December 2003 Archives

Days sounded pretty busy as I was coming home but I haven't heard much since I've been on the road in to work. New Years Eve could be a real hellish night or it could be dead. No telling. Come midnight all the stations will rotate to the new logs for 2004, check meds for expired meds and reseal all the spare and backup gear. In theory at least, When things get busy it's really hard to do the usual end of month chores and sometimes they may get left for the next shift with a sincere apology.

I don't know what kind of night I want. A busy night could be good if it were challenging although a slow night woth not much to do except chores and watch the new year come in while reading wouldn't be bad either.

I had a hat trick of unresponsive patients for various reasons. Each call was challenging in it's own right and frustrating at the same time.

The first call was probably the most challenging and also one of the stranger calls I have seen in my career. The call went out to respond to an elderly housing complex for an unresponsive person. The FD arrived several minutes before I did and there was no update from them which is somewhat unusual. What was really inusual was that there was no radio traffic at all. I arrived a minute behind the ambulance and was told that it was a "bad one" and that they were on the way out with the patient and I should setup in the bus. No problem, I set my gear down in the ambulance and started spiking a line and getting the monitor set up.

The patient arrive shortly and I found that I had an elderly woman who had been found on the floor by a neighbour unresponsive "frothing at the mouth". While she had a lot of secretions it certainly didn't look like froth to me but that was neither here nor there. The patient rejected an oral airway and was maintaining her own airway reasonably well but with lousy O2 sats and really variable heart rate and respiratory rate. Since she had a gag reflex I was going to have to start a line no matter what before I did much of anything so with surprising difficulty I got a line started. Every time I tried to start the IV the needle would enter the vein, you would hook up the IV, run in some fluid and the vein would just disintigrate. Not fun. On the third attempt I finally had a patent IV.

I just really didn't like the way that this call looked and as time went on I found that I was quite right. A quick check of her sugar showed a level of 27 (normal is in the 80 to 120 range). Ding, ding, ding! We have a winner. An amp of Dextrose 50% later and.....nothing happened. Another fingerstick showed a glucose of 36. Odd but could happen. A second amp of D50 and, nothing happened. Now I was getting worried, another fingerstick came back at 66. Better but something should be happening.

In the meantime the monitor was showing a paced ECG with multiple nonconducted pacer beats. Her respiratory rate had not improved any and the ambulance crew was assisting her ventilations with a bag.

Actually, I shouldn't say that nothing happened, the patient now had a firmly clenched jaw. 5 minutes since the last dextrose and it's decision time. I decide that the patient really needs to be intubated and we go about quickly setting up for an RSI. I gave her the Etomidate and her jaw loosened a bit and I was able to intubate her after suctioning lots of really tenacious secretions from her throat. What was unusual was that after I intubated her and before I coud secure the tube she started with the clamped jaw again, clamping down on the tube so hard that she started to block it off. A quick dose of the paralyzing agent and she stopped actively chewing on the tube but was still clamped down on it so that I could not get the bite block in. I ended up holding on to the tube for the rest of the trip while the crew bagged and prepped her for arrival at the ED.

Once we got to the ED it got even weirder with the patient eventually being extubated by the doc because she was fighting the tube so much. I don't have a problem with this but what was really weird was that 20 minutes later, about 45 minutes after I initially intubated her I was back in the room reintubating her after she had several long periods of not breathing. Her glucose level was still not responing much to an additional 2 amps of D50 and the IV was changed over to D10W. Ahha, core temp just above 90 degrees F. That's not good and explained a lot. Didn't really explain the respiratory stuff or the pacemaker not capturing on every beat but, well, you can't know everything I guess. This paitient was admitted to the ICCU with hypoglycemia, hypothermia, respiratory failure and, as of the end of the shift, was still tubed and on a vent. Curious and nicely challenging.

The other 2 unresponsive patients were from a local SNF one with a fever of 104 F and a rapid respiratory rate and eventually got intubated and transfered to one of the larger hospitals about 30 miles away. The second was a 99 year old guy with what ended up being such bad dehydration that the Doc said he had never seen such bad looking lab values. After 4 litres of fluid he was still hypotensive and unresponsive and had little urine output. Oh, and he ended up having a GI bleed too with hem positive stool. Heh, never simple.

My relief was in early and I was more than happy to pass the baton to him, finish paperwork and depart since I was back in as his relief in the evening.

Total calls for the night: 4
3 ALS transports
1 Cover assignment (really, really long)

Total Milage: 111 miles

CD for the night: "Vince Benedetto meets Dianna Krall"

I made it to work quite early tonight and had a chance to talk with the day medic about some of the depressing calls we both have had recently. Both of us have had our share of patients who have presented with unclear etiology and what ended up being end stage diseases. After a while this gets to be pretty depressing stuff.

I fell asleep in my chair while I was editing some of my writing. I was out very, very hard and slept soundly for almost 10 hours. I guess I needed it, but it didn't help me go back to a night schedule very much. Right now I'm waiting for my mom to come and watch the kids for a few hours so I can get some Benadryl induced sleep so I am not falling asleep tonight.

As nice as it would be to sleep the entire afternoon away I can't do that. The refrigerator that was supposed to be delivered yesterday to replace the dying one in our kitchen will be coming this afternoon instead. When it arrives I will have to get up and take delivery, supervise the installation and removal of the old one. Oh, yeah, and I suppose the guys will want to get paid for the new appliance. So much for new storm windows. Oh well, I'll just keep taking the overtime as I can even though it means working days now and then.

I should but I couldn't. It was not an earth shattering question, not a relationship changing question, not a question that mean the difference between life and death, but a question that rocked me back on my heels a bit anyway.

The question? Why do I, who has always been a very private person, keep a weblog? I understand why I have been keeping a journal, I understand the need to put thoughts down in paper, real or virtual, as a way to throw them out for examination and resolution. I can even understand the desire to share some thoughts with trusted friends for them to provide feedback. I tried to give these answers but they did not really answer her question and I was not going to be allowed to weasel my way out of it.

The answer she wanted is why I feel the need to put my life out for public inspection. It's an interesting question and one that I am not able to answer adequately, yet.

I don't normally count on getting sleep when I come to work but I really need it tonight. Because I got out late this morning and had company this afternoon I didn't sleep anywhere near as much as I should have or wanted to.

Before I crash though I need to do the usual check of the equipment and shuffle the usual start of shift paperwork. I also am supposed to help a friend move her websites from one server to another and get the ball rolling on the DNS changes. A lot of the foundation work has already been done and most of the work that remains needs both of us to be online at the same time. The plan is that by the end of the night things will be in place and ready to go once the DNS changes percolate through the internet.

All in all a pretty good night although a little more too do would have been nice. As the clock came around to 3am it got to be harder and harder to stay awake and alert. But even taking that into consideration I did get a lot of work accomplished and was pretty happy right until the end when the last call came in within 10 minutes of my relief arriving at the ED. Such is life. The call was worthwhile and the patient needed the care.

I ended up getting out about an hour late and headed out to the store to pick up the last few things that my wife needed to make dinner for my family this afternoon. When all was said and done it wasn't until almost 10:00 that I finally was done moving and was able to head for bed.

Total calls for the night: 3
1 ALS transport
1 BLS downgrade
1 Refusal

Total milage: 64 miles

CD for the night: "The Trombone Master" by J.J. Johnson

Not that I minded having the time off but I really am looking forward to getting back to work. I have so much that needs to get done and I am hoping that I can get some of it finished tonight, if not, I'd love to be busy with significant calls. We'll see what happens. If I can't do something significant I may as well finish my work and get some online CME work done.

Among the stuff that I need to do is submit some vacation requests. It seems that once again I have more than the allowed vacation time banked and I need to use some of it or risk losing it eventually. So I'll submit some days, a couple together at the end of March so I can accompany my wife to her conference in Boston and then a few scattered around to eliminate some schedule conflicts with my wifes call schedule.

