, I've paid for it and learned my lesson." the officers probably would have been inclined to just drive him home. Even if he had lied and said that he got lost while he was walking he probably would have gotten away with it and been driven home. Now he's shackled in restraints, and, once he's sober, going to jail for assaulting a nurse, and still trying to convince anyone who will listen that he was viscously and savagely attacked for no reason.

Maybe I'm getting cynical in my old age but this begs the question "Do I look that stupid that he thought any of these stories would work?".

An hour and a half into the shift and so far I have done 3 calls. Two involving people who were quite intoxicated and one cover assignment. I never realized that Thanksgiving was a "get drunk and beat someone up" kind of holiday. I figured that someone who was able to spend the day home with their family would be sort of happy at least. Clearly that is not always the case.

My day so far has not been all that great. I fell asleep early again last night and didn't get any of the things done that I needed to. Sleep came easy but staying asleep was tough and when I woke up around 0430 I had a searing migraine. I got up and took my medication for it and collapsed back into bed. Strange dreams plagued me for the remainder of the night, side effects of the meds I'm sure but it made sleep difficult.

Around 0900 I woke up in time to help my wife and kids get packed and out the door for their trip to my in-laws house for Thanksgiving dinner and a long weekend visit. They'll be away until Sunday evening. As I watched the drive away I had a very mixed reaction. I was very sad to see them go and know that for the next few days I would be working and home alone. On the other hand I had some happiness knowing that I was working and going to be home alone. Funny how you can be happy and sad about something at the same time. Being alone means that I will have the opportunity to get a good days sleep while they are gone, something that has become increasingly difficult when any more than 1 child is home at a time. Now I have the opportunity I just hope I can take advantage of it.

After they were gone I was still very tired and crashed again, sleeping until almost 1630, a total of about 14 hours. A huge amount of sleep for me and I can only assume that I had a backlog that needed to be filled. I was able to get up, turn on some music (that didn't involve cartoon characters or current pop stars), at a volume that I felt comfortable with and get some work done around the house. Much easier to clean up when there are no little hands doing their best to mess things up faster than you can clean!

A long hot shower to loosen up my back (I'm still a little sore from last weeks fall) and a shave. I thought of shaving my goatee off and decided against it. I know that will disappoint some people but I like it, even if it is starting to grey. I even thought of growing in a full beard but decided against it. Last time I did that it came in quite grey along my jaw line and while I think a little grey may look distinguished, a lot would make me look plain old, and I am not that old, heck, I'm not even 40 yet (not that 40 is old).

My shirts finally came back from the cleaners with enough starch in them. Of course I found that this means I can almost stand my shirt in the corner without it falling over and I laid out my uniform for work and sat down at the computer to write and check my email.

It's going to be a weird few days with no one else around. If I could have planned this I would have prefered to have this kind of time when I was not working so I could do some of the things that I want to be doing.

In the past few month's I have learned a lot about myself and gained a new appreciation for people who work in retail. I do not have the patience or the endurance to work in retail. Especially going into the season that's coming up. My coworkers at the Apple Store all felt that they could never do my job as a paramedic and, as I have learned, I can not do theirs either. I will stick to what I do well.

If someone sets up a wireless and elects not to enable any of the security measures does this mean that they are OK with others using their network to access the internet?

I guess the question really comes down to this: Is something to be considered allowed unless it is expressly forbidden or is something considered forbidden unless it is expressly allowed?

Similar example, I play my stereo with my window open, is it acceptable for someone to sit on the sidewalk in front of my house and listen to the music? If I wanted nobody else to listen shouldn't I have closed the window?

I just use the wireless networking example because it was the one that came to mind. OK, that and the fact that I have been known to "borrow" wireless internet connections in the middle of the night while on cover assignments.

Anyone have any thoughts?

Yes, I freely admit, I think too much some days.

I slept much better than yesterday but still not great. All three of my kids were home as was my wife so the noise level was higher than I am used to and I was woken up a couple of times by one kid or another shouting "Quiet, daddy's trying to sleep!" at the top of their lungs. I appreciate the thought but their implementation leaves much to be desired.

I was scheduled to have a paramedic student riding with me tonight but for the second time he is a no show, no call, no message. I hate it when they do that since I still need to send paperwork back to their program reflecting the no show. This is one of the first years that the programs have let students ride at night and some of the students are less than happy with the arrangement because they are seeing a reduced call volume. The acuity is higher and they are getting to do more interventions but for some reason the students keep looking for quantity and not quality. We'll see, I have several more nights in the next few weeks with students scheduled and we'll see what happens. I'm hoping that the students will continue scheduling and showing up for the night shifts since I love to teach and I have been getting a couple good teaching calls a night.

The night finished with a cover assignment for Medic 2 who had to transport to one of the larger tertiary hospitals about 45 miles away from him. I came down for the cover assignment and parked in a nice quiet spot to try and finish the paperwork from the night and woke up about 40 minutes later when the dispatcher called me on the air to tell me that I could stand down. Sheepishly I acknowledged and started to head back. It has been so long since I have fallen asleep like that and it's kind of embarassing even thought I didn't miss any calls. I really hate it when I don't sleep well, my first night is always tough and only is made tougher when I don't get good sleep.

Total for the night: 9 calls
2 ALS transports
1 turned over to the ALS ambulance
1 cancelled upon arrival
1 BLS downgrade
4 cover assignments

Total Milage: 127 miles

CD of the night: Meet me in Margaritaville by Jimmy Buffett (Disk 1 & 2)

Julie, over at Shorebound, had a very frightening experience today that reminded me just how important it is for all of us to keep our cool in a bad situation. She did a great job. I would have needed tranquilizers instead of aspirin.

Take a read .

Days was pretty busy with all all units out of their districts when the night shift began. One of the drawbacks to the modified System Status Management that we have been using is that you can end up anywhere. Not that I mind all that much it does add some variety to the shift but it means that the turnaround time is much longer since everyone has to end up back in their district by the end of the shift. It's one of the reasons that days never get out on time and nights rarely gets out exactly on time.

I'm actually pretty happy to be back at work. I enjoy having time off but the way my rotation works I end up with a couple of 4 or 5 day periods where I'm not working and it always takes me a while to get back up to speed once I get back. Not to mention catch up on all the memos and email.

I guess I can't and shouldn't complain, what I have is still better than earlier in my career when I used to have to work 24 on/48 off. If I had been in a rural area it might have been OK but in the States second largest city it was a very bad thing for me. I think that, more than anything else, is why I left that job. I'd work my 24, spend the next 24 recovering, and the 24 after that getting ready to go back. But that's ancient history, back in the days of Cadillac ambulances, colour coded paramedics ("Give 2 brown ones, a grey one, and a yellow one") and mother may I start an IV and put an EOA in. We've come a long way since then.

I just finished an ICQ chat with one of my old partners who was telling me about the new ballistic vest he just bought. "It'll stop everything except for an assault rifle." I know that he has been wearing body armour for the past 12 years or so and religiously puts it on each and every shift no matter if he is in an ambulance, intercept unit or a bicycle. If it makes him feel safer I guess that's a good thing but for me I'm not so sure.

