February 2004 Archives

It has been a busy weekend. Both Saturday and Sunday were arranged to accommodate my middle daughters schedule.

After a few hours of sleep on Saturday morning the family was out and about to take her to dance rehearsal and then a performance put on by her acting class at a local children's theatre. Watching her on stage I can truly say that she certainly has found her niche already. She was comfortable, she was confident, and she was having a great time. When they asked the children to find a "volunteer" from the audience to participate she chose my oldest daughter to come up and be a part of the performance. She knows how much her older sister likes to participate in things like this and even though she frequently misses the point and can't follow the instructions her sister chose her. What a mensch. What was so surprising was how well my oldest was able to follow directions, how much she participated, and how much she seemed to be enjoying herself. With all of her social skill deficiencies we didn't think she would do so well, but she did, and loved every minute of it.

After the performance was over we went upstairs to the main theatre where they were having a short performance by some of the older kids who were working on circus skills. These were teenagers who had clearly worked very hard. Some slapstick, clowning, juggling, sleight of hand, acrobatics, and some interesting unicycle performances highlighted the show. One of the strangest looking kids performing was also the one who frightened my youngest the most, a tall gaunt, goth, with a shaved head except for a small pony tail that came down from his forehead and covered some of his face who came on stage to very dark themed rock music and seemed very menacing. Menacing right up to the time he took the three brightly coloured balls out of the pocket of his cape and started to juggle. By the end of the performance my youngest was watching with interest and laughing as the juggler performed some seemingly magic maneuvers with florescent clubs in black light. One of the more impressive acts was the young woman who rode a unicycle about 10 feet high while wearing stilts. It was a wonderful show and these young men and women were clearly very good at what they were doing with such stage presence and comfort that they were having as much fun as we were.

We went home and everyone was getting tired and cranky, including me. My mood was made even worse when I found out that my oldest had done something to my only Windows based computer and brought it to the point where it would never finish booting. I was able to hold my temper and not get extremely angry, very frustrated, but I tried very hard not to take it out on those around me.

This morning I woke up with a screaming migraine and still had to get up and go about my business so that all my kids and my wife could get out to where they were supposed to be. My wife had to go make rounds on some of her patients in the hospital, my kids needed to be to religious school at 0930 with my middle daughter ready to be picked up by mom early so that she could make it to her dance competition on time.

Left with the other two girls I caved in pretty quickly and took them to McDonald's for lunch. Not my first choice, but it was theirs. They had a good time and were pretty happy. On the way home we drove back along the shore and past two of the lighthouses in our area. My youngest likes lighthouses as much as I do and she was very happy to have taken the ride. I was just happy to get out in the sun and some milder temperatures. It's been a long hard winter and as much as I love working nights I cannot deny that I have been effected by the constant cold and long lasting lack of sunlight.

Once home the kids sat down to do some drawing and read a book and I had a chance to do some computer work. Windows is not my specialty and to be quite honest I can barely keep the darnn thing running. I keep it only because my wife has some proprietary software that only runs on Windows to allow here to see the monitors on the Labour & Delivery floor from home. Other than that I use it for hacking with the programming on my portable radios and spending the rest of the time with it booted into Linux. After an hour or so I was able to repair a few of the things that I found wrong and, amazingly, she booted up with no trouble.

I was hoping to get a short nap when my wife got back but abandon that plan to celebrate when my daughter came back from her dance competition with 2 awards. She was glowing and everyone was happy with her and did their best to make her feel special.

So, no nap. I was pretty tired after the very short sleep yesterday and the awful sleep I got with the migraine but things just did not work out that way. We had some friends coming over for dinner and had to get ready.

They left a few minutes ago. It was great to spend time with them and have some grown up conversation while our kids played together.

As weekends go this one was very nice even without a lot of sleep and a nasty headache.

It was a rather odd night with not a lot of activity but a hat trick of ALS calls, each one a little bit interesting and challenging. The night started shortly after I got in when shortly after Medic 2 went out I got sent to cover a call in his area. It was about a 20 mile response and I arrived just as the patient was being brought out of the house. The patient was complaining of a severe right sided headache, similar to headaches he got after recent neck surgery to correct degeneration of his cervical spine. With his history of narcotic addiction there was not much I was going to be able to do for pain control but we were close to the ED so I got the ball rolling by getting his line and labs done before arrival. The patient himself was not all the interesting and maybe interesting is the wrong word for what struck me about this call. What stood out was the lousy attitude of the lead EMT on the crew.

I understand that the patients family was upset and were making quite the pain of themselves. I understand that after a short time they got on everyone's nerves. No doubt that they made the work that needed to be done more difficult. That being said, I was quickly appalled at the horribly condescending and disrespectful tone of the lead EMT towards the family. During the transport the lead EMTwas mocking the patients wife within earshot of the patient, making inappropriate comments to other members of the crew and generally treating them poorly. I was appalled, and after a minute or two of this I quietly pulled him to one corner of the patient compartment, told him that I felt his comments and attitude were inappropriate for the situation and asked him to stop. His response was to hiss "F**K You!" at me and proceed back into his previous behavior.

I spent the last few minutes of the transport constantly talking to the patient and the family to make sure that there were no pauses in conversation and no opportunities for anyone to interject anything offensive. I was surprised that I wasn't as furious as I would have expected, I was more sickened by the behavior. After the patient had been turned over to the ED staff he refused to even speak to me. The older crew member who had been driving the ambulance for the call then approached me and said that this EMT had been like this for the past few calls and that he was going to be calling the service chief and urged me to make a call of my own. I will be calling the chief of service in her office Monday morning.

The second call was several hours later with not much of anything in between. I was dispatched for an unresponsive person with difficulty breathing. I arrived on scene at the same time as the first responder and when we went in we found a 75 year old male who was deeply unresponsive. His wife had related a seizure history for which he had been noncompliant with his medication for over a year with a seizure earlier today. The ambulance arrived and we started to work the patient out of the house. He remained unresponsive for most of the carry and began to become slightly agitated when we reached the stretcher. By the time we got him into the ambulance he was extremely agitated and combative. This thin and wiry 75 year old man was tossing the three of us in the patient compartment around like we were children (and two of us were on the, ahem, beefier side). I managed to get an IV into him and with great difficulty checked his sugar, hoping against the odds that he had a low blood sugar, something that I could correct rapidly. No such luck. When we arrived at the ED the three of us along with 4 security officers managed to restrain him to the ED stretcher and the doctor order a large dose of sedative. The patient was still groggy and slightly disoriented by the time my shift ended but was no longer combative. He was to be discharged with a new prescription for anti-seizure medication as soon as he was back to "normal".

The final call came in about half an hour before the end of the shift. I was coming back from a cover assignment for medic 2 and was just about to get off the highway when the tones went off for a respiratory arrest at a SNF (Skilled Nursing Facility). Since I was already on the road I arrived in about 4 minutes, well ahead of the ambulance. The patient, when I finally found the room, was sitting bolt upright in bed in severe respiratory distress. OK, still breathing, that's a good thing. A quick assessment showed that the patient was cyanotic to the shoulders and hips, pale centrally, except for her neck and face which were also slightly cyanotic. This was not a long term patient at the facility, rather, she was a rehab patient recovering from a fractured hip 2 weeks before. Oxygen was applied by nonrebreather mask and I evaluated her vital signs. She was markedly hypotensive, with a blood pressure of 70/24, in severe distress, and generally looking like she was not going to last much longer. As the ambulance arrived I was working on IV access. I had already decided that this patient needed to be intubated quickly since she was looking worse by the minute. She got Etomidate and Succinylcholine and was intubated without difficulty. During the trip from the room to the ambulance she started to drop her heart rate and by the front door we were doing CPR. I had been afraid that this was where we were headed. 4 minutes later we were backing into the ED. 20 minutes after that the expected outcome happened and she was declared dead.

All in all the night could have been better but it also could have been much much worse.

Total calls for the night: 5
3 ALS transports
2 Cover assignments

Milage for the night: 184 miles

CDs for the night: "Blind Man's Zoo" by 10,000 Maniacs and "Cracked Rear View" by Hootie and the Blowfish

Both of my older daughters had play dates after school today so I got to sleep late. It was really wonderful to wake up at the time I normally would to get them off the bus and roll back over to go to sleep again. I slept for about 10 hours which is much longer than I usually do. It felt great.