Over the last several days I have seen my name creep closer and closer to the top of the mandatory OT list. I ended up closer to the top of the list than was comfortable. My kids are off from school until after the first of the year and I couldn't afford to be told that I would have to work on a day where I needed to handle the child care. I need to be careful, I don't want to get used to working days.

Instead we drove to my sisters house, just south of Boston. I can't say it was a difficult drive because I spent most of the trip asleep. I really hate travelling after working all night but this was when the family was gathering and, especially this year, I needed to be there and spend time with them. My wife took good care of me and settled me in in the passenger seat reclined and comfortable, listening to some light jazz. I was asleep fairly quickly and slept deeply until we arrived.

It wasn't long enough by a long shot and when I awoke I could tell I was going to be in trouble. I was still tired, and I was caffiene depleted. I can pretty much be assured of a migraine if either one, the other or both these conditions are present. Not being a coffee drinker and drinking only diet soda left me with no choices for the caffiene and I really wanted to stay awake to be with my family. It was my own fault and I knew the headache would come and soon after we arrived I ended up with a dull migraine that lasted the entire afternoon no matter what I did. Fortunately it never got to the roaring migraines I get sometimes and I was able to bear it and be reasonably socialable.

It was important to me to be with my family. Even though I don't celebrate Christmas in my home anymore, and even though I sometimes get annoyed with some of my family members this was the first Christmas since both my grandparents died and I felt that I really needed to be there with my family both to be of support to them and to get their support. Christmas was always a holiday that I associate with my grandparents as long as I can remember and my recent memories had been the best. I have vivid memories of my grandfather sitting in his chair with one, two, or even three great-grandchildren in his lap. He would be just beaming and all of the acceptance, warmth and absolutely unconditional love showed through. I remembered that feeling and relished it since I was a child. As much as I know that noone lives forever I had always hoped that my children would come to know those feelings that made my childhood, young adulthood, and my journey towards middle age as good as it was rather than as bad as it could have been.

Although none of us spoke a word it was clear to all of us that there was something missing. Also unspoken was the feeling that we would have to go on and adjust to our new family dynamic.

One thing that brought some tears was when I gave my holiday gifts to my family. Since the birth of my first child I have had a growing interest in my family history and as such had looked to trace the family back as far as I could. THe search led me to the archives at Ellis Island where after much searching and several false starts I was able to locate information of my grandfathers arrival in the United States with his parents and brothers. Copies of the ships manifest listing their names, ages, occupations, and the like, along with a photo of the ship they arrived on and a copy of a family photograph from shortly after they arrived had been order months ago. The idea was originally to frame a set and give it to my grandfather for a gift. Obviously that was not to be but when the photos arrived I thought that they would be a nice gift for the rest of the family and had copies made for all the family. As everyone opened them and looked back on a piece of our family history there were tears and looks of deep thought and rememberance. Some were more emotional than others but all of us were touched by the loss we had experienced and the history which will never get passed on to us. We never could get my grandfather to talk about his passage from Europe to the U.S., his expereinces at Ellis Island, and as a new immigrant.

I'm glad to have this connection with him even now that he is gone, some bit of information to tell me about his past and his trials in coming to America. When my children are older we will make the journey to New York and take the boat to Ellis Island and see for ourselves as visitors, almost a century later, what my grandfather experienced first hand.

I guess all the thinking put me in a down mood and my headache was persisting because I was very happy to be back int he car and headed back home. As much as I wanted to sleep for the trip home, I did not, spending the time talking to my wife about all the things going on in our life.

By the time we actually arrived home we were all exhausted. Our housework will wait until morning.

As busy nights go this wasn't bad. The calls were staggered enough so that my response to one was not delayed by the previous call. I did have a couple instances where I had to wait for a transport unit to be found for me which was kind of disturbing. I really hate being on scene with a patient and not knowing when the transport ambulance is going to come. I was also kind of disappointed that on Christmas Eve, a night when very few people have to work or have to work the next day a crew could not be had for love or money. I certainly understand people wanting to spend time with their families but there has to be some responsibility to the community as well. *sigh* Even the commercial service in the county was having staffing problems, only able to field a single paramedic ambulance where they normally have three or four.

The ED volume was steady but not overwhelming which was nice. Lots of food arrived from various places which made staying on the low carb diet difficult if not impossible. Once the holiday is over I'll have to be back on the straight and narrow.

Call volume for the night: 9
3 ALS transports
2 BLS downgrades
1 Unable to intercept
1 Fire Standby
2 Cover assignments

Total miles for the night: 187

CD for the night: "All for You" by Diana Krall

Since yesterday I have been in a very reserved mood. Feeling very much like I want to be alone and allowed to think or not think as I see fit. I just have a lot to think about and with my life being what it is I never have much time to think about it. I'm hoping that Christmas Eve will follow the trend of either being absolutely dead or wild beyond imagination. Either way I would get the chance to think or be so busy that I can't remember my own name. Either would be fine with me.

Right now it is driving rain and heavy fog in places which promises to make travel difficult in spots so I hope that everyone is safe in their travelling and partying tonight.

The hot spots for the night were anywhere that I was not. Even though I had 15 dispatches I only saw 4 patients and ended up transporting 3 of them. The night had started out busy and stayed busy in the ED for the entire shift. Lots of respiratory problems, not all of them significant, but lots of people there. With the flu going through the area like it is it is making everyone nervous, incuding the medical community. With all the hospitals in the area operating at almost full capacity I don't know where we would put all the people who would need to be admitted should a major outbreak occur.

Total runs for the night: 15
3 Cancelled enroute
1 Cancelled on arrival
3 ALS calls turned over to the ALS ambulance
1 ALS transport
7 Cover assignments

Total milage: 194

CD for the night" "Riding with the King " by Eric Clapton and B.B. King

I did a three way swap so that all of us working tonight ended up at the station closest to home. It seemed to make the most sense and gave me a chance to get a little work done at the hospital. When I relieved the day medic he still had several run forms to finish and the ED was hopping, a situation only made worse by the young MI that was being prepped for airlift to the tertiary care center for a cardiac cath. As usual both the oncoming and offgoing paramedics ended up in the room involved in caring for this critically ill patient.

It had been an unusual day with my wife calling in sick to work, something that she rarely does. I knew her schedule would catch up to her eventually and today it did. I envy her stamina for work, I could not work as many hours in a week as she does and maintain my sanity. She crashed into bed before I did and was well asleep before I got into bed. It was kind of strange to have someone else in the bed with me during the day but I suppose I could get used to it. Although I probably shouldn't since neither one of us is likely to be changing jobs or schedules anytime soon.

My sleep was mostly restful today which is something that I would like to get used to. I'm hoping I can repeat this for the next couple fo days. Even though I am not working tomorrow night it makes sense for me to stay on a nighttime schedule since I am working Christmas Eve. Actually I am going in early on Christmas Eve, I swapped into it so that one of my coworkers could be home for Christmas and agreed to come in early so that the medic working days could have some time with his family. It seemed like a nice thing to do and it really made no impact on my week. Truth be told, I like doing nice things for the people I work with.

Of course the video problem that I have been having has not occured all weekend. I'm really hoping that it will occur for the tech so that they can fix it. This is going to be a strange time for me, it has been many years since I have been tethered to a desktop machine for all of my online activities. The tech support people have said that it will be no more than a week but that frequently these things are done much sooner. Of course the holiday throws another wrench into the whole procedure between higher than usual shipping volume and the repair depot being closed for at least 2 days. I suppose if I have my laptop back by the new year I should consider myself very lucky.

What's going to make it even stranger is that the two desktop machines that I have available are either a server or are running Windows. Neither is an appealling prospect.

I admire her dedication but wish that she were able to take better care of herself. The same thing holds for me and a lot of my friends. Too much to do and not enough time to do it in. Something has to give and that is usually the time to take care of ourselves.

I woke up this morning to what sounded like a thundering herd of wild animals outside my bedroom door. It wasn't, it ended up being just three kids trying to figure out how to be in multiple places at once and do more than one thing at the same time. It was kind of amusing hearing them trying to figure out how to watch a video, play a game, and pretend to be school teachers all at the same time.