After I clicked off the thought ran through my mind that maybe I should go back to wearing body armour again. I do see many more weapons working in the rural and small town areas that I work in now than I did in the larger cities, they're just in different situations. I gave this some thought and thought about a lot of the EMT's and paramedics I know who do wear armour and how, at least to my eyes, it makes them safer or not safer.

I made the same decision tonight that I made several times in the past. Particularly in EMS strange things happen when personnel put on armour. They go places they shouldn't be going and they do things they shouldn't be doing. They feel like they are invinceable. Over the years I have worked with armoured and unarmoured folks and can recall many time where my armoured partner took off down the sidewalk after a mugger or wanted us to try to get ahead of the police foot pursuit to try and get in on the action. I also remember climbing the stairs on a tenement to the fifth floor half a stairway behind the police, hearing gunshots from the floor above, watching the police draw their weapons and rush in and realize that my partner was right on their heels.

Why do people do this? Well, part of it is the same reason we are involved in EMS. Someone has a problem and we are going to be part of the solution, sometimes, even if we have not the training nor the authority to be a solution. Some of it is the rush of adrenaline that overpowers the rational part of our minds to make us go places that we know, deep inside, that we shouldn't be but we go because someone needs help. I received a commendation for valour for pulling an cop to safety who had shot in the chest in an exchange of gunfire during a drug bust gone bad one evening early in my career. Why did I do this? Looking back it was a combination of these two reasons and a third reason. I was wearing my body armour, I was invulnerable or at least thats what it felt like. The though never crossed my mind that the cop who had been shot was wearing the same body armour as I was. The round that penetrated his vest would have done the same to mine. Not to mention that when I ballparked the coverage with the body armour I realized that even with it on, a sizable amount of my body, including some highly sensative areas (like my head) remained unarmoured. But those thoughts never crossed my mind until weeks later. I was doing what I pereceived my job to be.

As time has gone by I have thought many times about the advisability of wearing soft body armour not only to guard against gunshots but also to guard against edged weapons. I always seem to come to the same conclusion. I can assure my safety a lot better by being more aware of my surroundings, excercising a little common sense before I enter any situation, letting the police do the police work, and most of all listening to that feeling in the put of my stomach or the feeling of the hair on the back of my neck standing up to know that I am somewhere I ought not be and as quickly and as safely as possible removing my self from to a safe distance. I want and need that fear for my own safety to keep me in the here and now, and keep the scene and situation in perspective. As long as part of me feels the fear I remain grounded.

When I was still in paramedic school one of the police officers from the large city the course was based in would come and have lunch with some of us (his son was also in the class) and I remember very vividly being told by this 30 yr police veteran that "there is a fine line between bravery and stupidity, be sure not to cross it" and "if you get a commendation or a medal you probably did something that qualified as crossing that line". He retired as a captain in charge of tactical operations after 39 years on the police force. He also went home to his family after every single one of his shifts during those 39 years. THAT is what I want to make sure that I do, I want make sure that every time I leave for work has a corresponding return from work later on.

I am amazed at how much I got done today. The house is looking pretty good, I am almost caught up on laundry, I actually had a chance to do some reading. It's nice to not have a lot of work hanging over my head, although I do still need to clean the study which has become a total disaster area since I closed my business in June.

Time to box and archive the old records, take a fair amount of the books that I will no longer need and store them, sell off more of my old equipment on eBay, put away what I want to keep and once I have all that done throw away the anything else that remains. It will be a fair amount of work but it will be well worth it. I am hoping to take a day or two next month and just power throw the entire job. I'm anxious to get it finished so I can set the room up as a combination study and practice room. I am enjoying playing the trombone again but need to have some space set aside that can be setup specifically for the purpose of practice.

If I can I'll even take some of the vacation time that I have accumulated that put me over the maximum accumulation amount and get HR off my back. They really get cranky when people have more than twice their annual vacation stored for future use and I'm pushing 7 1/2 weeks of time. For our department the problem has been coverage. We don't have enough people to cover vacations if everyone took all of their annual vacation time in one year so after two people have vacations approved the week is closed and no one else can get the time off. It's kind of lousy but, for now, until we can hire some additional part time and per diem guys for coverage it's what we have to do. If HR sends me a nastygram I'll do the same thing I have done for the last two years, send it back to them with copies of all the vacation denied requests I have gotten over the past few years.

We're still running with two positions unfilled and one person out on medical leave (no it's not me, thanks for everyone's concern, it's nice to know that somebody is reading). Plus we usually have one or two on vacation or educational leaves in a given week and all of the sudden we are really tight. Last month overtime went from voluntary to mandatory, oh, excuse me, my boss doesn't call it mandatory overtime, he calls it administrative scheduling. No matter what you call it it means that conceivably I could end up working a shift that could be really inconvenient or even impossible.

The only way to avoid being assigned an overtime shift is to take one before it is assigned to someone. The OT list is a rotating list, if your name gets to the top you are next up for assignment of an OT shift. In another situation I might not care but with my wifes career and our three girls I have some pretty particular demands on my time. Volunteer to take an OT shift puts you at the bottom of the list just like you were assigned one. That has left most of us hanging on the pager watching for shifts that we could do without major rearrangements of our schedule.

As of this morning I was number 2 on the list, in the danger zone and with a pretty tight schedule due to my wifes call schedule. Time to grab something before I don't get a choice. Unfortunately most of what came across was while I was already working. Time to do something drastic. People that know me realize that what I did was so uncharacteristic of me that when I called in the medic on the other end of the phone made me repeat it three times. I agreed to work a day shift.

Day shift is just something I don't care for. I work 1 or 2 a year, just enough to remind me why I don't like to work them. I usually end up taking them for one of a few reasons. Either I need the money, they called me ont he phone while I was asleep (I'll agree to anything to go back to sleep), or the pager has been going off for a shift so much that I just can't listen to it anymore.

Why don't I like working days? Aside from the fact that I am, as my 6 yearold told her teacher, nocturnal? I am not totally sure. Part of it is the fact that while it is a busier shift I find that the acuity of the patients is not as great. Part of it is that the day staff in the ED tend to be much crankier than the night staff. I think that the main reason is that nights is a much more laid back shift with nowhere near as much management around. The motto of the night shift seems to be "it's easier to ask forgiveness than permission" and this leads to problems being dealt with in a much more timely fashion with solutions that are frequently easier to implement. The only saving grace for my day shift is that it's on a weekend so the number of management types around will be less than on a weekday. So I'll work my day shift and be reminded for the next 6 months or so why I don't like working days.

OT has been going out like crazy. I've got two OT shifts next week, one voluntary and one mandatory. Starting Friday of this week I'll work 4 12 hour nights (1900-0700) and be off for two days, and then repeat the 4 on 2 off. I will be really tired by the end of it but the house needs new gutters and storm windows, and those don't come cheap. Not too mention I'd really like to take some vacation time and get away during the winter. You need money for all of them.