No sick calls so it shouldn't be a bad night with staffing at full strength. The pager has been quiet and from what I can hear from my house it's pretty quiet now. I hope to have some time tonight to do the inventory of monitor equipment that I tried to start last night. I don't think that should take too long which is a good thing. Last night I talked for a while with the paramedic who took the position ofEMS Coordinator for our hospital and he wants to see some of the proposals for protocols and research that I have been working on.

The first one that I would like to get rolling is a research proposal looking at intubation success rates in our program. All of this information is already available in some form, I just want to take it, collate it properly, and gather data for a retrospective look at the rates. Then I want to go through a phase where we collect additional data on any case the requires airway management of any kind and look at success rates, outcomes, and complications. This whole thing got started when a doctor from Florida did a similar study that showed that paramedics in his area were only successfully intubating 50% of the time. Personally I find that hard to believe but it is enough to worry our medical director even if our rates are much higher.

Well the night worked out somewhat better than I had hoped but we still had a period where we were down a unit. The way it went was a bit convoluted but at least the coverage was mostly there. The day medic held over until 2100 when another medic came in to cover 2100-0100. He, like I, beleives that taking a unit out of service is just plain wrong and he decided to stay as long as he could. He made it to just before 0400 when he felt he was too tired to be safe and he had to go. I appreciate his situation, he had been up all day, work a good portion of the night, and was supposed to be in school at 0800. So Medic 2 came of line at 0400 and Medic 1 & Medic 3 were relocated to provide coverage. At 0402 I was sent to a call in Medic 2's territory about as far from where I was as you can get. By the time I was finished with that call my relief was in and covered the remainder of the Medic 2 shift from 0500 to 0700. In the long run we were only down a unit for an hour but it was a hour that, due to circumstances, really left one paramedic covering about 560 square miles. That is a heck of a lot of territory to cover with one unit.

The night itself wasn't all that bad, I did a number of cover assignments while the other units did calls but had very few of my own. Nothing challenging and nothing significant but I managed to get some reading done on the covers and supported the ED staff during a very busy night for them.

Total calls for the night: 8
1 ALS transport
1 Cancelled upon arrival
6 Cover assignments

Total milage for the night: 187 miles

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

Well another night, another sick call, another scramble for coverage. Looking at the pager they started putting out the opening around noon and so far have some of it covered but not all. There stands a good chance that we will go down to two units tonight which will really be unpleasant.

Tonights agenda is to inventory cables and accessories we have for our LifePak 12's and see if we need to order any, finish some paperwork, and, calls permitting, do a little reading.

We'll see. I'll take whatever comes.

The night was not very busy. I did get some work done and spent some time cleaning up the paperwork from the last 2 days which someone managed to royally screw up.

Medic 1 was kept online through the dedication of three of our medics who came through in a pinch. It was a good thing too since Medic 1 and Medic 3 were pretty busy. Some of it was covering for me while I was out on my calls.

Only 3 patients last night. I started out with a 20 year old 33 week pregnant woman who was having contractions. She had a history of premature labour and was supposed to be taking Brethine to keep her contractions under control. Of course, she was noncompliant with her medication which, at least to me, explains why she might be having problems. She needed top be transported to the L&D unit on the main hospital campus about 25 minutes north of the call. The transport was uneventful and I elected to not perform any ALS on the patient. During the trip I was able to speak to one of the patients doctors who concurred with the BLS transport unless things started to look wrong. While I was on this transport I missed 3 calls that Medic 1 picked up including a pediatric seizure that was emergently transported to the childrens hospital about 30 minutes down the coast.

I was not even back to the station after the first call when I got the second hit for a car crash in one of the more rural parts of my service area. It took a while for the ambulance to assemble a crew and I was onscene several minutes before the ambulance. When I arrived I found the Rescue boarding and collaring a 50ish male who had backed his pickup into a stone wall at moderate speed. I knew the patient, he was a member of the Fire Company in this town, and as such I interacted with him on many calls over the years. He had a multitude of facial abrasions and a small lack across the bridge of his nose. That seemed to be the extent of his injuries. The interior of the truck was intact although the damage to the back end was pretty significant. Things got a little more interesting when I started to talk to him and realized that he was drunk. He stated he only had 2 drinks, of course he didn't mention how big or what he had been drinking. The State Police had also arrived and were talking to the driver and asking him about his alcohol intake. They didn't like the story any more than I did. I downgraded hom to a BLS patient and sent hom to the ED via the BLS ambulance. As I packed up my stuff the trooper was talking with the rescue crew and I could tell from his body language he was getting frustrated. I always check with the Officer in Charge from the fire department before I finally clear the scene in case they need me for something else on scene. In this case as I approached I heard the Chief speaking harshly to the firefighters on scene essentially saying that he didn't care if the patient was a member of the fire company and that they had a responsibility to answer any reasonable question the trooper put to them. It seems nobody wanted their friend to get punched for DWI. After being chewed on by the chief for a few minutes the rescue crew agreed that they smelled alcohol on the patients breath as well. Between those statements and the statement they had already taken from me it was clear that the patient was going to be in some trouble. I had mixed emotions about this. As much as I hate a colleague getting in trouble I hoped this would be motivation for his long time drinking problem. Tough situation but I am glad that everyone made the right decision.

The last call of the night came a little after midnight while I was on a cover assignment while Medic 1 & Medic 3 were both out. I heard Ambulance 3 dispatched to a fall with a leg injury at one of the hotels in their town. I was not requested so I went back to my papwerwork. About 5 minutes later my tones went out off to send me to the same call for the severly angulated leg. I arrived at the same time as the ambulance did and as I was walkign down the hall on the second floor the police officer was calling to cancel me. I decided that I was so close I would pop in and see if there was anything I could help with.

I'm glad I did as when I poked my head through the door I found that this 80 year old woman was seated on the bathroom floor blocking the door from opening more than a couple inches. One of the extremely thin first responders had slipped through the tiny opening and was evaluating the patient. The patients leg was indeed angulated significantly at the knee. She didn't seem to be in too much discomfort until she needed to move when she complained of 11 out of 10 pain in her leg. While officially I had been cancelled I couldn't really leave the scene with the patient in such a difficult situation and in so much pain.

I called the dipatcher and asked to be put back on the assignment and said I would be tied up for a while. I would decide of I would be committed after we got the patient out of the bathroom.

Now things were getting interesting. The police were taking the bathroom door off the hinges so we could gain access to the patient and with a lot of work we were able to get the patient seated on the backboard. She would go no further though until we have her something for the pain. She had told me that she was allergic to Morphine (which is the only painkiller I carry) so instead I gave her some Versed, a sedative, to see if that would relax her a little and make her drowsy enough to let us do what we needed to be done.

In the meantime the patients family was calling the orthopeadic surgeon in California since the patient was post bilateral knee replacement surgury. They handed the phone to me when he called them back. I was surprised that the doc actually called back and made a call from California to Connecticut but was glad for the chance to talk with him. He was able to confirm that the patient was not allergic to Morphine and had just been made very naseous by it in large quantities. Perfect, because even with the sedation she was not allowing us to move her much.

I started out by giving her 3mg of Morphine and 12.5mg of phenergan. My hope was that the Morphine would lessen her pain and the Pheneragn would avoid the nausea. It worked to some extent and she was reasonable comfortable until it git to be time to get her the rest of the way out of the bathroom. With the angulation of her leg we found that she was too wide to fit through the door and the bathroom was too small to move the board around to get the leg past. This meant we were going to have to do some manual manipulation of the leg to reduce the angle. Now the general guideline has always been to splint the extremity in the position found but in this case it wasn't going to work without the fire department coming and demol;ishing part of the wall so the leg would fit through the foot.

Another dose of Morphine layer the patient was starting to get drowsy adn we made the attempt to straighten the leg slightly to reduce her width and fit though the door. It worked. By the time we got to the ambulance the patient appeared to be comfortable, comfortably snowed. Unless her leg was manipulated in any way she was very, very sleepy. probably a good thing at this point.

Atfer a 50 minute scene time and a 10 minute transport time we were able to get here to the ED for X-Rays and better pain control. The X-Ray showed a very nasty break in the distal end of her femur (the part of the thigh bone that meets the knee). It was a spiral (twisting) oblique (on an angle) fracture that extended right into the area where her artificial knee had been bonded to her femur. I'm no orthopeadic surgeon but I didn't think that this was going to be an easy fracture to repair or to recover from. The patient received about 14mgs more of Morphine (total of 19mgs) and was transfered to one of the larger hospitals down the coast that had specialists that dealt with fractures like this.