The kids are not happy that Mom is gone to the hospital and as such there has been some bickering and acting out but I am trying my best to deal with it in the best fashion I can. We'll see how the afternoon goes, it should be an interesting day.

Although I hadn't had more than a couple of hours of sleep it was nice to see friends and family and enjoy some peaceful time together. My in-laws and a family friend arrived from New York at lunch time followed closely by my father (my mother was under the weather and elected to stay home and rest). Much of the afternoon was spent preparing for the arrival of our other guests and when the time for them to arrive rolled around we were ready and looking forward to getting started.

It was a somewhat ecletic collection of guests ranging from a rabbi to a private investigator to another paramedic. As expected the conversations ranged from medicine to weblogging to religion to history to computers and it was nice to have grown up conversation while the kids were playing nicely (I said nicely, not quietly) in another room.

I have to say this publicly, my wife is a fantastic cook and an excellent party planner. The meal was excellent with lots of traditional foods including latkes and brisket and a home made cheesecake for one of the many items available for desert. (Clearly I fell off the low carb bandwagon for the night.)

The only bad part of the entire day and evening? I started to lose steam shortly after desert and by 2100 was a total basket case, barely having the energy to stumble down to bed and collapse.

The winter slowdown has definitely arrived and I am finding it almost relaxing. I could do with a little more action but that will come in good time.

I had the chance to read my hospital email. Lots of email, not a lot of good news. Our capital budget requests were turned down effectively killing our addition of CPAP to our treatment protocols. No radio equipment and no new vehicles. With all three of our stations running about 50K miles a year and last years replacements denied as well this could be bad.

Total calls for the night: 3
1 ALS transport
1 Refusal
1 BLS downgrade

Total milage: 48

CD for the night: "C'Mon, C'Mon" by Sheryl Crow

Days was pretty busy according to the day medic and the pile of paperwork still to be completed. No telling what the night will bring other than cold. Personally, I'd be happy with a night with a few calls well spaced (as if I have any say in the matter).

I am hoping to get some continuing education done online tonight and maybe some reading as well. Cold nights are good for that kind of thing.

From the Union of Reform Judaism website:

"Alexander the Great of Greece conquered Judea, the home of the Jews, in 333 B.C.E. At that time Alexander allowed the Jews to maintain their beliefs and traditions. With Alexander's death, the lands he ruled were divided between the Ptolemies, who ruled Egypt and the Seleucids, who ruled in Syria. The Ptolemies and Seleucids fought for control over Judea. The Syrians under the influence of the Seleucids became Hellenized, adopting Greek culture and habits. In 198 B.C.E. Antiochus III, king of Syria, conquered Judea. Like Alexander, he also allowed the practice of Judaism. All this changed in 175 B.C.E. when Antiochus IV, also known as Antiochus Epiphanes, came to power.

Antiochus Epiphanes wanted to Hellenize the Jews. He outlawed Sabbath observance, circumcision, and Torah study. The Temple in Jerusalem was desecrated with a pagan altar and Syrian soldiers set up altars to the Greek gods throughout Judea. A Jewish resistance movement began to grow, led by a priestly family known as the Hasmoneans or Maccabees. The leader of the family was Matityahu (Mattithias) along with his five sons - Judah, Yonatan, Eliezer, Yochanan and Simeon. Three years of fighting ensued and though the Jews were greatly outnumbered they prevailed. This was a great victory for religious freedom.

The Temple in Jerusalem was cleansed and a ceremony of rededication was held. The Hebrew word Chanukah means dedication."

The URJ website continues:

"The rabbis of long ago faced a dilemma; they did not want Chanukah to be looked at as a military victory alone. In the Talmud, the rabbis recorded the legendary miracle of the oil: When the Maccabees had cleansed the Temple and they were ready to kindle the Ner Tamid - Eternal Light, only one small jar of oil marked with the seal of the Cohanim - High Priests was found. It would last only one day and it would be eight more days before more oil could be prepared. But a great miracle happened; the oil lasted for eight days. According to the rabbis this is the reason we celebrate Chanukah for eight days.

In choosing the haftarah for the Shabbat of Chanukah, the rabbis sought to teach us another lesson about faith. The haftarah, Zechariah 4:1-7 includes the verse, "Not by might, nor by power, but by My spirit, said the Lord of Hosts." This was to remind us that it was not by the military force of the Maccabees that the Temple was restored, but it was by the spirit and influence of God that these events occurred."

Kind of strange but that's is what happened. He didn't tell me exactly how or why but he had some concerns that he and I needed to address. It was actually a very nice conversation and went much better than I had been suspecting. It always injects a lot of anxiety in to my life to have a message on my answering machine that my superior wants to talk to me. It really doesn't matter who that is or what job it has been for messages from the higher up in the chain are always a cause for an anxious feeling in the pit of my stomach.

After we talked I had to agree that his concerns were valid and need to be addressed. Even though I had talked with a friend of mine who is an attorney before I started blogging publicly there were and are some things that should be made clear to anyone reading.

Even though I am paraphrasing the what my attorney friend said it still sounds like a legal mumbo jumbo. I apologize for that but this stuff needs to be said and then we can carry on.

1. The opinions expressed here are mine and mine alone. They do not and should not be considered the opinions or positions of my family, employer, friends, or enemies. If I say, it I own it, nobody else.

2. This weblog represents my life as I see it. Others may, and probably do, see the same incidents differently. I can speak for myself and nobody else.

3. Identifiable information about coworkers, patients, other responders, and the people I encounter during the course of my day to day life will not be published. Enough information will be given to provide the flavor of what I am writing about but no more. In the same vein, the actual identity of my employer will remain unpublished. Information regarding the system that I work in will be enough to allow for understanding of the unique nature of my job but the actual identity will not be published directly.

4. Blogging will be done on my own time, not that of any of my employers. This is not to say that entries will not be composed while there is down time during the course of my day, but publication will only occur on my time. Entries that are composed in this fashion will be "backdated" so that they are in proper chronological order. The computers and networks belonging to my employer will not be used for the purpose of making any weblog entry.

5. Comments on any entry are appreciated and welcome. However I reserve the right to delete any comment that I find detracts from the value of the entry. After all, this is my blog, people who don't like it are welcome not to read it.

A standard disclaimer boiling what I have listed here down to a few sentences will be placed on the front page of my blog so that it is available to all readers.

There was more to the conversation but it was of a more personal nature and will not be repeated here.

I appreciate the fact that my boss did not ask me to stop what I am doing, he did not ask me to explain why I am doing it, and he did not allow this to become a major problem before talking to me about it. Curiosity makes me wonder how he found and indentified me but in the grand scheme of life it is information that makes no difference.

I also want to take the opportunity to publicly thank my boss for allowing me to take a few minutes while on duty to go to the synagouge and say Kaddish for my grandmother. I deeply appreciate his sensitivity.

Not that is was all that busy with emergencies but it was very busy with cover assignments. The evening was very busy for both the other units. As soon as I came in I was out the door to intercept one of the ambulances that had been sent to a "sick person" call and when they arrived just didn't like the way the story felt. When I intercepted with them I have to say that I agreed that the story was not at all comfortable and it took me all of 15 seconds to decide that I would be accompanying the patient to the ED. The call had been for an elderly gentleman who had been found naked on the floor after not being seen following his normal pattern of activities. He was confused as to when he ended up on the floor and how he ended up there and had no idea why the heat was off in his house. He was cold to the shoulders and had multiple contusion on both sides of his body but more on the right. Glucose was fine, no focal or general neuro symptoms, no significant injuries, the story just didn't make sense to me. I did routine ALS and transported to the ED where the nurse and the doc all agreed that the story made them uncomfortable too. I was sent out again pretty quickly after that and didn't get back until much later. I didn't get a chance to talk to the attending doc about the case but I did get my research assignment for tonight, investigate rhabdomyolysis.