The other reason? Shhh, don't tell any of my coworkers, I'd rather take an extra shift than either have one of my coworkers get screwed or have the truck taken out of service and the shift left light. I have this very idealistic mindset that if I do what I can to make everyone's job easier they will do the same for me when I need it. I am an idealistic and dedicated fool but usually it pays off in the end.

I survived the afternoon by moving like an old man until my wife got home with my prescription for Flexeril. Wonderful stuff that realxes the muscle spasm but in the process knocks me for a total loop.The evening was a write off as I was feeling much to foggy to do anything productive.

Another dose of the meds and I am off to bed. I'll sleep like a baby for sure. Getting out of bed in the morning will be an experience I'm sure.

Actually more of a crash or a thump. I finished the night with only 2 runs neither of them ALS. Clearly the annual drop in call volume is at hand and has been for a few weeks. Come fall, especially at Medic 2 which is stationed along the shorline, the call volume drops off when the cold weather. Much of it is due to the departure of the warm weather residents for warmer climes.

So the first of my two calls was for the elderly woman who was having shortness of breath. When I arrived the police were already on scene and talking to her. Boy were they talking to her, she was talking a mile a minute with absolutely no indication of shortness of breath. The longer we talked with her the less she complained of her breathing. Lungs were clear, room air sat was 99%, no edema in her feet or ankles, no distention of the neck veins, no wheezing, no sign of any difficulty breathing at all. After a while and a lot of talking we got down to the root of the problem. It was the anniversary of the death of her husband and, accoding to her and confirmed by her son over the telephone, she has had significant anxiety attacks at this time every year. Even after a long talk she still wanted to be transported to the ED. The crew brought the stair chair up and we prepared to get this woman down from the second floor down a wooden outside staircase.

I slung my pack onto one shoulder and one of the cops took the monitor down and I started down the stairs backwards to help steer the guy at the foot of the chair down so he wouldn't fall. Everything is going fine until the guy on the top of the chair missed a step. All the weight of the woman and the chair was unexpectedly thrown to the guy at the foot of the chair. He started to list to one side and leaned against the railing. The crack the came next was unbelieveably loud and the railing started to fall outward from the stairs. I reached out and grabbed the guy at the foot of the chair by the shoulder and tried to steady him so he wouldn't fall. The guy at the top of the chair regained his footing and is taking some of the weight. Unforunately I was still trying to keep the guy at the foot of the stair chair stable and as a result I am not stable myself and as I try to shift my weight to stay on my feet. I overcompensate and fall backwards landing square on top of my Thomas Pack with my head pointing down the stairs and roll over on my left shoulder and off the stair falling about 4 feet onto the ground, landing hard on my left hip.

I'm told that it was a pretty spectacular looking fall. I lay on the ground stunned for a few moments and then start trying to disentangle myself from my pack and struggle to my feet. Quick inventory of my body parts; OK, nothing obviously broken, glasses intact, major damage seems to be my pride, the narcotic kit in my pocket and something wet that is seeping out of the Thomas Pack.

As I slowly staggered to my feet the cop says "Man that was impressive." and all I can do is grunt. I'm feeling a little battered and I know it's nothing like how I'm going to feel later. The BLS crew asks if I need to be boarded and collared and I respectfully decline while I scowl at them. They laugh and depart for the ED.

I sling the pack onto the cabinet at the rear of the truck and zip it open to see what is leaking. Somehow I ruptured a bag of Ringers and it is slowly leaking out of it's protective overwrap. Nothing broken in the med kit, I check the RSI kit and find that the only casualty there is a smashed bristojet of atropine. I replace these out of spare stock and turn to the narc kit in my thigh pocket. I can already tell by the damp spot on the pants that I've broken something in the kit. I pull it out to find that the plastic case has been smashed on the top and I have cracked both carpujects of Valium, 1 vial of morphine and 2 vials of versed, bag it in a plastic zip lock biohazard bag, and lock it up in the narcotic locker out of sheer habit and climb in gingerly to drive back to the ED.

When I got back and parked the truck in the garage I really didn't feel like moving much and just sat there for a few minutes before I motivated myself to head inside with the broken narcotic kit to return to pharmacy and replace it with an unbroken one.

Looking back on the whole thing I can see it was clearly my fault for trying to do anything while carrying a 40 pound pack full of gear on my back and not really paying enough attention to my own body position and balance. I feel kind of foolish and it serves me right. It was a pretty foolish thing to do. I fell because I didn't want to make 2 trips, one to help with the carry and the other to get my gear. Like most accidents that happen at work I knew better. Just about everybody I know that has been injured has known better and probably could have prevented or at least reduced the severity of the injury if they had been paying more attention and used some of the common sense I was ranting about earlier in the week. Just goes to show that even dinosaurs like me can make mistakes. I'll be feeling the discomfort from this one for a while yet, I'm sure.

Total Calls for the night: 3
1 no medical emergency
1 BLS downgrade
1 cover assignment

Milage: 64 miles

CD for the night: Mirrorball by Sarah MacLaughlin

I'm on my way back from the LOL (Lonely Old Lady) call and am asked to swing by an intersection to "check out" a reported minor accident. I have no idea what they expected me to do since they make it sound like this is strictly a police matter but I turn around and am on scene in less than a minute. One car versus mailbox no occupants. The police were actually already on scene and they said they had not found any occupants.

The damage to the car is minor and I see no evidence of any injury on the interior. I'm not too concerned but still, I'd really prefer to see a live person before I just take off. A car pulls up and the drivers tells the trooper that there is a guy walking down the street about 3/4 of a mile south of us dressed as a waiter.

The trooper takes off and I follow at a slower pace. If the guy has made it that far down the road chances are pretty good that he isn't hurt too bad.

Par for the course it's an intoxicated guy who drove into a mailbox. The airbag deployed in his car so he is covered with powder. The trooper gives him a choice. "Hospital or Jail". I hate it when they do that, foisting their problems off on us. I understand that he's getting close to shift changes and doesn't want to process a DUI and have to stay late. I mean, we're getting close to shift change as well.

Four times this guy is offered the choice of going to the ED and going to jail. Four times he chooses jail. I'm confused, does he really understand what happens if he goes to jail? Oh yes, he knows that jail means a DUI arrest and that hospital means sleeping it off and being cut loose when he is sober. Jail.

OK, who am I to argue. The trooper packs him off into the back seat of the cruiser and I hit the road to return to station. I don't get it and probably never will.

The day medic was somewhat busy but we made shift change before he coul dget sent out again. The ED was full, it's becoming the usual, but nobody was acutely ill so I was able to do my beginning of shift equipment check, and grab some dinner.