By the time the night ended I was still feeling pretty good and it wasn't until I was almost home that the drowsyness hit me like a ton of bricks. When I got home I went almost directly to bed.

Total calls for the night: 4
1 ALS transport
1 BLS transport
1 BLS downgrade
1 Cover assignment

Total milage for the night: 83 miles

CD for the Night: Between Black and White by Hiroshima

Over the past couple of days I have read a number of articles both about EMS and computer science. One of the common themes of them was how to be the "best" at what you do. One of the articles was by Eric Raymond who, among other things, is the author of "The Cathedral and the Bazaar" which is a collection of essays about software and the open source movement.

For the sake of this discussion it is important to understand the difference between a "hacker" and a "cracker". A Hacker is someone who is adept at his chosen field, delights in solving problems, and continually strives to overcome limits of some kind. A Cracker on the other hand, is one who uses his (or her) skill to break the security of a computer system. In a nutshell, Hackers build things, Crackers break them.

Raymond discusses the "Hacker Attitude" in one part of his book. When I read this I found it to resonate with me professionally. Raymond lists the 5 things that outline the Hacker Attitude.

1. The world is full of fascinating problems waiting to be solved.
2. No problem should ever have to be solved twice.
3. Boredom and drudgery are evil.
4. Freedom is good.
5. Attitude is no substitute for competence.

As one who considers himself to be a serious geek and, when time permits, writes computer software for fun and relaxation I can see how these elements are relevant to the classic definition of a hacker. I can also see how they, along with the entire hacker ideal could work in almost any profession. As I was reading this I was in the company of an ambulance crew who, while I believe they meet the minimum standard, has no desire to surpass it.

When I put the 5 elements of the Hacker Attitude into an EMS perspective they fit quite well and seem to point to how one can assure that they will be "the best" in their field.

In EMS the world is always full of fascinating problems waiting to be solved and EMS folks have been doing this since the beginning. Look at some of the tools we use every day. Initially many of them were not designed specifically for what they were being used for and various EMT, paramedic, and yes even as far back as "ambulance driver" hackers saw the problems and had the vision to find new and unique solutions to them. Some of these solutions involved modifying existing tools and some of them involved the building of completely new tools that had never even been thought of before.

In EMS we should never have to solve the same problem twice. We strive for this and in a larger sense we succeed by finding the general principle that solves the problem and inventing numerous ways to implement it. Even in those things that have multiple procedures and/or multiple devices to solve the problem the general principle of each always seems to be the same. It is our own ingenuity that allows us to apply these principles in different ways to meet the needs of different situations.

I don't know a single person in any field who would not agree that boredom and drudgery are evil. Look at our coworkers who we see as having the bad attitudes, the ones who take no pride in their work, the "bad apples". What do they all have in common? They are bored with what they are doing, they feel that they are doing the same thing day in and day out. None of them started out that way. Somewhere, somewhen, someone or something stifled their ability to think on their own, to expand on what they are experiencing and harness that energy and information to continuously think about the problems and come up with new solutions. I'm not saying that "the best" in EMS never complain, rather that if you listen to them they frequently complain and voice possible solutions to their complaint in the same breath. Their enthusiasm lets them look at the problems as a challenge to be met rather than a limitation that forces them into the same path day after day.

Freedom is good. In general the hackers in any field are anti-authoritarian. Not to say that they fight authority, rather to say that they see that authority for authorities sake is appallingly stupid, anyone who orders you not to continue to solve the problems that you encounter and are fascinated by for the simple reason that they can and it better serves their purpose is appallingly stupid. Authoritarians thrive on censorship, secrecy, and the use of force. The hackers among us believe that reasonable adults do not need censorship, secrecy, and the use of deception or force to compel them to excel. They excel because they want to and because they are given the freedom to.

The last element, attitude is no replacement for competency, is so unbelievably simple that it is no wonder that so many people fail to comprehend it. Hackers worship competence, it is their holy grail. Attitude alone will not make one good at what they do just like acting like a professional athlete does not make you one. Respecting people for their competence and abilities and striving to move your own level of competence continually higher is actually enjoyable to the hacker. Learning and the acquisition of knowledge is an ongoing process. The hackers in our profession recognize this and this allows them to develop a healthy attitude, one of confidence in their abilities and in their dedication. There is no disdain for those who are less skilled than they are as long as they continue to strive.

We have hackers and crackers in EMS just like every other profession. It is easy to see the difference between the hackers, who are always trying to make themselves better and do a better job, and the crackers who believe that they know all they need to know and are try to do nothing more than, at best, simply meet the minimum standard, and at worst, try to drag those around them with a hacker mind set down their level.

I am sure that we all can point out people we work with who have the hacker attitude or the cracker attitude and we know how being around them effects us. I know that I revel in being around the hackers in my profession. As strange as it may seem, some of the people I consider hackers, are not the best paramedics I have ever worked with. What they have in common with some of the best paramedics I have worked with is the continuous striving to make themselves and their profession better.

I have always said that some days you get the bear and some days the bear gets you. Last night the bear got me something awful. First I had a technical problem with my server. Well, with the DNS for my server. For some reason the DNS decided that it would be a fun idea to start supplying IP addresses that were a few years out of date. This caused me no end of frustration since it meant that not only was my email and websites down but several clients were as well. I will say that the folks at New York Internet Tech Support we right on the ball and were able to help me work through the problem. We still don't understand why it was happening but everything seems to be working now.

The bear got me on the other side because I did not have the peaceful night that I had wanted. For this station the call volume was much higher than usual and it didn't start until around 2300 when we all wanted to snooze. The first call was the typical nursing home shift change difficulty breathing call that "just started" even though the patient said she had been short of breath for "a few hours now". Followed a couple hours later with the 26 year old with chest pain and difficulty breathing. Since things got worse when she coughed, moved, or took a deep breath I was pretty confident that this was not a cardiac problem and I downgraded her to the BLS unit for transport.

The last call came in at 0430 or so for the fall down a flight of stairs. It was one of those calls where on the surface everything looks fine but there is just something about it that makes you uncomfortable. Dad had been carrying his 5 1/2 month old son down the stairs to give him a bottle when he tripped, probably on the cat, and fell heavily onto his side. Unfortunately his son took a good whack to the back of his head as well. When we arrived Mom was holding the child and both parents were understandably upset. The child was calm, quiet, and seemed to be just taking everything in. There was an obvious lump on the back of his head but otherwise he seemed uninjured. He had cried as soon as he hit the ground and was recognizing his parents so things looked OK. On the other hand it's the middle of the night, the kid was awake because he needed to be fed, he didn't want to nurse and he didn't seem at all upset that these strange people were in his house looking at him and poking at him with their cold hands. I knew I would be transporting with him at that point. Something just wasn't feeling right.

I felt a little better when he started to get agitated at us while we were trying to immobilize him in his car seat, thrashing his head side to side violently against the towel rolls. If he had a neck injury this certainly wasn't helping any. Drop back and punt I guessed and I decided that since he didn't mind being touched all that much I would just hold his head for the trip to the ED. This was tolerated much better and, until we arrived at the pediatric ED and the resident started complaining about the lack of some type of c-spine control device, worked quite well. The resident decided to use towel rolls to do the same thing we had tried to do and had the same result. He elected to leave them in place and have one of the nurses hold the child's head against the thrashing. I failed to see how this was going to help matters but, well, I'm not a doctor and obviously he knew better (NOT!). Both mom and dad were wrecks and there was nothing that I could do to console them at all. I sympathized with them and could only imagine how I would feel if the same thing had happened to me.

By the time we got back to the station and I had restocked everything it was 0600 and after a little paperwork I finally collapsed in my chair and fell asleep until my relief walked in.

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

Total milage for the night: 16

No CD for the night but I did listen to the January 2004 edition of the EMS Journal Club on tape.

It has been a pretty nice day. After I had dinner with my wife I came back home, watch some TV (History Channel, of course) and fell asleep on the sofa. When I woke up around 0100 I headed to bed and promptly fell back asleep until my wife got home in the morning. I really needed the sleep and since I am scheduled for a sleeper shift tonight I'm glad I got it and didn't sleep all day.

We left home around noon to drive to her parents and pick up the kids who called us a couple of times this morning to tell us that they were having a great time. I was happy to hear that especially that both my oldest and youngest were having a good time. This was my youngest daughters first time sleeping away from home without Mom & Dad and to hear Grandma and Grandpa tell she did wonderful. My oldest just doesn't deal with changes in routine very well but, aside from making a few phone calls that nobody knew about (back home and to other relatives, not to some island in the Pacific like I did when I was a kid) she was calm and happy for the entire time.