For the remainder of the evening I went from cover assignment to cover assignment putting over 140 miles on the truck by midnight when I finally got back to the ED for a while.

The night slowed down considerably for all of us and the ED staff as well. I only had one more call which was for a middle aged diabetic in a SNF who, at his 0400 glucose check was below 30 (normal is 80-120 depending on the lab). The SNF staff gave him a shot of Glucagon and called 911. Glucagon is, in very basic terms, a medication that can be converted into glucose in the body. Given as an intramuscular injection it takes a while to work and by the time I got to the scene the medication had started to kick in and the patient was awake, still groggy, but definitely coming around. I check his glucose and got 75, confirming that he was on the upswing and that the medication was working. By the time the ambualnce arrived he was awake, alert, and talking rationally with us. The staff still insisted that he be transported to the ED. Enroute he told us that he thought he got 16u of insulin instead of the 6u he was supposed to get. Hmm, the situation makes much more sense now.

Total calls for the night: 8
2 ALS transports
6 Cover assignments

Total milage: 180 miles

CD for the night: "The Trombone Master" by J.J. Johnson

I feel like the standard operating procedure for my life is run as fast and as far as you can, collapse, recover, do it again. The last couple of days I have been recovering from my nights at work and my funky sleep patterns for the past week or so. I don't know what it is but I just have not been sleeping well during the day and that is troubling since it is always something I have been able to do without any trouble at all.

Anyway, yesterday ended up being a very good day, talked with a couple of friends for a long time, got some work done around the house and spent some time playing trombone, all three kids even got showered or bathed (against their will I might add)and I actually had a few minutes to relax. Of course I fell asleep. It seems to me my modus operendi.

This morning I woke up feeling pretty good and managed to get a lot done that I had been putting off for way to long. The only thing that could have made it a better morning is if I had not run out of stamps and had had some air mail stamps in the house. When I don't need them they are all I can find, when I need them there are none to be found. So I know that this afternoon will be taken up by trips to the bank and the post office at least.

I am really hoping that I can finish with my work on the early side so I can spend the evening with my family and then, after they all go to bed, go back to the trombone for a while. I am getting better very, very slowly. It still hurts after a while but it takes longer for the pain to start. I still have nowhere near the range that I once had but that will take time. I am starting to improvise some very basic stuff to try to put some of my feelings into music that I can't put into words. Eventually though I will have to sit down and put some of this on paper and, I suspect, add some additional instruments to cover the entire range of what I want to express. Right now I am leaning to some odd combinations. I'd probably like to add a violin, tenor sax, and maybe an oboe to the arrangement to give the entire composition better range. Of course I have never played any of these instruments so I will have to seek out those who have and see if what I am envisioning is even possible to be played. In earlier days when I was playing professionally I ran into one or two pieces that were physically impossible to play on the trombone because of the range between notes or the speed with which the composer expected the musician to change positions and fingering. Admittedly I have never composed something like this but, well, how else can you grow if you don't push the envelope once in a while?

At best, not too good but not too bad. I was pleasantly surprised. Things started to look pretty good when I found out that, while not broadband, the car dealer had telephone jacks available for customers to access the internet while I was waiting what promised to be about 5 hours to finish the work on my car. Then I found that I was actually getting work done, sending out emails that I had been meaning to send out for several days, cleaning up loose ends on various projects. A nice early morning chat with a friend from the west coast really did a lot to boost my mood as well.

Then while I was making all this progress I was contacted by an old friend that I haven't seen in, probably 8 or 9 years. It was a wonderful conversation. We have much more in common now than we ever did before, talking about work, kids, and "ancient history" on both sides. I really hope that this is the beginning of a closer relationship between us after almost 10 years of little contact of substance. I really miss some of my old friends and look forward to rebuilding a relationship that goes back a long time.

It was very enjoyable to have talked with 2 friends, one old and one newer, within the same hour and it really gave my mood a boost.

The day got even better when the service department finished with my car over an hour ahead of schedule. This meant that I was able to get home earlier than expected and spend some time with my trombone before my two oldest kids got off the school bus.

All in all quite a good day so far.

I had scheduled my car for service today because of a recall notice. The initial plan was for me to drop my car off and have the courtesy shuttle bring me back to my wife's office where I could take her car and do the errands I need to get done today. It's a good plan and has worked well for us in the past. Today pretty much the one thing that can screw it up happened. My wife's car had a dead battery, a deadline as to when she had to be at the hospital, and, of course, we couldn't find the jumper cables.

Well that just stunk. A rapid change of plans left me with no choice but to drive her to work and then wait for however long it takes for the service to be done.

So I am left sitting in the "service lounge" at the dealership waiting. I think, no, I know it is going to be a long wait. I suppose as long as I make it home in time to meet the bus I will be in good shape.

I'm a little frustrated though, when we left I forgot to bring my iPod and am now stuck here without my music to listen to and with out my audio books. This is going to be along wait, I just hope I can keep busy for the wait and not go crazy from boredom.

According to my wife I fell asleep on the sofa around 2000 and stayed asleep until midnight when she rousted me down the hall to go to bed. By that time I figured I would be awake for a little while and do the things that I wanted to do and talk with the people I wanted to talk to, but that was not to be, It seems that I fell back asleep and slept pretty soundly through to morning.

Now I'm awake and reasonably well rested but frustrated with the stuff that I didn't get done. *sigh*

I can't say that I am disappointed at all. This means that I will not spend the entire night out on the highway at crash after crash, and that my kids will go to school, my wife will go to work, and I will go to sleep come morning.

Slow night so far with just one call. I am looking forward to the end of the shift.

The trip in to the station was pretty bad. Sleet and freezing rain coming horizontally across the road driven by strong cold winds. We got a little snow, maybe 3 or 4 inches but before I woke up this afternoon it changed over to this stuff.

I slept pretty well but could have used another hour or two (when isn't that the case?) and woke up reasonably refreshed.

The day medic was pretty anxious to go home and he left as soon as I got in. I envy him, he is going home to his significant other to sit in front of the fireplace with a bottle of wine and watch a movie. It sounds really nice, not with his girlfriend of course, but as a sort of generic idea it sounds really nice and I could really go for that kind of thing.

So it was not a busy night, as a matterof fact it was such a slow night that I had a hard time staying awake at times. Just one call, and ALS transport for an elderly woman who had a syncopal episode. Everything came back negative and she was discharged within a couple of hours. Other than that I stayed at my desk most of the night and read and did some holiday shopping online.

Now it's time to brave the cold again and head home to go to bed.

Total calls for the night: 1 ALS Transport

Total milage: 14

CD for the night: The best of Thelonius Monk by Thelonius Monk

2100 and it is already 21 F/-6 C and pretty windy. I am not a happy camper and if I end up spending a lot of time outside tonight I will be even less happy. Let's call a spade a spade, when it comes to being too hot and too cold I am a serious wimp.

The day shift was only moderately busy but still managed to be getting out 2 hours late. I'm hoping he gets some good sleep since he is my releif in the morning.

Sometimes I don't know what my boss is all about. He sent out a memo prohibiting the paramedics from bring laptop computers into the hospital buildings. We ccan use them all we want outside the buildings and in the trucks, just not inside. No explaination, no justification, just a 2 sentence memo. Quite a few of us are not happy with this policy as we use our personal computers to do a significant amount of department related work. So far all the paramedics that I have talked to feel pretty much the same. No laptops in the building? OK, but none of us will do project work on our computers except while we are in the trucks, essentially limiting it to cover assignments. My suspicion is that one paramedic ticked someone off and the knee jerk reaction is to punish everybody for it. I don't kow this for sure but that would fit the previous patterns. *sigh* Whatever. At least he hasn't banned books, pen and paper, and sitting down in the buildings...yet.

For a change I was finished with the paperwork, had all the equipment restocked, and the vehicle cleaned (well, as best you can in 24 degree weather) by the time the day medic arrived.