While I was out getting fuel I swung through WalMart to grab a couple of the low carb snack bars, one for my lunch around 0100 and the other to keep in my locker if I were to need something on another shift. They're palatable but I wouldn't want to have to live on them for any significant amount of time. I can;t complain too loudly, the low card diet is working pretty well and I am down almost 50 pounds (22.7 kilos) since May. I stood outside on a windy night a fewe days ago and my shirt was billowing so much behind me that I could feel it pulling me backwards. I'm feeling pretty good and the only thing that I don't like is now I seem to be much more sensitive to the cold. When I go to buy uniform shirts I'll have to buy long sleeves for the first time in I don't know how long, 12 years maybe? I already used my uniform allowance for 2003 so these are going to have to be on me instead of the hospital. I was goping to try to wait until the 2004 allowances came out in March but it's not going to happen, I need the shirts too bad.

A pretty good night, steady throughout the night with lots of dispatchs but no transports until right before shift change. I finished out the night with an unresponsive patient who degraded to respiratory arrest and then cardiac arrest. I was pretty much expecting this to happen as she was in a complete heart block on my arrival and moved fairly quickly to a wide complex, very bizarre ventricular rhythm that eventually lost pulses.

This call reinforced two things that I firmly believe. First, most of the time patients are going to live or die despite what I do. I may make them more comfortable and be there to make sure that they do not die alone but I do not save lives all that often. Second, when it is your time to die there is very little that can be done to stop it.

Some people have told me that I am belittling my profession when I make statements like these but I don't feel that way. I feel that these statements are realistic and reflect the reality of the practice of medicine be it in hospital or out of hospital. We have come a long way and can cure many diseases that would have killed thousands a few hundred years ago or even a few decades ago. That being said there comes a time in every person life where death comes to us all. It is unavoidable, unstopable, and perfectly natural. There are even times when I think that medicine should not try to stop or delay the inevitable.

Lots of people don't understand death and fear it. According to the husband of my patient this morning he and his wife somewhat understood death and no longer feared it. They had accepted the inevitability of it. With all of the death that I have witnessed in my 23 years in EMS I have come to recognize my own mortality. But I still struggle to accept it.

Total runs for the night: 9
1 ALS transport
2 BLS downgrades
2 Cancelled enroute
1 Unable to intercept
3 Cover assignments

Milage for the night: 134

CD of the night: The Best of Del Amitri by Del Amitri

I also finished listening to "Naked in Baghdad" by Anne Garrels. Interesting footnote, during the book the reader/listener learns that Ms. Garrels is an EMT-I with the volunteer ambulance in Norfolk CT.

These things happen. When I arrived at station a couple of minutes later I had the intention of meeting him on scene and releiving him there so he wouldn't have more paperwork to do. Things didn't work out that was as when I signed on as Medic 4 they told me that I was the only Paramedic available in the county and that I should stay available until the night shifts at Medic 1 and Medic 3 could come on line in spare vehicles as Medic 5 and Medic 7. Within 10 minutes I had gone from covering the "world" to just covering my area again as the night shift medics came on line.

Medium busy day from what I can see in the logs, 4 emergency responses and several cover assignments. I'm hoping that we can keep up the pace for the night. I'm pretty well rested after a good days sleep and I wouldn't be adverse to having a steady night. Temps are pretty cool so far and are likely to spend the night around freezing.

I feel like it will be a good night.

Nothing too difficult, I just needed to get them done. Nasogastric tubes and the bougie Endotracheal Tube Introducer were the skills of the morning. I took me all of 5 minutes to get checked off, longer for the paperwork than the skills. With these completed the EMS Coordinator tells me that the only thing I need to complete by the end of the year is my Advanced Cardiac Life Support (ACLS) recertification. I'll do that by computer sometime in early December and be done with everything on time for a change.

A kind of bizzare night last night. Everybody was very slow. I only had 2 responses in 12 hours and neither of those resulted in me transporting. I guess winter has really started but even for winter that was a slow night. I did manage to get a lot of work done although by 0400 I was doing a little bob and weave at the medic desk. Sometimes it is so hard not to get drowsy.

Total responses for the night: 5
1 turned over to the ALS ambulance
1 BLS downgrade
3 cover assignments

Total milage: 114 miles

CD for the night: Meet Me in Margaritaville (Disc 1) by Jimmy Buffett

Still listening to Naked in Baghdad by Anne Garrels off my iPod as well.

What you can't teach is professionalism and common sense. tonight is a good example of that.

"Medic 1, responding to [address deleted], meet the ambulance already on scene for chest pain. The engine company is responding to another job, advise if you need further assistance."

The call is about 6 blocks away from the hospital so I arrived there pretty quickly. Directed to the second floor by the homeowner I found the ambulance treating a 60ish man complaining of "not feeling right". Now that is a pretty weak complaint, it doesn't give us much to go on but you work with what you have. After some judicious questioning we further learned three additional pieces of information. One, he has an implanted defibrillator that has not fired. Two, he just flew in from Florida this evening and drank considerable amounts of alcohol during the flight and since he arrived. Three, he smoked a marijuana (yes, you heard me right) tonight for the first time since the 60's.

It really doesn't matter since a 60+ man with a cardiac history buys the full workup whenever he doesn't "feel right". It's cardiac until proven otherwise.

One of the EMT's fromt he ambulance heads outside to pull the stretcher from the ambulance and get a stair chair. Pretty much everybody in the area knows that I have a low tolerance for making patients who are or could be truly sick walk downstairs. I don't do it and I won't let them do it.

Stair chair comes up to the second floor and the crew starts to secure the patient to it for the carry downstairs. I grab my gear and the ambulances gear and head downstairs in front of them to drop it in the ambulance while they are carrying.

By the time I get back to the front door they have the patient carried outside and seated next to the stretcher. He's wrapped in a sheet and has nothing but his boxers on underneath. Did I forget to mention that it's about 24 degrees out, windy, and snowing?

So what do they do next? You bet, unwrap the sheet have him stand up and sit down on the stretcher and rewrap him in the sheet. It's freezing out, it's snowing out, with the wind chill the temp is well below zero.

I grab the blanket from the bench in the ambulance and bring it up to the crew only to be told "we were going to cover him up when we got inside". Say what?!

Let me get this straight. You're going to carry a man in his underwear outside into the freezing cold, wind, and snow, make him stand up, uncovered, and move himself to the stretcher, and NOT cover him with a blanket before you get him to the ambulance?

[rant on]

To me this lacks any common sense and shows a remarkable lack of professionalism. I freely admit that I can be a tremendous pain in the ass when people comes to things like this. I freely admit I set very high standards for myself and expect that others will at least try to meet them. I freely admit that I am not perfect either. But what the heck are you thinking when you can't even wrap a patient in a blanket when it's cold, windy, and snowing out?

Common sense tells me that when it's cold out that I need to keep my patient warm and out of the elements. My sense of professionalism tells me that I am responsible for safeguarding my patients dignity while he or she is in my care. This patient was neither protected from the elements nor left in a dignified position. Know what? The patient and the family noticed. They noticed and commented when they got to the hospital.

Yes, I sure am cranky this morning but I came in to work in a pretty good mood and looking forward to seeing what the night brought. I wish stuff like this didn't bother me or that I could just ignore it. But I can't and I won't.