It was a pretty uneventful trip down and back with us returning home just in time for me to throw on a uniform and get out the door for work. I am looking forward to a calm night and a few hours of rest.

I just woke up and it was quite delightful and somewhat unexpected. I had forgotten that my in-laws were coming this morning to take all three kids back to their house for an overnight adventure. This could not have come at a better time as after last night I was pretty well exhausted.

Tonight's plan is pretty loose. I'll head back to the hospital to have dinner with my wife and then figure out what I am doing from there. She has two patients in labour so I know that she will be staying for a while yet.

In the meantime I am enjoying the quiet and solitude of an empty house.

The Dogs of War (Unabridged), Part 1 by Frederick Forsyth

Sometimes being in the right place can make all the difference. The way last night began I figured it was going to be a pretty lousy night. Everything was either alcohol related or just plain stupidity related and it wasn't doing much to put me in a good mood. By midnight I was in a pretty foul mood and convinced that the night would be a total washout.

A little after 0100 I was dispatched with one of the volunteer ambulances to an elderly man with chest pain. Nothing all that special about that, we do them all the time and the routine is always pretty much the same. Because of the geography I arrived on scene first, a few minutes in front of the ambulance so aside from my usual ALS gear I lugged in the extra bags I would need to have a full complement of BLS gear as well as my usual ALS gear. A very pleasant 86 year old gentleman was seated in a chair and didn't appear to be in too much distress. As I evaluated him it didn't take me long to decide that I would be transporting with him. Actually, I had decided that I would be transporting with him before I even went into the house unless I could come up with a good reason not to. Let's face it, an elderly person with chest pain is heart related until proven otherwise. His story was very convincing. He couldn't go to sleep because of a nagging pain/discomfort in both of his breasts that started while he was watching the news on TV and was unreleived by antacids, motrin, and a heating pad. Yes, he said, he had had some episodes of difficulty breathing and had been fighting nausea for a few hours, even before the chest pain started. As usual, he was convinced it was nothing more than indigestion and was mildly unhappy with his wife for calling 911. Vital signs were unremarkable, survey was unremarkable. I did a quick 12 lead ECG and while he was having some premature ventricular contractions there was a good chance that this was his baseline cardiac rythym. He did have some ST depression in a couple of his V leads that made me curious, but, I thought, they were probably old and this was probably his baseline.

He had rated the pain as a 5 on a scale of 0 to 10 (with 0 being no pain and 10 being the worst pain he had ever felt). The ambulance arrived as I was putting him on oxygen and since they had come in with the stretcher already we agreed that they would load him up right away and meet me in the back of the ambulance since the patients chest pain was improving. I left as they lifted him onto the stretcher and headed to the ambulance to setup my IV and get ready to go.

They arrived a minute or so after I got in and slid the patient into the back. He was still pleasant and in very good spirits and, while the driver seat belted his wife into the front seat, we got him situated on the onboard oxygen, comfortable temperature and the like. As soon as the driver was in his seat I told him to start heading for the ED nice and easy. I would do whatever I needed to do on the move. We were about 10 minutes from the hospital and that should be just enough time to get everything done.

His IV was established with no difficulty, bloods were drawn, and the IV secured. I had just finished when he said, "You know, I'm really dizzy right now." I took a quick glance at the monitor and was kind of surprised that my seemingly stable and improving routine chest pain patient was presenting with this:

Ventricular fibrillation, chaotic movement of the heart muscle, which, while pretty to watch on the screen, means that for all intents and purposes, the patient was clinically dead. He had no pulses, his breathing went to next to nothing and he suddenly went unresponsive. I was not expecting this, not that too many people do expect this to happen and as one hand reached out and gave him a precordial thump (which aside from pointing out how much of a dinosaurs I truly am) did nothing. The EMT in the back with me laid the head of the tratcher back and started CPR while I fumbled to get the defibrillator pads out of their wrapper (damn wrapper or is it damn hands?) and applied them to his chest. After a single shock he reverted back to a "normal" rhythm. I was just happy that he had a pusle with it. Within 20-30 seconds the patient was again awake, alert, and talking to us like nothing had happened. Something had happened, and in a short time his ECG had developed rather pronounced changes that told me that he was having an heart attack.

His wife was extremely grateful and gave me a hug and a kiss on the cheek which just made my night. Calls like this make all the crap we put up with worthwhile. I was feeling ten feet tall.

I had just returned to the city after retreiving my vehicle from the scene when I got hit with my next dispacth. It was to an address that I knew, having been there multiple times before, and I also remembered just how upset I was the last time I had transported the same patient.

It was a pretty classic presentation for this 44 year old female. Seated on the edge of the bed in significant respiratory distress, breathing treatment in one hand cigarette in the other. Breathing fast and hard, sweat pouring off her like it was a hundred degrees, blood pressure, heart rate, and respiratory rate through the roof. This time she hadn't waited as long to call 911 and my hope was that we could be at the hospital before she crashed. The hairs on the back of my neck were standing up and I really wanted to get moving. We continued to give her continuous breathing treatments but still could hear very little air movement in her lungs. Quiet lungs are bad lungs as far as we are concerned. Quiet lungs mean that not much air is getting in to keep the body and brain alive After the carry down from the third floor and trip to the back of the ambulance ambulance she looked no better, and even a little worse.

This time things went better. The IV was established in a timely fashion and was good. The meds I wanted to give were now in our arsenal and as we headed for the ED they were starting to work. Her wheezing was getting worse. I took this as a good sign, more wheezing equals more air moving and more air equals better outcome. By the time we got to the ED I had started an infusion of Magnesium (a smooth muscle relaxant, among other things) which was something I had never done for asthma in my entire career and between that and the continuous breathing treatments she was starting to breath better. She was really tired and I was still worried that things would take a bad turn but she was doing better for the moment.

The ED doc was really happy with what I had done and since they had gotten an early heads up they had respiratory therapy there with the helium/oxygen mixture ready to go. She still wasn't out of the woods but was starting to turn around. 2 hours later when I got back to the ED she was looking pretty good. Still on oxygen, getting more meds but definitely getting better. As I sat down to do the paperwork I felt like I had redeemed myself from the awful disaster that had happened last time we had crossed paths.

So two significant interventions that both ended well. A good way to finish the night. I sure am tired, but I sure do feel like I accomplished some good.

Total calls for the night: 13
2 ALS transports
2 BLS downgrades
2 cancelled enroute/on arrival
1 unable to intercept
5 cover assignments

Total milage for the night: 167 miles

CD for the night: Live in Paris by Dianna Krall

For the second day in a row I am waking up feeling pretty well rested. I'm mentally sharp and looking forward to going to work. Hopefully I will have something to challenge me tonight since I feel like I am on the top of my game and last night didn't challenge me much at all.

What I don't feel like doing is any of the project work that I have to do and as a result, I probably won't. Instead, if the ED is slow or I am spending a lot of time on cover assignments I will probably just read a book.

Tomorrow promises to be a little more difficult. My wife is on call and I have to plan for the worst. The worst, in this case the worst is that she has a patient in labour and spends her entire 24 hours at the hospital. This will leave me with little if any sleep. Pretty much just what cat naps I can grab on the couch while the kids destroy the house, excuse me, I mean, while the kids play nicely.

Sometimes I just don't get it. Tonight I had one of those calls that just makes you go "what the ____?". Medic 1 responded with Ambulance 11 to a SNF for respiratory distress. I arrived several minutes before the ambulance did and went upstairs. When I arrived on the floor the nurse met me and walked me down to the room while giving me the run down. The patient was a 72 year old male who had been found complaining of being cold, especially in his hands and feet. The staff took his vital signs and found that his oxygen saturation was 81%. Clearly he must be having difficulty breathing so they put him on oxygen by a nonrebreather mask at 5 litres a minute.

Now for the nonmedical readers out there there are a few facts that we need to discuss. First, the air we breath has about 21% oxygen in it normally. Second, a nonrebreathing oxygen mask is capable of delivering 100% oxygen if properly fitted and given adequate oxygen supply. Third, no matter what, when provided with inadequate oxygen supply a nonrebreathing mask can provide less, sometimes significantly less, than 21% oxygen. Since there is no mixing of the oxygen with the room air the oxygen flow must be enough to supply the all the patients needs. Lastly, the pulse oximeter measures the concentration of oxygen in the blood by shooting a beam of light from one side of the probe to the other and measure the amount of light absorbed. Usually we use a finger, toe, or earlobe as a spot to do the measuring.