For some reason it was respiratory night, almost everybody had some kind of respiratory ailment. On the other hand there were no calls that required me to spend a long time in the cold weather.

The weather report says that we should expect snow by Sunday that will continue through Monday some time. That does not thrill me very much since I have to work Sunday night and, if it snows as they say, school will likely be cancelled for Monday which will leave me home with 2 or 3 kids all day Monday. I love my kids but I would really like to get some sleep after working all night and cat napping on the couch just doesn't do it for me.

Total calls for the night: 10
2 No medical emergency
3 ALS transports
2 Cancelled enroute
3 cover assignments

Total milage for the night: 102

CD for the night: "Live in Paris" by Diana Krall

I always wonder when they seem that happy that their relief is in, do they know something I don't? He gave me the rundown on the truck and equipment. His day was not all that bad, 5 calls, 4 ALS transports and 1 cancelled enroute. Not too bad. He managed to leave right on time which is unusual for a day shift.

They started the latest construction in the ED. They are in the process of turning 3 storerooms, the locker room and the bathroom and shower into a behavioral health suite. We have the largest population of substance abusers and choronically mentally ill patients as any place I have ever worked. It is not uncommon for us to have between 10 and 15 of these patients awaiting disposition on any given day. This is a lot for a community hospital. Part of this is probably due to the fact that we have the only remaining State run hospital for the mentally ill and substance abuse patients left located about a mile from the hospital. Patients discharged from the State hospital frequently have no other places to go when discharged and are transplanted to our fair city.

Don't get me wrong, I like having days off but find that I get restless when I have more than a couple of days off in a row. I think part of it is the feeling of being "out of the loop". Part of it is that, believe it or not, when I am at work my life actually has a little more structure and predicitability that it does at home.

I also need to get my mind off the things that trouble me. Sick friends and family, the recent deaths of almost an entire generatioon of my family in about 8 months, financial troubles, health problems, both mine and family members, and the fact that I will be 40 next year and am filled with anxiety wondering how long I can remain a paramedic and what I would do if I were injured to the point where I could not continue.

Being home with down time leaves me much to much time to think about things and, as discussed in a previous entry, do the paramedic thing and imagine the worst case scenario first.

As unsettling as this stuff may be, I have been back on the treatment for my chronic depression and it has been helping. I still worry but the lows are nowhere near as low as they had been in the past and my low periods last much shorter time periods.

It's kind of interesting, although I don't know the cause and effect stuff, but as I talk with my colleagues I find that many more of them are being treated for various depressions, anxieties, stress related disorders. I don't know, although I do suspect, if these things were present before we all started working in EMS and it speaks to a personality type that gravitates to healthcare or if they were as a result of working in EMS, or some of both. What I do know for sure is that the culture of EMS (and other emegency services, as well) tend to look at the need for psychiatric care to be a sign of weakness or inappropriateness for service. Which, I believe, is the reason that so few emergency workers are either not offered some type of mental health care or choose not to utilize it.

We need to face the fact that we are frequently called to bear witness to bad things happening to good people. It is impossible to repeatedly see these things and not be effected in some way. The admission that they need help to adequately deal with these things is not a sign of weakness but rather a sign of strength, it requires much more strength to seek help than to do nothing and accept the status quo.

I am speaking to the nurse much more often than I like to and the only thing that is a small consolation today is that when she called, she didn't wake me up. Today's disaster comes in the form of my daughter getting sick in the lunchroom after eating her entire lunch in about a minute and a half. We have known for quite some time that she does not like the lunchroom at all, too loud, too many people, too little structure. The fact that lunch is followed by recess which has the exact same problems makes me really wonder just how sick she is and if this isn't just a new way for her to get out of surroundings that are uncomfortable for her.

When I arrived to pick her up she was quite happy and bubbley in no apparant distress. On the way home she asked several times if she could have a snack and was terribly upset when I said no. I tried to explain that if she threw up after eating her lunch it would not be a good idea for me to give her any snack food. We would consider some very bland foods in a while but right now her stomach needed a rest. Her response? "Oh Man!"

I can't tell of I am getting much better at picking up on the actual undertones of my daughters behavior or if I am just gettign cynical enough to think that all of this is just another case of it not being about what it's about.

What I woudln't give for a better understanding of how her mind works. What I wouldn't give for her to be normal. *sigh*

I really expected that I would want and be able to come home and go back to sleep for a few hours but that was not to be. Meetings at the school with my oldest daughters teachers. An appointment with the Naturopath about my daughters diet. Post office, bank, pharmacy, gas, many phone calls, down to the synagogue to fill out some paperwork, return a borrowed defibrillator to the salesperson that loaned it to me, my own appointment with the doctor, and home in time to get my oldest off the bus.

Then more things needed to get done. Laundry, straightening, a trip out to the office supply store, drive my daughter to dance class and then drop off some WiFi equipment that I am loaning to a former client.

By the time I got home I was thoroughly exhausted. Even though I had had every intention of spending time with my wife, chatting with some friends and catching up on my email and blogreading it was just not going to happen. I sat down for a moment and woke up quite a while later.

I guess I need the sleep so I am going to bed.

For a change it really worked in my favor to be at this station for the night. Aside from the one call we had no activity and, very unusual of me, I slept for about four and a half hours last night. I needed it badly and could use a few more hours of sleep too.

Total calls for the night: 1 ALS transport (expired during transport)

Total Milage for the night: 5

No CD for the night, the minivan has no CD player and I didn't spend enough time in it to listen to anything else.

Sleep: 4.5 hours of delicious refreshing sleep (for a change) that I got paid for.

As soon as I walked in the door we were out for the "Altered Mental Status" call. When I arrived we were directed to an upstairs bedroom where and woman in her midsixties was lying on the bed restlessly moving around. She had that greyish looking colour that just makes the hair on the back of your neck stand up.

The family related a history of breast cancer which had spread to her liver and had been at the hospital earlier today to have fluid drained from her abdomen.

Both the ambulance crew and I knew that this was just not looking good and one of them shot back downstairs for the stair chair while her partner and I got vital signs and placed her on oxygen. Surprisingly her blood pressure wasn't bad and her pulse, although irregular, was strong. As the crew was carrying her downstairs I talked with the husband regarding her medical condition and how agressively they wanted her to be treated should anything happen. He said that she had a living will that specified no "heroic" measures. That doesn't mean a lot and since no legal DNR paperwork was present As I went down the stairs I was dialing the phone to talk to the doctor at the ED. I've known the doctor I was talking with for over 15 years and his order was to do as much or as little as the husband wanted but don't be afraid to stop.

Shortly after we started to transport the patient began to have periods of apnea and episodes of V-Tach. I had a really bad feeling about this and asked that the ambulance be stopped and the husband moved from the front seat to the patient compartment. After this was done and we were underway again I explained what was happening to the husband and that he would need to tell me just how agressive he wanted me to be.

That is not the situation that I want to be putting anyone in but it was time for a definitive decision. I can only imagine how difficult a decision it must have been and after I answered a couple of questions he decided. Intubation no, defib yes, one round of meds, if nothing then we stop. Pretty much it went in that order and after a few minutes we were at the end point. I was comfortable with it, the husband was as comfortable with it as he was going to be. I felt like the right thing had been done and I had given him one last chance to say good bye to his wife

I was sad for the patients husband but felt like I had done the compasssionate thing.

Right up until we got to the ED. It started when I called in and explained the situation to triage. Triage immediately started giving me directions to the morgue and got VERY testy with me when I said that I thought the morgue was not the appropriate place for us to go since I had the husband on board and the son following. I've brought patients directly to the morgue before. It's cold, dark, with no real place for families to mourn. Most definitely not where I would want my last memory of a loved one to be. Once we arrived the reception was no more pleasant than the phone call had been but after some discussion the nurse gave in and we were directed down to a quiet empty room. The entire discussion happened in front of the patients family and with the husband and son weeping quietly next to the stretcher.