[rant off]

When I politely (really, I was quite polite and nice when I brought it up) called this to the crews attention after the call the crew told me that they honestly didn't even think about it and that they had always done it this way.

I could only walk away shaking my head.

I'm not sure which it's going to be or if both are the problem. It's 2030 and it's already well below freezing and extremely windy. They weather report is calling for snow in some amount although the forcasts are conflicting. Since I lost weight I have become much more sentistive to cold. I never wore long sleeve shirts, never wore a sweater, rarely wore a heavy coat, and lately I find myself feeling pretty darn chilled even when I wear my coat. Methinks that I will actually have to purchase longsleeved shirts this week something I haven't willingly done in years.

The day medic only did 4 calls total today so I don't know what the night will hold. So far just one call that was transported BLS for the patient in the SNF who choked earlier today on a cough drop and the staff thought she should be "checked out".

I did get some news about my cardiac arrest from the other night. Even though the family declined to have an autopsy performed I talked with one of the ED physicians over dinner and he concurred with my assessment that she probably had a large blood clot in her lung, probably right side since that side was giving me trouble. Not as satisfying as having a pathology report but it makes me feel more confident that I didn't miss anything.

Three more of our area services have contacted me for training to use the Combitube which I think is a really good thing. It proved it's worth to me again during that arrest where it allowed us to secure an airway in cramped quarters. I would love to see this device added to the standard BLS standard of care but there is a lot of resistance. I figure it will happen in time. A few years ago I was tilting at the every EMS vehicle should have an epi-pen windmill without much luck and last year it became a state law that they should. Tilt at a windmill long enough and loud enough and sometimes you make enough waves to catch someone elses attention. We'll see.

That doesn't mean that it was an exciting day but it all had to be done. My wife spent the night at the hospital with a labour patient so I was solo for the morning craziness. I have got to get a new alarm clock because, once again, I slept through this one getting up half an hour before the kids had to be out for the school bus. Everybody got out the door on time but it was a race with against the clock. As usual, I guess I perform better under pressure.

My wife was off call at 0800 and left the hospital to attend a meeting with my oldest daughters teachers, psychologist, speech and occupational therapists. They do this monthly on an informal basis to talk about how she is doing and to fine tune her educational plan. She's been doing fairly well this year and we are pretty pleased. Last year she had considerable difficulty with her Aspergers Syndrome and the anxiety and poor social skills that come along with it. Early in the school year we decided to try something that some people had had good results with. We put her on a glutten free diet and this had been a topic of discussion back and forth between all parties.

Initially she resisted this terribly being a kid that likes lots of things with glutten and dairy products (also restricted on this diet). For a quite a while we didn't think we saw all that much difference and stopped the special diet for a couple of weeks. It took us less than 10 days to figure out that the changes in her had been subtle as the diet took effect and that her anxiety, inability to concentrate, poor socialization and erratic behavior came back with startling rapidity. Without hesitation she was back on the glutten free diet and has rapidly been moving in the right direction again. I'm sure that her rapid change in direction again was a topic of discussion this morning as well.

When she returned from the meeting she told me that I was correct and the results of the diet change were a major topic of discussion. As soon as she was home we were off and running for our errands for the day. All the stuff we weren't able to get done over the weekend had to get done today.

We got a lot accomplished. Not everything got done but the major portion of it did and I feel pretty good about that.

Now it's a little before midnight and I have got to keep myself awake for a few more hours so that I can spend most of the day tomorrow asleep in preparation for my Medic 1 night shift tomorrow night.

I'd like to say that I am going to continue to be productive but the reality is that I'm pretty spent and I know that I will get very little serious work done.

I worked last night and knew that because of the Veteran's Day holiday I would need to be home with my oldest 2 girls. It promised to be a less than great situation as there would not be all that much sleep, only what I could grab in cat naps on the sofa.

As expected there was very little sleep involved and the girls were fairly high maintenance. It is always tough for my oldest to go through a day with little or no structure and today was no different. She had several periods of intense anxiety. Not the greatest day for her.

After picking up my youngest at day care and dinner at the hospital with my wife we headed home. The call that mom was not coming home tonight because she had a patient in labour threw all three kids into a bad mood. I swear, if I didn't know better I would swear that they don't like being home with me.

Finally all three are asleep and I am free to do all the stuff that I didn't manage to get to during the day. Laundry, dishes, lunches for the kids for tommorow, lay out their clothes are just a few of the chores that need to be done before I can crash and get some sleep.

If I had to pick a word to describe last night that word would be "sucked". Last night sucked. It would have been passable or even good if I hadn't had to deal with the angry 8 year old who's mother I treated but was not able to succesfully resuscitate. I know he is angry and greiving but that is enough to throw anyone off their stride. I need to sleep a little and think a little before I'll be able to get this off my mind.

Total for the night: 8 calls
1 ALS transport
2 canceled
5 cover assignments

Milage for the night: 168

CD for the night: "It Just Happens That Way" by Mindi Abair

I also started listening to a book on CD. "Naked in Baghdad" By Anne Garrels

It's after midnight and this is the first chance I have had to sit down and write anything be it blogging or writing my run forms.

The night started out with just a few cancellations and a cover assignment to cover Medic 3. As I arrived at the cover I was dispatched to an "unresponsive woman, EMD in progress". In and of itself the fact that the dispatcher is giving them prearrival instructions doesn't really change anything for me. An unresponsive person can be anywhere on the spectrum from drunk to a diabetic with low blood sugar to dead.

I heard the police arrive on scene and the ambulance moments after that. The call came back that CPR was in progress just as I turned onto the street. I arrived a moment later and grabbed my pack and monitor and headed inside where I was met by an 8 or 9 year old boy who said that everyone was upstairs in his parents bedroom.

Up the stairs I went and arrived in a very small bedroom that was almost completely filled with a bed and a single dresser. Wedged on the floor between the far side of the bed and the wall is an obese women with CPR in progress. Both of the EMT's doing CPR and ventilating her had to lie across the bed to get at her to work. From her feet I was able to get the pads on to look at her rhythm. V-fib, charge to 200 joules, everybody clear?, shocking, look back at the monitor. Almost as I expected asystole, flat line, a very stable rhythm but not one that I can do much with.

There is no room to work. The rescue company has been requested but has not arrived yet. I can't get at her to intubate her, I can't get at her enough to start an IV. I insert a Combitube (an alternative airway adjunct to help us ventilate) and ventilations become somewhat easier. We need to disassemble the bed to give us some room to work but without tools we can't get it to come apart. OK, gotta try something else. Let's bring the backboard in from her feet and try to get her on it from that direction. It is not the easiest or most graceful thing I have ever done but after a lot of work and a lot of sweat we get the board under her and strap her to it as best we can. She is so obese that none of the usual tricks to keep her arms from flopping down and getting in the way are working. I end up taping her wrists together and we struggle to lift her from this awkward position on the floor to the bed so we can readjust our grips and get her down the stairs.