When I walked in the room I found this patient with a well fitting nonrebreather mask and an inadequate oxygen supply. Funny how it works, inadequate oxygen supply = low oxygen saturation readings. I am very very glad that I was able to quell my first instinct which was to say something to the effect "why the hell don't you just put a pillow over his face?". Instead I went to turn the oxygen rate up and found that the regulator would not even go above 5 litres. OK, well this adds a twist.

I took the mask off under the pretense of finding out what his oxygen saturation would be on "room air". Amazing, it actually went up. (If you missed the dripping sarcasm read it again.) After a couple of minutes his oxygen saturation was back to where it normally was. Indeed his hands and feet were cold but then again, so was the room. Hmmph, doesn't look all that bad now. The ambulance still had not arrived so I pulled the paperwork out of my pocket and began to read it. The last note on the page was one stating that the patient had extremely poor peripheral circulation. No kidding.

The ambulance arrived and as they loaded the patient onto the stretcher I asked the nurse where they did their measurement of his oxygen saturation. "On his finger of course." OK, all makes sense now. So they put the probe on a finger of a man complaining of cold hands who has poor circulation in his hands and feet. l wanted to say "Gee, do you think that maybe someplace on the body that actually had GOOD blood flow would of been a good idea?". But I didn't.

As we rode down in the elevator I gave the whole story to the ambulance crew who were alternately disgusted and amused at the whole thing. They loaded the patient into the ambulance and closed the doors, not even giving me a chance to ask if they wanted me to come along. I cracked the door and was told that they didn't think they would need me and that I could move on to the next call. They were polite about, but it was clear that they wanted to do the transport and head back to bed.

No problem as far as I was concerned. I was going to ask them if they thought they could handle it without me. I gave the ED a call and gave them a heads up on what was going on. Funny, the patient was discharged before I even finished the paperwork. "Poor peripheral circulation, attempted asphyxiation."

It amazes me the people can forget something so simple as to "treat the patient, not the hardware". After some thought I found the entire situation pretty scary and was very glad when the night was over.

Total calls for the night: 7
1 ALS transport
1 BLS downgrade
1 Cancelled upon arrival
4 Cover assignments

Total Milage for the night: 91 miles

CD for the night: The Look of Love by Dianna Krall

It was so nice to spend the day asleep. I crashed around 0500 and it felt great. It finally felt like my life was returning to normal. I don't know if it was because I was going back to work again or if it was because I was sleeping when I felt I should be asleep. Either way it was a good day, even if I did wake up around 0730 with a migraine. I took my meds and went back to sleep and by 1500 when I had to get up I was feeling pretty good.

Even the bad stuff that happened didn't ruin my mood. I normally would have been kind of ticked off when I found out that my flatbed scanner was broken and the manufacturer wanted a hundred bucks to even look at it to find out what was wrong. Geez, you can get a new one for well under that price. If things are quiet later tonight i may surf a few places and see what I can find. When I was working at the Apple Store we sold a decent quality scanner for $49 which would do just fine for what I need even if it doesn't have the one feature I want, a sheet feeder. I would love to take all of the paper that I have filed in various places, scan it, and turn it into PDF files. To get a sheet feeder you need to head towards the high end of scanners and since I just don't use it all that much I can't justify the expense.

After that and a quick shower the whole family went out to go to HomeDepot. They just opened a store in my area a few weeks ago and, as I expected, we are there entirely too much. Todays target was the bathroom floor. It really needs help. Physically it's fine but to is stained in places and colour wise, let's just say that, you can tell the house was built in the 50's. The floor doesn't match the wall tile which doesn't match the fixtures. Looking at the big picture of colour the combination is pretty nauseating. The initial thought was to renovate the entire bathroom. A good idea, right until we figured out how much it would cost. OK, Plan B was to just put some new tile down to cover the stains and hopefully bring the colours together so it doesn't look like something that was put together out of construction leftovers. Eventually we'll do a total renovation but we have just a short list of things that have to come first: new windows, insulation, paint the house, seal the driveway, redo some plumbing...OK, it's a big list. We'll get there eventually.

I am hoping for a fairly busy night even thought the day shift has not had one from the sound of things. The weather, while still cold, is not expected to be bitterly so. The other medics working tonight are really good at their jobs and can be counted on to keep their eyes and ears open to the status of the entire system so that we should be pretty efficient. It has always amazed me how much smoother the nights run when everyone working pays attention and tries to be where they are needed before they are needed. A little common sense and some knowledge of the system and it's pretty easy to do that. It also helps us all to stay active. I would so much rather stay in motion of some kind for the entire shift than have to sit around.

Drowning from the album: Cracked Rear View by Hootie & The Blowfish

Well, not really but I spent another day clearing everything out of my office. I'm to the point where the desk is almost completely clear, the closet is empty, and the floor is visible in all areas. My wife and kids are astounded. I don't know why I am rushing since the sooner I get done the sooner I lose my office and have to turn it into a guest room. Well, whatever, I am finding lots of stuff to get rid of on eBay which will be a great help both in terms of finances and storage space.

I have a couple more hours that I can get some more work done since I need to stay up late and get myself back onto a nighttime schedule. I am looking forward to getting back to work. As nice as it is to have time to get things done but I really get squirrelly when I am out of work for too long. Strange but true. Too much stress or not enough, I guess I need to find a happy medium.

Hannah Jane from the album: Cracked Rear View by Hootie & The Blowfish

Well, it has been an extremely busy day. My office looks worse than when I started but I know that this is frequently the way it goes. I'll work more tomorrow. I needed to take a break to do a few things, bath my youngest, download some software I wanted to try, and install MT-Blacklist to try and cut down on some of the comment spam I( have been getting. Doc swears by it so I figure I'll give it a try. The install was fairly simple except that I could not use the easy installation because of some weird configuration on my server. The not so easy install actually wasn't to bad and worked well enough.

The other software I wanted to download and try was Ecto. Ecto is a Mac OS X based client for posting to Movable Type Weblogs. I really wanted to find a better way to write entries off line and upload them when I get back to a network. I have downloaded it and am writing this post with it so we'll see how it works. It actually looks pretty nice and interfaces with iTunes to boot so all my adoring fans (sic) will know what I am listening to as I write.

I Love Being Here With You from the album Live in Paris by Diana Krall.

Todays goal is to start cleaning my office. It amazes me just how much stuff you can put in one room. How much? Let's just say that my trash man is not going to be happy with me.

Yesterday was geek day. Today was domestic day. My wife and I spent a good portion of the day cleaning closets which seemed like something akin to torture today. I was in a very cranky mode and that didn't help matters at all. On the otherhand now that my closet is liberated of clothes I don't wear, unifroms from jobs I no longer have and stuff that is just plain worn out it becomes pitifully obvious how dull and sparse my wardrobe is.

I had an appointment with my MD this morning and among the things we talked about was my difficult sleeping patterns. I was less than happy when he said that these things happen to people as they get older. Damnit, I'm not even 40 yet, I am most definitely not "older". Well, as I put my shirt back on and looked in the mirror at the receeding hairline and the spots of grey in my beard, I began to figure that maybe I am getting older. Not "old" just "older". We're going to try some Ambien for those days when I have trouble sleeping and see if that helps. The sleep trouble we can fix. Balding and graying are probably a lot less likely but in the long run they don't mean a heck of a lot anyway.

Today has been a long, long day. It was moving day and there was so much work to be done that I was up at 0400 to start the process of readying the server to move. For the next few hours I was busy making DNS changes, editing configuration files, and making as complete a backup as possible.

After a quick shower and a bite of breakfast I drove the 45 minutes to my old hosting company to remove the server. During all the years that I did computer consulting I always was nervous shutting down servers that have been running for a long time. My server had been up and running for over 9 months. The shutdown went without incident but the real test would be 2 hours later when I got to the new data center in New York City.

I didn't mind the drive to New York, I drove by some interesting places. Some of them I would like to go back to and see closer and then some I would just as soon ignore. On the same trip that I drove by the United Nations, the New York City Fire Acadamy, Wall Street, and within sight of Ellis Island and the Statue of Liberty I also drove by the headquarters of World Wrestling Entertainment, the site of the L'Ambiance Plaza, and some of the most poverty striken neighbourhoods in the Northeast US.