After finishing up the paperwork we started back to quarters. When I got back I was met by the ambulance supervisor who informed me that I violated the services guidelines by having a family member in the patient compartment. He wanted no part of any explaination and made it clear that there was no excuse for going against the operating guidelines.

So here I am having been given a hard time by the triage nurse and then by the ambulance supervisor for doing what I felt was the compassionate thing. I am just astounded by the total lack of concern and compassion for the family that both of these people had. I wanted two things by doing this. First, I wanted clear direction from the husband how he wanted us to proceed. I got that. Second, once I realized that the patient would not live to see the hospital I wanted him to have the chance to say goodbye. He got that. To me it seemed like everybody got what they needed and because of that a bad situation was made a little less bad.

My brain and my heart hurt.

There's a new house under construction across the street from me. I have gotten used to sleeping through the hammers and saws so I figured today would be no different. How wrong I was. After getting my kids out the door for school and the youngest dropped off at day care I came home and pretty much collapsed into bed counting on a reasonable amount of sleep today so that I could be fairly well rested for work.

I actually did sleep well, for about 45 minutes. Why only 45 minutes? Well, it seems that this new house being built needs a well and, lucky me, today was the day they were going to start drilling it. First is was the whine of the hydrulics as they erected the drilling tower and then it was the repeated clanging as they drilled into the rock. I was less than pleased and pretty much unable to sleep any more for the day. When I finally got out of bed after doing little more than dozing off and on for the early afternoon I figured this was one of those days where the bear, most definitely, got me.

The bus pulls up and honks the horn, the kids get off and start to walk up the driveway and my beeper starts to go off. I'm already working tonight so I know I am not getting ordered in, my wife is working so I know I'm not going in early. I am however being relocated for the night shift. My shift as Medic 2 has been changed to Medic 6. For the first time in a long time I am actually pretty happy with this. Medic 6 is a sleeping shift, the only one that remains in our schedule. I am saved! I can try to sleep some at work tonight. It isn't often that I'm happy about being assigned to that station but today is the day.

It wasn't great by any stretch of the imagination but I was able to accomplish what I had to do. Before we left home each girl put together a backpack of stuff to do which, at least in theory, would keep them occupied for a while.

I have to say that I was impressed with the tolerance and understanding of the people I was teaching. When they had heard that I was going to have to bring my girls they made sure that they had snacks, books, and some small toys available which help considerably.

All of this was not a panacea by any means. My oldest was still difficult. As I was demonstarting the use of the Combitube (an airway managament device) she kept coming up and standing between me and the mannequin and every time I turned away she would take the pilot balloons and stuff them up the nose of the mannequin. I another context it might have been amusing but I was quite embarassed.

I suppose the important thing is that I was able to complete the class and train 14 people that needed to be trained. I didn't like the way I had to do it but it was done and done as well as I could under the circumstances.

Still doesn't make me feel any better about it.

I tried and failed to get a babysitter to watch my daughters tonight while I teach. This is going to make life interesting to say the least. When I called to talk to the training officer of the service I am teaching tonight her response was "bring 'em". I have to say that I am extremely apprehensive about doing this and against my better judgement I have agreed to do just that.

I am very torn about how I feel about this. On the one hand I feel pretty happy that I do not have to cancel a class that I committed to and that took quite a bit to actually find a date for. On the other hand, I am worried about appearing to be unprofessional by bringing my kids with me to a class that I am teaching. I have never done this before and I am not sure I like the implications of it. Especially since the ambulance service is paying the hospital for me to teach this class.

I'm between a rock and a hard place, either way I go it seems that I lose. My only hope now is that my kids will cooperate and sit quietly and behave well while I teach and that I can get this over with without too much inconvenience for the students. Less than an ideal situation but I can't see any other solution.

So it was a pretty busy day. Lots of responses, not a lot for me to do. The snow stopped around noon and by midafternoon it had become sunny, windy, and freezing cold. I actually had to find my sunglasses, something I haven't had to do in a long time.

Total calls for the day: 14
1 ALS transport
1 Refusal
2 BLS downgrades
2 Cancelled enroute
2 Fire standbys
6 Cover assignments

Total milage: 228

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

Not a lot of transports but a very busy day with a lot of calls and a lot of milage. It's also been one of those shifts where not much has gone my way. Every dispatch has been to a location on the other side of my district or out of my district entirely giving me 178 miles by 1500 in 9 dispatches. Then throw in a vehicle problem that required me to terminate a response and change out vehicles in a rush because no units were available and it means that I have been running nonstop since the beginning of the shift. Fortunately it has stopped snowing and the plow crews are finally making some headway. It's still cold and icy but it's getting better than it was this morning.

My only ALS transport so far has been a 4 year old girl who had been experiencing a croupy cough for the past 2 days along with a fever. this afternoon she experienced a near syncopal episode and was severely short of breath. When I arrived the fire department was carrying her out to the ambulance. I could tell from looking at her that I would be going with her to the hospital. She had the limp "I'm really sick" look that made me really concerned. As soon as I touched her I understood why she was acting so sick. She was burning up with fever and significantly short of breath with audible wheezes without a stethescope. Enroute she got a couple of breathign treatments which improved her breathing, although she still had a barking cough that said croup to me, but had begun to perk up slightly. When we got to the ED we found that she had a fever of 104.3F/40.2C and even though she was breathing better and acting less sick than she had been when I arrived at here house she was still a very sick child.

I'm hoping that the day will start to quiet down so I can get caught up with the paperwork and maybe even get to eat something. No chance to do more than grab a Diet Coke on the way from one place to another so far.

I don't do it very often and it just feels very weird to not only be awake but actually at work. Add the snow into the mix and it is a doubly strange thing.

The snow that had predicted fizzled, no 18" this time, only about 8"-10" depending on what part of the county you were in. That hasn't stopped people from do wild and crazy things. I am convinced that when it snows everybody thinks it is a grand idea to go out for a drive and see what the landscape looks like. So far I have encountered people in sports cars, a golf cart, bicycles, and a motorcycle. Add to these wonderful folks the people with their four wheel drive vehicles who have not yet figured out that four wheel drive does a wonderful job giving you traction to move faster but it does absolutely nothing to help you stop. I am just totally amazed at the total lack of common sense some people demonstrate. Come on folks! If I didn't have to be out in weather and road conditions like this I would be home with my family looking out the window and appreciating the fact that I didn't have to be out slipping and sliding all over the place.

So far I've been to a couple of motor vehicle crashes, a fire standby for a kitchen fire on the 8th floor of an elderly housing complex, and 3 cover assignments. Not bad for less than three hours into the shift. I even managed to get my morning loading dose of caffeine so I'm awake and reasonably happy.

We'll see how the day goes, I know it's going to be busy. I have set my threshold for being happy at the point where I stay pretty dry and keep my feet warm. If I can manage that the day will be a success. Even if I don't manage that, todays shift dropped me to the bottom of the mandatory OT list and for that alone it will be worth it.

The trip has to be cancelled due to the weather. Looking out the window right now, a little after midnight, we have about 4 inches of snow. Normally I wouldn't let 4 inches of snow change my plans. It's not the 4 inches of snow that are concerning me, it's the additional 8 to 14 inches of snow they are calling for over the next 36 hours that is making me change our plans. Even though we were going to take the train from New Haven to Grand Central and not driving in once the snow gets over 6 or 8 inches I expect the travel, even by train, to be difficult, and the idea of walking through New York City from Grand Central to American Girl Place does not appeal to me very much.

I have to be honest that the prospect of travelling to a shopping district in New York City during the Pre-christmas shopping season is also pretty unappealing as well. I'll go to wherever my kids want to go, I want them to be happy and have a great time. I am not one who likes crowds and crowds and New York City are standard fare for the holiday season so deep down I am not totally disappointed that the trip is cancelled for now.

In the morning we'll sit down and break the news to them and hope that my oldest can deal with the last minute change of plans. I have already started looking at the calender and come up with some alternative dates after the first of the year. Hopefully having another date to write on her calender will allow her to deal with the change of plans better and not have tremendous agitation or anxiety.