Down the stairs, stretcher at the bottom, ambulance backed up to the door the crew decides that we should just head for the ambulance. The monitor still shows asystole and since my ALS gear has already been put in the ambulance I have no choice but to agree, at least I can see one of the EMT's spiking an IV set for me. In the ambulance I check the monitor again and still see asystole. Now that we have a little room to work and access I can intubate her without difficulty. We start to transport. Strange, breath sounds are less on the right than the left side, the tube is in the right place and everything looks and sounds good. End tidal CO2 shows good waveform and the belly is silent. Tubes good. Meds down the tube, one round and then another, nothing.

I finally get an IV started and switch to giving meds by that route. Still no change. Something just doesn't look right, the tube is in place, everything indicates that that is the case but the patients face and head keep getting more and more cyanotic, she's a medium purple. I get an uneasy feeling.

Follow the protocol, shit, I am running out of things to try. How long has she been down? Nobody knows. OK try some Sodium Bicrab, maybe she's acidotic. No change. Diabetic? Many obese people are. Dextrose 50% 25 grams IV. No change. OD? Narcan 2 mg, no effect. By the time we get to the ED I am starting to run out of meds and ideas.

She's a deep purple now and I recheck the lung sounds for what seems like the 50th time. I revisualize her vocal cords and can clearly see the tube in the proper place. 2 minutes out from the ED. OK, lets get ready to go in, switch over to the portable oxygen, get the monitor secured on the stretcher, resecure her hands.

The ambulance stops, the back doors swing open and we head inside. Over onto the stretcher. The doctor sees the same thing I do and looks again to confirm that the tube is in. The patient is a very deep purple from the base of her neck up. Still asystole. More epi, more atropine, what else can we try? Draw an arterial blood gas and try to use the external pacemaker. Nothing. Blood gases come back. Her oxygen level is 18, way below what it should be. All I can think is that she threw a big blood clot in her lung and that was the cause of the whole thing.

"We're out of options." the Doctor says. "We're done." I leave the room and head outside with my water bottle to cool off. As I stand outside, steaming from the sweat that is running off me, I drink the litre of water without stopping for a breath. Did I do everything that I could? Yes, I used everything at my disposal and did the best I could with the information I had. A less than ideal situation the we handled as best we could. Time to restock and do the paperwork. I walk inside to the nurses station.

Before I can get to the nurses station someone runs into me. I realize that it is the same kid who let me in at the house. He's crying and screaming at me while he punches me. He's too short to reach my chest or head and is pummelling my midsection. He is angry. "Why didn't you save my mom? That's your job! Why?" I grab his wrists and kneel down in front of him. One hand breaks loose and he smacks me across the face. My glasses go flying across the corridor. Then I'm rescued by a nurse and the kids dad. I tell them both that I did everything I could. I mean it but it still rings hollow. That's not enough to ease the greif of the man and his son. There is nothing that I can tell them that will help, I know that. I have to settle for saying that I tried my best, everything that could be done was done, and that I was very sorry that she died.

I really don't want to do the paperwork right now. What I really want is to just go home.

My original intent was to stay up for a few more hours tonight so I could sleep during the day tomorrow. That plan changed when my wife got called in to the hospital for a patient in labour. Now I'm soloingin the morning which is always a challenge. Getting 2 kids out to school, 1 kid out to daycare, and me out to go to the burial all by 0830 should be a real trick. I'll manage it somehow, I always do.

After I return it'll be back to sleep, but only until a little after 1530 since I need to get my kids off the bus and pick up the little one at day care. I had to swap a night to get Tuesday night off and am currently scheduled as Medic 3.

Since the layoffs Medic 3 is no longer a fun, easy station. Medic 3 has become a high milage station which runs all night for calls or cover assignments. It's OK if the entire system is slow but Medic 3 always takes a cover assignment no matter which of the other paramedics goes on a call. I'm going to try to touch base with the medic assigned to Medic 1 since he lives closer to Medic 3, in Medic 3's primary response area, and I live closer to Medic 1. I would much prefer to drive 15 minutes to get to work rather than 45.

I really can't wait to have the stress start to bleed off and let my schedule get back to what serves as normal for me. I know I'm stressed, I actually talked to my wife about moving to a day shift. I knwo it's bad when I say that, I hate working days.

The service was what I expected it to be, a pretty typical Lutheran service. That service has become unfamiliar to me having be living for the last 12 years as a Jew and having been rasied as a Catholic. It was pleasant but what was extraordinary was listening to what the speakers from the family had to say.

My uncle, my mother and my sister all spoke very eloquently and touched on some of the things that made my grandmother special to me. They all talked about their relationship with her and how they see her influence in their daily lives. All talked about how my grandmother taught us by example both in her day to day life and her faith. I agree with that wholeheartedly.

My sister expanded on this somewhat by noting that every person who spoke couldn't help but mention my grandfather as well. Not that my grandmother was in his shadow. Quite the opposite, they were partners, Yin and Yang, soulmates with one compensating for the deficiencies of the other. Together they were greater than the sum of their parts and they were inseperable. They loved and respected each other very much and that was clearly evident in how they treated each other and how they looked at each other. The look of love that was in their faces from pictures in the 30's was still there in pictures taken in recent years.

Afterward the family had a chance to sit quietly to talk and remember. I came to realize that all of us were greiving that she had died but were somewhat joyful that she was joining the only person who could complete her. Since his death she had always been saying the "he's just around the corner, waiting for me." and I believe he was.

As I drove home and thought about what had been said throughout the day I again realized that my grandparent both taught us by their example. Their love and respect for each other, their faith, and their unwavering attention to family are only some of the qualities that I admired in them. I also realized that some of what they had taught me had been easy for me to learn and other parts have been more difficult. I can only hope that I am able to learn all the lessons that they had to teach both while they were alive and as I recall their memories. I can only hope that I can be the man, husband, parent, and friend that they tried to teach me to be.

Not as many tears as I expected from anyone including the kids present. Everyone who came was telling stories about her, including some of the students she had when she taught 4th grade in 1962.

I also got to see my cousin who is a Major in the Marine Corps and has not been able to make it to a family function in a few years. I was glad he could make it to this one.

We talked about a lot of things including some topics where we differed in opinions (the war in Iraq, politics, favorite authors) and a number of other topics that we did agree on (after learning the hot button topics to stay away from). The first thing that we agreed on was just how silly it was to have to take 4 days to actually bury our grandmother. She died Thursday early evening, wake this afternoon, funeral service Sunday afternoon, but since the cemetery is not open on Sunday, actual graveside service will be Monday.

We both agreed that there is some merit to the Jewish tradition. The Jewish tradition (not universal, but by far the majority) is to bury the dead within 24 hours unless that would have fallen on the Sabbath (sunset Friday to sunset Saturday) in whihc case it would be completed the following day. No muss, no fuss, do what needs to be done and mourn afterward, Shiva as it is called in Hebrew. A very interesting tradition.