The drive itself was pretty comfortable with weekend traffic only being heavy sporadically. I'm glad I wasn't making the trip on a weekday, it would have been brutal. The new data center is in the Financial District a block away from the New York Stock Exchange. Surprisingly I found on street parking with little difficulty and took the elevator up to the 21st floor.

I freely admit that when I finally made it through the security systems and into the data center itself my jaw dropped. I got the grand tour and was very impressed. We installed my server into the locked cabinet and hooked it up to the high speed backbone and we were ready to start. The moment of truth, was the server going to startup after being shut down, cooled off, jostled on the rough roads in to the city, rewarmed and installed in a new environment? Oh Yeah! I was very happy when the server sprangback to live and ran through the startup diagnostics like it was fresh out of the box. Pretty good for a server model that Sun abandon several years ago.

The support people were friendly, knowlegable, and serious geeks. The last thing we had to do before I was finished was enter my biometric data so that, should I need to come back to work on the server at all, the security system would know who I was and let me in. Very cool, they scanned my thumbprints 3 times each and now I can be identified at any of their 5 data centers in New York.

The drive home was uneventful as well but I was really glad to be home. 278 miles and 5 hours on the road is a long trip to make in one day. The work was almost done.

Once I got home I still had to finish some of the server configuration and make sure that all the sites I host were accessible and ready to go come morning. Everyone seems to be up and running, the stream of email is starting to pick up again and I am about ready to head to bed with the feeling of a successful transfer.

My honest hope now? I don't have to actually see my server in person for a few years.

The night started out very busy with the first call coming in before my shift was actually supposed to start. It ended up not being anything very serious but from there I ran straight for the next few hours. Still nothing even remotely needing paramedic care. It wasn't until almot 0300 when I finally got a call that needed a paramedic and even so it didn't make sense for me to spend the time to do the ALS. Why? Because the patient was at an assisted living facility less than 50 yards from the ED entrance. Even though she was having a stroke it made much more sense for us to effect a rapid transport than to stay on scene doing the ALS. That's the way it goes sometimes.

Total calls for the night: 6
2 Cancelled enroute
3 BLS downgrades
1 cover assignment

Milage for the night: 97

CD for the night: "Jagged Little Pill" by Alanis Morrissette

I'm listening to the scanner and am hearing the day shift get sent all over the place. Nobody seems to be where they belong and it sounds like it has been busy.

I got some good sleep today and am ready for the night, busy or not, it will be OK with me. I'll enjoy it if it's busy, if not I'll get some of the logistics of my upcoming server move written down so I am sure to make them in the proper order. I really need everything to go smoothly since I am making the move well ahead of when I wanted too and haven't had much time to work out the details. Except for the DNS propagation I don't expect any problems.

Sunday is the day for the move, I have an appointment at 1000 to remove the server from the old data center and a 1300 appointment to install it in the new data center. In between will be the drive to New York City. Driving to New York is never something that I really enjoy but on a Sunday the traffic should be somewhat better than a weekday.

I couldn't do it today. After our staff meeting on Monday I just couldn't go back for another one, especially one where the discussion would be about the same stuff. Since our layoffs we have had a fairly substantial change in our operations. No way to avoid it with 24 less unit hours a day. In order to allow us to do more with less there was some modification of our dispatch protocols. Then it was nothing major, just some fine tuning, changing of wording to better reflect what was supposed to have been happening for the past 16 years.

Since then my boss has been looking at the numbers and these changes have worked, sort of. Our call volume is down a little reflecting the drop in some of the inappropriate dispatches but our transport rate is also down. Since, until another funding model is worked out, decreased transports equals decreased revenue this is a bad thing.

Some of the reasons our transports are down are understandable and unavoidable. With less unit hours our overall availability has gone down. There is no way to avoid that. Not a tremendous decrease but a couple of percentage points. But when you figure we are receiving about 10000 requests for service a year a drop of a single percentage point is 100 requests that we are unable to respond to. It all adds up.

Another reason that our transport rate is down is necessary changes in the policy for turning ALS patients over to the ALS ambulance that operates in part of our service area. In the past calls would be turned over if there was routine ALS being done only. If the patient required more involved intervention the hospital paramedic would transport with the medic on the ambulance. This protocol was put in place when we still had the 2 additional units on the road and, to a greater or lesser extent made sense. Like any commercial service this one has some medics that are excellent, some that barely meet the minimum standard, and a lot that fall in between. It's hard for even the weakest paramedic to mess up routine ALS.

Out of necessity our mindset has changed. Whereas in the past we would have had no hesitation to hop onboard and transport with patients that were going to receive simple ALS (i.e. the patient with asthma who gets a nebulizer treatment and gets better) now we have to balance that with the need to stay available for calls in the area that does not have any other paramedic coverage at all. We still always have the option of doing the transport but with our availability in mind the bar has been raised for us to come along. Patients that almost certainly would have been transported with the hospital paramedic now must be much sicker or need a medication, protocol, or procedure that the ambulance cannot deliver for us to do the transport. This also decreases our overall transport rate.

In my mind the biggest reason our transport rate is down is geography. Our service area is almost 600 square miles. We serve the entire county and several surrounding communities as the primary ALSresponder and provide backup response to several more towns. With such a large area it becomes difficult to provide coverage with only 3 units around the clock. It is made even harder when one or more units are already tied up on other calls. This can result in responses from one side of our service area to the other side which can be upwards of 30 minutes or longer response time. Sometimes we are stymied by the geography and just can't get there in time requiring the ambulance to either transport without ALS or try to get another ALS intercept depending on their destination. There is nothing more frustrating for me than this. You can only expect a single unit to cover so much territory. We just plain lack adequate manpower. This is exacerbated when the boss takes a unit out of service because of a lack of staffing rather than provide some of the staffing himself.

While I respect my boss for his ability to look at things from a totally numbers based standpoint it is frustrating to me because I still, rightly or wrongly, look at our operations from a strictly operational standpoint. The prupose of our department is to put a paramedic on the scene of as many calls we are requested to as possible and provide appropriate care as indicated. In order for this to happen we need to be staffed appropriately. So a lot of my ideal solutions involve the availability of additional manpower and unit hours. My boss looks at things from a bottom line perspective first, improve efficiency and keep costs down and we won't need the additional unit hours.

I think the answer is somewhere inbetween. Yes we need to keep the bottom line in view, we need to improve our efficiency and control costs. We also need to maintain adequate staffing. What the best answer for us will be? I don't know. So far none of the solutions that have been proposed have been workable either because of the financial aspects or because of the operational effects they may have.

The only thing I know for sure is the my boss and I are coming at the problem from different sides and we both need to keep the other side in mind as well. I need to be more administratively aware and he needs to be more operationally aware. Until this happens my frustration level at these meetings is so great that I have a hard time convincing myself to attend.

This was a pretty rugged night, not because of what I had to do or the weather but rather because it was so slow I found it difficult to stay awake and on task. It wasn't just me, everybody was dreadfully slow. I started the night trying to actually get some work done but by 0200 or so I knew that I was going to get nothing productive done. I fell back to chatting with the staff that were working and doing some mentally non-taxing answering of email. Other than that, and a short drive out to pick up some Diet Coke the night was uneventful.

Total calls for the night: 0

Total milage for the night: 16

CD for the night: "Just Go Ahead Now: A Retrospective" by The Spin Doctors

We got quite a bit accomplished today even though I didn't get a chance to nap. I will have to do that this evening though since one of the night medics called in sick. After seeing the page for the open shift 3 or 4 times I decided that I would see if they would let me take part of it since I didn't want to/couldn't work the entire 12 hours without any sleep. The medic working days is holding over 4 extra hours until 2300 which will give me a chance to get a couple of hours sleep before I go in to finish the rest of the night shift.

I can't say that the overtime, night differential, and emergency call differential aren't a big incentive. Lot's of stuff that needs to be fixed around the house and that can be expensive.

You know what happens when you sleep a lot during the day? You can't sleep at night. If I were working this would be a good thing. But I'm not so we'll have to just roll with it.

Lots of errands to do today. My wife is off today so we actually get to see each other for a change. Some of the errands will take us to Hartford, a city I used to work in and where I trained as a paramedic. I'm hoping that things will work out so that we can try to have lunch at one of my favorite places. Which one? I don't know yet. There are so many to choose from. Polish, Italian, Greek, Vietnamese, Korean, Ethiopian, Indian, Chinese; I just can't decide yet.