I have to say that I am intrigued. There seem to be many benefits and the only downside seems to be the additional bill every month and the fact that the phone stops working if your broadband connection goes down.

On the other hand the rates for long distance are almost ridiculously low and some of the options are very nice. I especially like the idea of being able to obtain a "virtual" phone number in another city. The idea of getting a Alaska telephone number so my cousin could call without incurring a toll charge is a neat idea. It works for essentially anyplace in the US and Canada.

Very cool. I am not sure I could replace my standard telephone service, at least not yet but it may be worth it just to decrease my long distances expenses every month. With friends and relatives all over North America this would certainly prove to be useful.

So far the leading contender is Vonage. If I decide to go with this I will let people know how it works.

Since it's been a slow night I have had the chance to browse through it and see what is offered this year. Salt Lake City on March sounds kind of nice.

I've even looked at the list of sessions and selected the one's that I would attend:

EMS Command School (2 day preconference workshop)
Ultrasound Use in Field EMS
Pathogenesis and Management of Shock
EMS in the Trenches-Trench Rescue Awareness for EMS
Trauma in Pregnancy
Adult Intraosseous Infusion
Controversies in Airway Management
CSI: Clinical Clues from Lab Values
People Care: Practices and Perspectives for Professional Caregivers

It's nice to hit a good portion of my continuing education requirements for the year in a matter of 5 days.

I'm not sure why I am even bothering to look though since it is highly unlikely that I will be able to go unless a fair amount of money drops into my lap. Travel to the the other side of the country is expensive.

I have been to this conference a few times before once in Philladelphia and twice in Baltimore. All three times we great and I learned a lot. It's a conference that is dramatically different from the state conference here in Connecticut which just never seems to live up to it's billing. The lecturers seem to be of a higher caliber, the staff seems more organized, and the crowd seems much more interested in learning. It's also an interesting time to socialize with people that I would never get to meet otherwise.

This past year in Philladelphia I had the chance to sit down and talk with a paramedic from Israel and talk about the differences in what we are doing in the field, what worked for us and what didn't. We were joined halfway through our discussion by a paramedic from South Africa who gave us another point of view. Very cool. Very interesting.

I'd love to do this but, well, I can't see it happening. There's always next year when they come back to the East Coast.

One of the things that the owner was absolutely adamant about was that the appearance of both his ambulances and his employees was impeccable. The ambulances were cleaned inside and out daily (at least) and compounded and waxed on a regular basis. All employees were required to be in the exact uniform that was specified by the employee manual. No batman utility belts. No extra pins. Shirts were to be white and pressed, not sort of white, pants were to be clean and without holes or tears and hemmed to the correct length. Shoes shined. All equipment was set up exactly the same. All patients were secured on the stretcher the same way and the little things all had to be remembered, feet always covered, heads covered when it was cold out, blanket always folded the same way wether on the patient or not. This guy was so focused on making a good presentation to the public that each ambulance carried a hand knit afgan for use when it was too warm for the heavy blanket but too cold for just a sheet.

At the time many of us thought all of this was just the obsessive-compulsive behavior of "the old man". We did it because he was paying us to do it even though we didn't know why. One night the "old man" was in his offcie and came downstairs to the crews quarters to roust us out of bed to clean the ambulance (which was filthy from snow and mud). After we were done I had the opportunity to ask him why all of this was so important to him.

The answer was kind of surprising to me, an 18 year old EMT-B working in his first ever paid EMS job. He said simply "The public has absolutely no idea if you know what you are doing or not. What they do know is if you look and act like the professionals that they expect you to be. If you look like someone who is inattentive to how he looks and how his ambulance looks they are going to assume, rightly or wrongly, that you are inattentive to how you care for patients. If you look like you are attentive to your own appearance and that of your ambulance and equipment and you pay attention to all the details, no matter how small, the public will believe that you are attentive to everything. That is why I insist that you all pay attention to even the smallest details."

I'm not sure that I understood this then but I respected his opinion and learned to do things his way and eventually found that it became what I always expected of myself and what I always expected of my partners.

Tonight I was chatting on ICQ with a friend of mine as I was getting ready for work and commented about how I had to go and get my shirt out of the corner it was standing in (plenty of starch, just the way I like them) and finish shining my shoes. I lamented the fact that after the first call my shoes always looked like they had never been shined but that I did it anyway and wished that it didn't matter to me. She commented that I do all of these things because I care about how I look and how the public perceives me.

She's right of course, I do care, and I have always expected my partners and coworkers to care. I remember the words of "the old man" way back in 1984 and they still effect me almost 20 years later. "The devil is in the details" they say and for us in EMS that is a very true statement. "The old man" was right that the general public has no idea if you know what you are doing but they do know if you look and act the part.

That's why I shine my shoes before work every day, that's why I starch my shirts to within an inch of their lives, thats why I always try to remember the little things, like making sure that my vehicle is clean, and my equipment always in order. Little things like talking to my patients like they are people, remembering their names, treating them with respect even when they have done nothing to deserve it. Most of all that's why I always try to do my job as best I can and make sure that I look the part of the professional.

Too many of our colleagues don't remember these things, I see it every day. People who forget the impressions that attention to detail can make. Even such small things as making sure that a patient is comfortable in bed and warm enough before you leave. Small things like actually talking with a patient, not just collecting information for a PCR or billing form. Small things like helping the nurse or aide get the patient off of all the extra sheets have been accumulated during transport. Small things, like remembering to take our patients dignity and privacy into account and just plain treating them the way we would want to be treated if it were us on the stretcher.

It's the attention to detail that makes the biggest impression on the people around us. We all need to remember that and strive for it, that is, if we want to get the respect that we all feel we deserve.

As hard as "the old man" was to work for I have to thank him for instilling in me a healthy respect for attention to detail as well as the desire to be the best EMT and paramedic I can be. It's paid off tenfold.

I was in just as the day shift rolled in with an unresponsive OD that they had intubated. Another newly hired paramedic starting his orientation today to fill one of the two vacancies that we have. One more full time vacancy and a few per deim positions still to be filled before the schedule starts to look better. This is my 5th shift this week and I am pretty well toasted. I sure can use the money but I would love to have some time off too.

Two calls so far neither of which resulted in a transport. Syncope at a banquet facility with a patient refusal prior to my arrival and what ended up being a public service type of call. A guy on home oxygen complaining that his tubing was clogged. We didn;t find any obstructions in it but we changed out his cannula anyway and he was happy. I cleared this one as no medical emergency.

For a change I don't have much project work to do tonight and I am hoping to do some reading tonight. I randomly selected a book out of my ever growing stack of books that I want to read someday. I hope it's as good as the description in the jacket sounds.

A single call in 12 hours. Just one, and that one barely ALS. If I hadn't been bored I could have downgraded it to the BLS unit but I was looking for something to do.

I don't know what I did but I aggravated my back again, same spot from my fall a couple weeks ago so I'm going to baby it for a while. Lots of Motrin, rest, and a heat pack to see if I can loosen the knot up. What I really need is a massage but that's not going to happen so I'll have to stick with Plan B.

Total Calls for the night: 1 ALS transport

Total Milage: 24 miles

CD for the night: "Mirrorball" by Sarah MacLachlan

Low Temp for the night 11F/-12C

I'm hoping to sleep better today and be well rested to work Medic 1 tonight.

At the moment I am having trouble deciding if it is something physical or something in what's left of my mind. I'm not sure which I hope for.

Right now, as of 0130, I have done one call, and the patient was discharged before I was done with the paperwork. We have only one patient in the ED at the moment, a drunk sleeping it off, and I am having trouble finding something to do to occupy my time. It's not that I don't have anything to do, I have plenty of things that need to be done, I just can't motivate myself to do them.

For some reason I have an underlying feeling of anxiety the source of which I can't put my finger on. If it weren't so cold I would head out and go sit on the sea wall, think, and see if I could sort out the source. But the temperature is in the single digits and going out is not high up on my list of things I want to do.