The other thing that we had a hard time understanding was the concept of the wake. We both knew that before medicine was exact enough to confirm death with near 100% accuracy the deceased was laid out for a day to make sure they weren't going to wake up, hence the term wake, I assume. But in this day and age why do we still feel the need to display the dead. The last memory I want of a friend or loved one who has died is certainly not the image of the embalmed, heavily made up body, lying in a coffin. I want to remember people as they were when they were alive and I'm sure others may feel the same way. Why not close the casket and cover it with photos and memories of the person who has died? Why not remember them for their life rather than their death? Isn't the life and legacy of a person something worth displaying and sharing with all comers?

When I die that's what I would want. Some light jazz, lots of pictures, memories, and stories and the focus on the fact that I lived a good life and left my mark in some way on the world. Let my friends and family remember me that way, not as a body in a coffin.

I've had so much on my mind for so long that I really think it is making it difficult for me to stay even and focused. Too much that needs to be done, too much that I want to get done, not enough days in the week, and not enough hours in the day to accomplish these things.

I think that things might get easier for me if I stopped burning the candle at both ends and start to get enough time to sleep, enough time to keep up with my responsibilities, and enough time at least look around and enjoy life.

That being said, I also have had a nagging feeling that I need to prove something to myself and others. One of my friends told me that she thinks I need a quest. I think she may be right but it needs to be a quest that does not send me searching for the unfindable or tilting at windmills like I have done so many times before. I'm not sure what my quest should be but I will be thinking about it at the same time that I think about trying to simplify and streamline my life.

The night is over and I finally get to go home and sleep. Only two calls last night, one at the beginning and another at the end of the shift. In between was quiet and almost boring. This was totally OK with me since receiving the news about my grandmother didn't really want to be at work but, even though I could have taken the rest of the night off without being questioned, I didn;t want to be home either. Strange funk and I may as well be getting paid for it.

Calls for the night: 2
1 ALS Transport
1 Cancelled upon arrival

Mileage for the night: 34

CD for the night: The Best of Del Amitri

This has actually been good since I am in a weird state of mind where I don't want to be at work and I don't really want to go home either. I'm settling for looking over the new protocols that went into effect today so I know what they say before I go ahead and sorta, kinda, but not really follow them.

Added to the Paramedic Guidelines:
RSI moved to standing order
Antiemetics
Etomidate added to RSI protocol
Nasogastric tubes
Endotracheal Tube Introducers

as well as a bunch of operational guidelines.

Not all that interesting but it's something to do.

It's over. My grandmother died this evening at about 1950. She went peacefully and is finally at rest and where she really wanted to be, with her husband of almost 70 years.

I am sad that she is gone but I am also releived that her wait is over and is at peace. I miss them both and will for the rest of my life.

She is alive with a heart rate in the 30's and a blood pressure in the 50's but is totally unresponsive. It's awful to sit there in her room and watch nothing happen. She isn't getting any better and she isn't getting any worse. Her eyes are vacant and the person that I know and love appears to be gone. Her body just doesn't know enough to stop. I am terribly afraid that this is going to be one of the worst experiences of my life.

She is doing poorly enough that the doctor has said that the family should be nearby as her time is limited. It seems that when the cardiologists talked about putting a pacemaker in they decided that she would not survive the procedure. Her children decided that she would want to be kept comfortable and nature be allowed to take it's course.

My grandparents were very important to me throughout my childhood and into my adult life. In January when my grandfather died suddenly a short time before my grandparents 70th wedding anniversary my grandmother was devestated. He had just had his gall bladder out and was recovering well and quickly. His death was entirley unexpected. While she said she would go on with her life because that's what he would have wanted her to do we all knew that she was just passing the time before she would join him. She always maintained that he was "just around the corner" waiting for her and it is somewhat comforting to know that she was knew that it would be only a matter of time before she we rejoin him.

Even though my grandmother would not have wanted it and my mother has said that I should not I will be travelling to the bedside this morning. I did not get a chance to see my grandfather before he died and I have been saddened by that fact since. My hope is to be able to see my grandmother one more time and tell her just how important she and my grandfather were to me, how they, more than anyone else, are responsible for the man, husband, father, and friend that I am, and that I will never forget them. I never told my grandfather this and, although I think he knew how I felt, I wish I had taken the time to say it. I can't allow my grandmother to die without hearing the words that I need to say and that she needs to hear.

This afternoon my grandmother, widowed earlier in the year, was taken to the hospital by ambulance for a period of unresponsiveness and hypotension. The initial call I got was that things were looking quite grave and that they were not sure about her prognosis. Since that time she has improved and I have, finally, gotten information as to what was and is going on.

After her fall of a couple of weeks ago she had been sent to a Skilled Nursing Facility (SNF) to help her regain her strength. Apparently she has had a couple of episodes of low heart rate (bradycardia) over the fast several weeks that she never told anyone about. Tuesday morning she apparantly had another episode but unlike her previous occurences it did not spontaneously resolve itself.

She was brought into the ED with what sounds like a complete heart block. In a very simplified description complete heart block is a situation where, instead of beating in a coordinated fashion between the top part of the heart and the bottom, the heart beats with no coordination. This results in the lower part of the heart, the ventricles, which provide most of the pumping force not being able to take advantage of the faster rate that the atria (the upper chambers) provide. The heart falls back to the "natural" rate of the ventricles to keep the blood pumping through the body but this is rarely fast enough to support what is considered a "normal" blood pressure.

In the short term the paramedics and ED staff were able to increase her heart rate to a point where her blood pressure was high enough to keep her alive and awake. As of now she is in the CCU being rules out for a heart attack and prepped for a pacemaker insertion.

What's my point here? I don't really know for sure. I guess I'm feeling very uncomfortable knowing that I started 2003 with 3 living grandparents and I would like to finish 2003 with a grandparent period. I know in my head that my grandmother will not live for all that much longer but I am not sure I am ready in my heart to be without all of my grandparents yet. They were very important to me as I grew up and I am not ready for a world without them as a source of wisdom and guidance.

The premise of the story is a group of 21st century men and women from widely varied backgrounds are selected to crew an 18th century sailing vessel. The vessel, H.M.S. Endeavour, was used by Captain James Cook on his historic exploration of the Austrailian coast and the neighbouring seas travelling from Mission Bay to Jakarta. What made this such a challenging trip was that it was to be made using 18th century methods of sailing, navigating, and even living in conditions that were designed to duplicate the conditions experienced by an 18th century Royal Navy Sailor.

The work looked hard, backbreaking, and even somewhat dangerous. The food looked awful with casks fo salted beef and authentic hard tack (minus the bugs). Sleeping was in replicated hammocks slung in the gun deck in the hot tropical weather.

Why does this kind of experience attract me? Several reasons I guess but probably the biggest is the challenge of it. These 40 21st century men and women had to come together as a group of individuals and forge themselves into a crew capable for working together towards a mutual goal while performing strenuous and unfamiliar tasks at any time of the day or night in situations not encountered often in modern times. I am attracted to the pure physical nature of the work. It's hard, sweaty, difficult work but every job gave a result that was tangible and perceivable. I am also attracted to the simplicity of the life of an 18th century sailor. Their jobs were well defined and the expectations of them were well known. Not that it was an easy life by any means but it did have a certain lack of complexity that is rarely encountered in modern society.