One of the things I miss living and working in small towns is the lack of neighbourhoods with strong ethnic identities. It was always nice to have all sorts of choices for meals and neighbourhoods with flavor and personality. I have missed some of the Italian, Jamaican, Greek, Lebanese, Brazilian, and Vietnamese specialties (to name a few) that I used to be able to get often. Variety makes life interesting.

The other thing that was fun was being able to learn about the culture of other places and people. Growing up in a small homogenous rural town pretty much everyone was like me and this led to a pretty "white bread" existence. Spending time in a larger city exposed me to the cultures, languages, holidays, and yes, even some of the prejudices, of these other people and it helped me to learn and expand my horizons (how else would I have found out that I like Finnish folk music?).

I lied, I signed the contract to move my server tonight. The actual move won't happen for at least a week (one of the sites I host is going to be mentioned on TV and it would be poor form if it were down when people looked for it).

So, in several days the server will reside in Manhattan, just off Wall Street at New York Internet. They had everything I was looking for and then some. Heck, even their backups have backups. I was impressed. Of course my costs are quadrupling to get all of this so if anyone needs cheap hosting feel free to drop me a line.

As much as I really didn't want to sleep yesterday I knew it had to happen eventually. I slept fitfully from about 0300 to 0700 when I had to get up and get the kids out the door for school. After everyone was out and where they were supposed to be I sat down on the bed to put on some shoes and, well, woke up about 5 hours later. While I still had a lot on my mind it was a very restful sleep. I guess my mind just ran itself to the point of exhaustion and just shut down. I feel much better.

[Philosophical diatribe on]

I really needed the sleep and needed to wear myself down to the point of exhaustion to actually get it. I'm glad this doesn't happen very often. I always used to be able to sleep no matter what had, was, and would be happening. I always thought that that came with experience and some of it probably does. What also seems to come with experience is the need to look back and see the "big picture". Not just the trauma or medical emergency but also having some handle on the short and long term effects of what is happening to the people it is happening to and what effects it is and might be having on you now or in the future. That's something that we never get taught and is never stressed enough in our training and education, the call may be over but for all of those involved the effects can last for a very long time.

Yes, almost everyone in EMS will have one call or more that will rock their world to the core. Some will never even make an effort to understand why and deal with the effects, some will let it sour their attitude for the rest of their careers, if not the rest of their lives. Some will try to see the incident as a moment in time and attempt to understand how we came to be there and what changes it will have on our feelings and thoughts in the future. When all is said and done I still think that this is a good thing. It keeps us humble, it keeps us in touch with our emotions, and most of all, it keeps us human. It reminds us of the strength of human compassion and the resiliency of the human will.

Experiencing the horrible things that we do both the first time and then again through our thoughts, and sometimes our nightmares, makes us appreciate some of the simple pleasures that can be had in our jobs. Just something as simple as a smile or a "thank you" from a patient or family member can make the scale tip to the side of "the good stuff" and keep us from becoming bitter, frightened, and unfeeling. Many EMS professionals never realize this and as a result they never figure out that our job is not completely what it seems.

It seems like the job of an EMT or Paramedic is clear cut, provide medical care to the sick and injured and to a greater extent that is true. What is frequently forgotten is that our job is also to provide a sense of security and comfort to our patients, their families, and ourselves. With few exceptions people call 911 because they don't know where else to turn to for help. Sometimes the help they need isn't the physical staunching of bleeding or the splinting of a broken limb. Sometimes they simply need a calm demeanor and a human touch to let them know that, as bad as things seem, they are under control, they are not alone, and that someone cares.

Not every EMS provider seems to be able to understand this. Most often I believe it is because they spend so much time walling off what is happening around them. They don't want things to effect them. They don't want to let their guard down and actually invest feeling and emotion in each and every patient they work with. Why? Simple, when you allow yourself to feel you have sleepless nights (and days) like I had yesterday. You are allowing yourself to be emotionally vulnerable. But, in order to have any sort of compassion, being emotionally vulnerable is required. Compassion involves the trying to understand someone elses situation and in order to do that we need to be able to put ourselves in their place, and that means that we cannot wall ourselves off from the world.

As much sleep as I lost in the past of 24-36 hours I can't say that I would want it any other way. The feeling lets me know that I am alive and that I am, and will be, human.

I have wonder for a while about using open Wi-Fi nodes that I come upon during the course of my day (or night) for Internet access to grab and send some quick email. It's an interesting question and one that I have given a lot of thought to over a number of months.

Dori Smith at Backup Brain had given some thought to the same question and points out this article written by an ethicist at The New York Times. The arguement makes a lot of sense, and not just because it supports my feelings on the matter.

I really don't, but I know I should and I know I need to, but my sleep this morning was pretty bad. Last nights call just made it difficult for me to get to sleep and stay asleep. Not nightmares but lots of thoughts and trying to understand what happened and why. My mind was just too busy for me to sleep well.

I think everything went extremely well, my performance was right where it should have been, and that there was nothing I would or could change.

When I was younger I would sometimes be bothered by the physical deformity from serious trauma. As I age I find that I am less bothered by the actual trauma but more by the situations that lead up to and and results that follow the incident. I guess what makes this particular incident troubling is the convergence of coincidental facts. The patients were the same age as my wife and I, the accident happened on a stretch of road that we, and especially me, travel often, and the total lack of any ability of the victims to change the outcome.

Yet another thing to point out my own mortality.

I feel like the angel of death this morning, I always do when I pronounce patients on the scene of a call. Last night was not very busy which is a good thing but two of the dispatches I had kept me going with paperwork for almost 5 hours.

The first call was pretty much routine, an 81 year old male who had a sudden onset of left sided weakness and an inability to walk. We transported him to the hospital in the next county and that was the end of it.

The second call was a catastrophy. To listen to it must have been weird, I know when the dispatcher played the tape of the 911 call it was one of the scariest 911 calls I have heard. The call was for a rollover on I-95. You could hear the caller giving the information to the 911 operator, then you heard the screeching of tires and a loud crunching sound as the caller was struck by another vehicle.

I knew it was a bad thing when the tones started going off for the call and they seemed to go on forever. "Station 38, Station 39, Ambulance O2, Ambulance O3, Ambulance Y1, Medic 2, Medic 11, Medic 12 respond with the state police for a multivehicle rollover..." Anytime that many units get sent on the initial dispatch I just get this sinking feeling in the pit of my stomach. It didn't help that the temperature was hovering around 14 degrees F. Shortly after I responded I got an update from the dispatcher stating that an off duty US Army Medic was on scene reporting 6 patients, 2 critical and that he requested 2 helicopters. Of course both of the in state helicopters were tied up and the nearest air ambulances that could be found were 40 and 53 minutes away. *sigh* This just isn't going to be good. When I pulled up in the northbound lane I could see that the southbound lanes were blocked with 2 rolled over vehicles and another vehicle broadsided into the guard rail on the side of the highway. One vehicle was on it's roof with all the windows blown out and appeared to be unoccupied while the other vehicle was rolled over on to the passenger side with extremely heavy damage to the passenger side and the roof. The army medic was standing on top of the drivers side trying to squeeze in a broken side window to gain access to the patients inside. Quick size up was 6 patients total, 2 still entrapped, 4 out of their vehicles and walking with what appeared to be minor injuries. OK, cancel Medic 12, keep all three ambulances coming, keep the helicopters coming for now.

As I approached the vehicle lying on its side I was able to see that the roof had been crushed to to the level of the seat tops on the drivers side and well below the level of the dashboard on the passenger side. The driver was pinned between the top of his seat and the collapsed roof with his chest being compressed about 5 or 6 inches. He was well entrapped, still belted into his seat, pulseless and with only agonal respirations. The rescue pulled up and they pulled both sets of jaws and started firing them up. The other patient in this vehicle was entrapped so badly I only had access to the right arm and from the pelvis down. A large pool of blood and clear fluid was collecting on the pavement below this patient and I had a really bad feeling about this. This patient was pulseless as well.

It was a very difficult extrication as whatever was done to free one patient caused additional forces to press against the other. The rescue did an incredible job of securing the vehicle and freeing first the driver and then the passenger while minimizing additional injuries. The driver was freed after about 17 minutes of work with the 2 sets of jaws. When he was finally freed he was placed on a backboard and collared and quickly moved to the ambulance. I had 2 ambulances on scene but was still the only paramedic. I wish I could say that there was something to do but one chest compression was done and between the blood welling up out of his mouth and nose and the fact that his chest did not come up again that left little doubt in my mind what the final result was going to be. When the monitor was put on it showed that he was asystolic with no cardiac activity at all. I had made contact with the Medical Direction Physician back at my base ED early on in the extrication and he had concurred that it did not look very hopeful for these two patients. If they were disentangled and extricated and had injuries that appeared incompatible with life I should presume and move on to the next patient. I did just that and the crew removed the body from the ambulance to a spot on the shoulder of the road where it would be away from the action and watched over by one of the cops on scene.