I can't figure out if I am getting sick, depressed, bored, or a combination of the three. All I know for sure is that I am looking forward to the night being over.

While the weather report keeps telling me that the temperature is going to be in the high teens and low twenties tonight I think they are full of it. 2000 and it's already into the single digits and I am really cold. Such a change from previous years. I am trying to dress for the cold and finding that I don't have any of the right clothes. What is happening to me? I have never been cold like this before.

I was exhausted when I went to bed this morning and slept for a good portion of the day. I wish I could say that it was a restful sleep but it was full of strange and somewhat disturbing dreams and waking up every few hours during the day. I went back to sleep easy enough but it was not very restful sleep.

The physicatrist and we were able to make some plans for changes in her treatment plan both as far as medication and her plans for school. I wish I could say that I was confident that this is what is needed but I am not. I feel like I am betraying my daughter but I think this is just one more step in a long and painful process whose end is still unknown.

Once I got my daughter back to school and my wife off to work I was home alone. I expected to use the time to finish much of the work that I had to do. Bills needed to be paid, laundry needed to be done, dishes washed, telephone calls made. I wish I could say that I made progress on any of these tasks. I can't. I was totally unable to focus, I was so distracted that the sum of the time I spent actually doing useful work was well less than 30 minutes. The rest of the afternoon was spent trying and ultimately failing to accomplish anything useful and worrying about my daughter and her future.

There is much to be done and I have little concentration left to actually do it.

The Continuing Education session I was supposed to go to this afternoon was rescheduled for this morning. My oldest daughter has an appointment with the psychiatrist at the Connecticut Childrens Medical Center to see if we can bring some of her anxiety, obsessive-compulsive, and ADD type symptoms under better control. Needless to say I am extremely worried about her future and todays appointment is a source of much anxiety to me and my wife. Her lack of impulse control, high anxiety, and inattentiveness are very concerning to us and have really been in the forefront of our minds for the past several weeks. I really hope that we can make some progress at bringing her condition under better control so that she can have as normal a childhood as possible and the chance to have an adult life that allows her to be functional. We know that she will never be "normal" but unless better control is acheived her chances of being a functional member of society as an adult are very limited. I'm not sure how I will deal with that possibility. I would give anything I have, including my life and well being for her to be better, I truly would without hesitation.

After my frustrating experience this morning I came home, threw my uniform into the closet, slammed the door, and tried to sleep. I did sleep eventually but was too tired and forgot to set my alarm clock. I woke up with the school bus honking the horn outside. Not a great way to wake up but at least I woke up.

Tonight I had to go talk with one of the services we respond with about training to use the Combitube. The membership was divided about it and they wanted to get the information straight and have a short demo of the device. Since I was doing this as a favor for the service chief it was on my time. I enjoyed giving the presentation and answered every question posed to me. At the end the group voted unanimously to go ahead and apply for the training.

Now I'm home and getting pretty sleepy. I don't think I'll last much longer but I do want to talk with a friend for a bit and get my papers together for tomorrows continuing medical education session. It's almost the end of the year and I need to have all my documentation together by then.

This morning finished with an very frustrating call. One that should not have been frustrating at all, actually one that, even though it ended with the death of the patient would have been somewhat satisfying.

My last call of the night was a dispatch to a SNF in the next town over for difficulty breathing. I responded and arrived at the same time as the ambulance and the fire department. After we all waited 10 minutes at the ambulance entrance for someone to come let us in we were ushered down the hall to the patients room.

The patient, an elderly woman, was unresponsive in bed, with obviously laboured breathing getting oxygen via a simple face mask at 4 litres (which we immediatly changed to something that was not suffocating her). She was cyanotic almost all the way to the shoulders and was cold to the touch. The staff related to us, after much prodding, that the patient had a history of end stage emphysema and had been having worsening shortness of breath all night but had refused transfer to the hospital. We were told that a Do Not Resuscitate order was in the chart and that her attending physician was going to be in to sign a Do Not Hospitalize order before 0700.

Even some fo the untrained firefighters recognized that this patient was in the final stage of what looked like an agonizing death.

The question had to be asked of the staff and I was frustrated enough alrady to be the one to ask it. "So if the patient expressed her wish not to go to the hospital, her DNR status was clearly defined, and an order was pending to not hospitalize her why are we here?" The answer only frustrated me more. The staff related that once the patient had become unresponsive they were no longer able to have her stay at the SNF even though her wishes were quite clearly made know over the past several hours and that they had been in contact with the physician already this morning and received a verbal order to not send her to the hospital they did not have a written order so they felt she needed to go.

I suppose I could have argued the point but I suspect that would not get me anywhere and probably made the situation worse. I asked the staff for the paperwork which the nurse left the room to go get while I called the ED for a physicians order for "comfort measures only" which was approved before I could finsih talking.

When the nurse returned to the room she handed me a stack of paperwork which included the standard transfer form giving history, meds, incident, and the like, along with a copy of the State Transfer of DNR Order form. One problem, the form was blank except for the patients name scrawled in one corner of the paper. None of the required information was present meaning that the document was not legal and as such I could not accept it. Bloody Hell. The nurse left the room again to go complete the form as we finsihed loading the patient onto the stretcher and getting a set of vital signs. BP 60/20, pulse 72, respirations 40, O2 sat 57%, and End Tidal CO2 if 11.

Down the hall to the nurses station for the paperwork as the patient began to have short periods of apnea. I was handed the same form as before with the onlly difference being that the patients name had also been written in the appropriate place. No physician name, no date, no doctors name, no RN signature, nothing else that I needed to have it be valid and legal. I am on the verge of becoming really pissed off. I explain, as nicely as I can manage, EXACTLY what I need on the form so that it can be accepted and legal. The nurse pulls out the chart and starts to madly flip through the pages.

While she wildly turns pages I call the ED on the phone and talk to the ED attending physician again. I inform him of the wrinkle and he says he will do what he can to verify that the DNR order does exist and that his previous orders were predicated on a valid DNR order being in place. Hold on, he says. The nurse is still flipping pages like crazy as I stand there, cell phone in one hand waiting for someone to get me out of this sticky situation.

I know very clearly what I want to do, I know very clearly what I am leagally supposed to be doing, I even know pretty clearly what the patients wishes are. I only lack the one sheet of paper with four lines of text on it that can give me the right to do it. I really do not want to have to intubate this woman and prolong her suffering any longer, especially against her wishes.

Still the nurse continues to look at page after page of the chart. After a couple of minutes the secretary in the ED comes on the phone and tells me to hold on she has the doctor on the other line. Click, click, beep, click and I find that I am not only talking to the ED doc but that the patients doctor is also on the line. The DNR is confirmed to me verbally by the patients doctor and my orders from the ED doc are reissued and we are off down the hall walking somewhat quickly. The nurse running down the hall behind us screaming "Wait, wait! I haven't found the DNR order in the chart yet!". No need, I explained, no time and we load and start to the ED. All the crew and I can do is watch, and bear witness to the patients downward spiral to the inevitable end, the expected end, even the desired end.

We get to the ED just as the patient began breathing only in occassional ragged gasps. The ED doc and the patients doctor are both standing in the door waiting for me. and we go down the hall to one of the quieter rooms in the ED to await arrival of the family (who, we found out shortly, the SNF staff had never even called).

The patient lived for less than an hour but didn't die until her family had arrived along with the priest. After she died the family looked almost relieved.

I, however, was still frustrated with how this call unfolded. It has been a long time since I beleived that every patient should be agressively resuscitated and for many years have beleived that patients with terminal diseases should have the option, if they desire, to refuse treatment that would extend their life and suffering and be allowed to let nature take its course with dignity. The last thing I would have wanted to do is have to agressively resuscitate someone, like this patient, who's desires were so well known.

Total calls for the night 7
2 ALS transports
2 ALS turned over tot he ALS ambulance
3 Cover assignments

Total Milage 73

Cd for the night: "It Just Happens that Way" by Mindi Abair