Simplicity, challenge, and the physical nature of the work make me wish that I could experience that kind of life even for a short time.

I am definitely not used to sleeping while at work. I did it for 4 hours which is much more than usual but I really had to work at it.

Total for the night: 1 cancelled upon arrival

Mileage: 2.3 miles

No CD for the night, the minivan has no CD player.

I usually don't like working Medic 6. Between the almost nonexistant call volume and the total lack of connection to the rest of the system it isn't a station that I look forward to working. I have managed to arrange my schedule so that I am only here twice a month. Unfortunately for me on those nights none of the other paramedics want to work this station either.

Then there are days like today where I have screwed up my schedule and end up with only a couple of hours of sleep before I had get up and go to work at the Apple Store for the afternoon. This is what happens when I try to schedule things without getting enough sleep. Hopefully I'll spend a good portion of the shift asleep and will not get interupted much.

Whew, I am glad that the night is over. It ended up being not so bad as I had the rare opportunity to actually save a life. I say rare because interventions that truly save a live are few and far between. THe situation was a patient with a sudden onset of difficulty breathing who called EMS after about an hour. When I arrived the Rescue and Ambulance were both on scene, the patient had high low, high concentration oxygen in place and looked really, really awful. She had skin color that was so gray I could tell we were in very bad shape without getting close or even turning on the lights in the room. The fluid that was collecting her lungs was audbile across the room and she was really looking tired.

Both the ambulance and the rescue were on the bounce and were already prepping her for the transfer from the house to the ambulance before I arrived. Since they were ready to move her I set up in the ambulance. When she arrived at the ambulance she looked no better in the light and was actually starting get very sleepy. Her blood pressure was therough the roof (300/220). Before I even started her IV I gave her a double dose of Nitroglycerine and 2 inches of NitroPaste to see if I could bring her pressure down. As soon as the stretcher was secure I told the crew that we needed to "get busy and go" and we went at best possible speed heading for the hospital about 25 minutes away.

I got an IV into her and gave 100mg of Lasix (a diuretic) and additional nitroglycerine. Unfortunately she was not looking all that much better and was looking like she was drowning in her own fluids. I picked up the radio to get RSI orders so I could paralyze her and intubate her. At the same moment the doctor picked up the radio the patient rapidly dropped her heart rate from 148 to about 12. This made the doctors orders pretty much a moot point.

CPR was started and I quickly intubated her without pharmocologic assistance and we started suctioning her airway of the copious amounts of fluid that was welling up out of the tube. More medications through the IV to try and stimulate her heart back to beating were administered. By the time we got to the Emergency Department, unlike so many other times, we had pulses back and she was starting to chew on the tube. A little sedation and we headed into the cardiac room where the staff waited for us.

It is so infrequent that we actually are able to bring someone back from the brink of death but this time we did. I was pretty happy. OK, I was really excited and if I could have done backflips I would have. I was happy that things worked the way they were supposed to. I was happy that my performance was on the bounce. I was happy that the ambulance crew and the rescue crew were on the ball and that nobody paniced when bad things happened.

As of 0800 the patient was till on a ventilator in the CCU but was looking much better and her chances for survival to discharge were looking pretty good.

All in all a more positive than negative night even if I did get out 90 minutes late.

Runs for the night: 7
2 ALS transports
1 Cancelled enroute
4 COver assignments

Milage for the night: 72 miles

CD for the night: Hymns to the Silence by Van Morrison

I just couldn't bring myself to go back to the station right away so I took a longish drive. One of the nice things about working alone is that I can do this without worrying about inconveniencing my partner. I can listen to whatever music I want, whenever I want. I don't have to worry about what someone else wants for dinner. I don't have to put up with someone elses phone calls

On the other hand working alone sucks sometimes because of just that, you're alone. A lot of the time I don't mind working alone but tonight, tonight it grates on my nerves. I know I could Nextel any of the other paramedics on tonight but it's not the same as having a living, breathing, thinking being sitting next to you. Someone to share the experience with, both the good and the bad. Someone to act as a reality check and sounding board when things go right or wrong.

Tonight I have thought about a lot of those times when things went wrong. It's just that kind of night I guess. If I didn't know better I'd swear I was depressed and needed to chat with a shrink. Humph, maybe I should and maybe I will.

Today was a wash for getting anything done except sleep. I crashed when I got home and slept straight through until 1700.

When arrived at the ED helicopter was there to take out a patient who walked in in complete heart block. and needed emergent pacemaker insertion. Medic 2 is stationed at a freestanding Emergency Department with limited capabilities and no inpatient ability so whenever something comes in that needs admission or interventions that are not available here they need to be shipped to another facility, sometiems quite rapidly. That was the case with this patient. The external pacemaker that had been applied was not helping and the ability to put a pacemaker in transvenously is just not available here.

The day medic only did 3 runs for the entire day but they were all in the same 90 minutes period so she was busy with paperwork. I took over for her and told her to forget the restocking and I would take care of it. At some places that I have worked some medics would have left the restock for the paramedic that used the equipment but that never made much sense to me. I'm paid by the hour and once I'm on the clock my job is to do what needs to be done. If I can do something to facilitate the day person getting out closer to on time thats great because it means they are much more likely to do it for me when the tables are turned. It just seems like that goes along with being a team player and it's the nice thing to do.

I am two thirds of the way through my inventory of our durable equipment, although I am not happy with it. I am finding that with 2 locations inventoried we are still short some LifePak batteries. Unless Medic 3, the only location I have not inventoried yet, is hording batteries we may have a slight problem. I am pretty sure that the missing batteries were actually disposed of and not taken off the inventory when they were sent for recycling. We bought 7 LifePak 12 units 3 years ago and the initial crop of batteries have been failing and being replaced over the last few months. I'll see what things look like once all three locations have been inventoried and drop an email to Clinical Engineering to see what they think. If all the missing batteries are from the early lots we bought I think they will just write them off and assume that they were disposed of.

The night started out fairly busy in the field and ended up extremely busy in the ED. Fortunately for me I was not responsible for any of the business in the ED. The ED was not helped by the fact that the local University was having some sort of Halloween Bash which brought several students in over the course of a couople of hours for various injuries and for being in various states of intoxication from various substances. Some days I just don't understand how some really smart kids can be so really dumb.

Only 2 ALS calls for the night, the first being a cardiac arrest that we worked and presumed in the apartment and the second being a near head on MVC with the ejection of one driver through the windshield. She was air evaced to the regional trauma center.

Things slowed down and I was able to plow through all of my paperwork by 0630. This made me pretty happy since the day medic from yesterday didn't leave until almost midnight.

Total runs for the night: 10
1 ALS pt evacuated by air
1 ALS pt presumed on scene
1 Refusal of service
2 BLS downgrades
5 Cover Assignments

Mileage for the night: 102

CD for the night: "Understanding Islam" by Thomas W. Lippman