Back to the vehicle, and the rescue had just about pulled the roof down enough to get at the other patients head and chest. One of the EMT's squirmed into the newly opened space and backed out just as fast which only motivated the crews extricating to work faster. I'm not sure if they thought that there was still a chance to save this one or what but they started to work quickly and deliberately. Total extrication time was 22 minutes and the patient, a woman I could tell now, was brought out on a backboard and rushed to the same ambulance we had used a few minutes earlier. From the neck down this patient was remarkably intact but any hope was dashed when I got a look at the deformity on the left side of her head and the blood and clear fluid draining from both ears, eyes, and nose. Again, asystole. Another presumed dead on scene. She was removed from the ambulance and placed next to the other occupant of the car.

Both the helicopters were still quite a ways out and I knew that even if one of the other patients needed to go to a trauma center we could get there by ground faster than waiting for the aircraft. I cancelled both helicopters.

Medic 11 arrived followed quickly by the third ambulance. I asked 11 to just take a look at the walking wounded and make sure that nothing was missed. He agreed and headed to the other side of the scene with one of the BLS crews.

Three patients were refusing all treatment and the driver of the first car that rolled over completely appeared to be uninjured but was "just not right" so I agreed with the BLS crew to transport to the hospital with them. Our survey could not find any injury except for some small lacs from glass on her left hand, everything else was unremarkable, but still, something wasn't quite right. She was talking and answering questions but seemed very distant and like she was in another place. For the moment all I did was monitor her and observe during transport. We transported to the same hospital I had gone to on my first call of the shift. When we got there she finally broke down and was racked with sobs and tears. Clearly she had some understanding of the magnitude of the accident even though I am pretty sure she did not know about the fatalities yet.

Both the BLS crew and I were pretty subdued, just wanting to finish our paperwork and the usual after call chores and go find somewhere else to be. Nobody enjoyed this call all that much even though it was certainly a challenge.

Grand total for this call. 2 fatalities, 1 ALS transport, 3 refusals initially who later decided they should be checked out and were transported BLS.

When we returned to the scene and I was giving my statement to the troopers I found out the sequence of events as near as they could piece them together. It seems the 18 year old that we just finished transporting had been driving home from a weekend away, got sleepy and drifted off the right shoulder. She was jarred awake and over corrected rolling her SUV over three times according to witnesses. A car that had been behind her had pulled over to assist and while they were making the call to 911 was struck from behind by another SUV that rolled over several times and slid roof first into the guard rail. The story fit but 
it was even sadder knowing that the two fatalities were not involved in the original accident at all.

I finished giving my statement and returned to my ED to wade into the mountain of paperwork that now needed to be completed. I was not happy. I really just wanted to go home to hug my kids and climb into bed with my wife and go back to sleep but that was not going to happen. 5 hours later the last "i" was dotted and the last "t" was crossed and I was just ready to call it a night. Call it a night, except that the shift wouldn't be over for another 4 hours.

Pretty lousy call on a really frigid night.

The rest of the night was nicely uneventful with a BLS downgrade and a cancellation. All I could do was look forward to heading home and to bed so I could rest and try to forget how bad a night it had actually been.

Total calls for the night: 4
1 BLS downgrade
1 Cancelled enroute
2 ALS transports

Total milage for the night: 107

I'm heading in to work early since I want to have a few minutes to talk to the day medic. We've known each other for a long time and worked together in many different capacities. I trust his judgement and value his opinion. I don't have anything in particular that I want from him, just a reality check on my current job situation and on the "working staff meeting" we have scheduled for Monday afternoon to discuss some operational issues.

The day was mostly uneventful except for the major disaster of our DVD player breaking just when my kids wanted to watch a movie. *sigh* They just don't make these things to last. When our VCR broke last year we found that it would cost more to have it repaired than it would to just buy a new one. I am guessing that it will be the same with the DVD player. Yet another thing to spend money on. *frown*

Another cold night coming tonight and although I would like to do something I really don't want to go outside much. We'll see.

Well I have hit the limit of my patience with my current colocation provider. I have had some nagging reverse DNS problems ever since I moved my server in and they have been unable to solve the problem. Add to that the service outages that have been growing more frequent and longer in duration as time has gone on and you'll understand why I'm at the end of my rope.

I have run my own server for a number of years giving away space to some friends and local non-profits, providing hosting to some of the local EMS agencies at a greatly reduced price, and continuing to provide service to some of the clients I had when my consulting business was going full speed. For the most part it's easy work that doesn't require much hands on administration so when I closed the business I kept the server just because I like to have the freedom to do whatever I want.

Over the weekend I decided that it was time to move the server somewhere where they could keep the connection up, have dependable power, and give me some tech support when I had problems. So I started looking and found several providers some local to me and a few based in New York City who had the features I wanted.

None of them were going to be able to match the price my current provider had given me, about $300 a year, but then again, I got what I paid for.

All the local providers were quickly ruled out either because they were very expensive (I'm sorry but $400 a month for the amount of traffic my site and the other sites I host generate is ridiculous) or they would only rent me a quarter cabinet minimum (I'm sorry, my server is about 1 1/4" high, the idea that I would need to rent almost 2 feet of cabinet space boggles my mind).

So now I'm down to two providers that I am considering, both in New York City, both very reasonably priced both with multiple levels of redundancy for power, connectivity, climate control. Oohh, and the crowning touch? Neither of them are located in someone's basement.

Both are about equal on price and services provided but one offers better security and the one service that I really need to have if the server isn't going to be close to me. One of them will let me leave a "Care Package" with the server with replacement parts like a power supply, fans, hard drive and the like. If a part croaks all I need to do is let them know and they will handle the replacement of the part for me. Sure they'll charge me a fee to do the work, but it sure beats me having to drive down to New York City (a couple of hours each way) to spend 10 minutes replacing a part. Besides, if something goes that I don't have a replacement for chances are they can find the part pretty quick even in the middle of the night, I mean, hey, it's New York, the city that never sleeps, right?

The kicker? Earlier this week I sent another email to my provider complaining about the reverse DNS problem. The reply was friendly but the message was pretty clear. They're going out of the colocation/hosting business and it just ain't worth trying to fix it now.

The final decision hasn't been made but I don't think it will be too much longer before I make a decision and then the only delay will be finding a time to remove the server from one place, drive to New York City, and install it in the new one. Sounds good to me and I'm hoping to be signing a contract early next week.

The night was interesting. For Medic 1 and Medic 3. The roads got icy early upcounty and didn't start to ice downcounty until almost the end of my shift. Aside from a single cover assignment early in the shift there was no activity for Medic 2 at all. That always makes it a difficult night. I spent some time sweeping out the garage, rechecked some equipment, shuffled some paperwork, read some, and really pushed the caffiene so that I could stay awake.

I'm back again tonight for what I hope is not a repeat performance. Since we have been told that we cannot use our laptops in the ED it has made it much harder to actually get work done and I need to make some revisions to the presentation and curriculum for the Combitube class that I teach. I need some of those cover assignments so I can get this work done while I am on the clock.

Total calls for the night: 1 Cover assignment

Total milage for the night: 86

CD for the night: "90125" by Yes

Well so my sleep wasn't exactly as I wanted it. Noise from the house they are building across the street woke me up a couple of times but I still managed to get enough sleep to feel rested.

I had a better day than my wife did, that's for sure. She spent the day playing chauffer to our three kids which was only made more difficult by the dead battery she found when she went to start her car. She had used mine yesterday in the bad weather and had not seen the light that had been left on in the back seat. After 24 hours there wasn't much juice left in the battery so rather than waking me up (Thanks, my love!) to deal with it right away she just took my car again and woke me up early enough to deal with it then. I did manage to come to the conclusion that there must be some corellary to Murphy's Law that says something about the jumper cables always being a foot too short. With some creative jockeying I managed to get my car close enough to hers to do the job but it required way to much thought for having just gotten up.

While I was struggling to get her car started my wife and daughters were very nice to me and ironed my uniform for the night and made sure that I had all the clothes I would need for a cold night.

I haven't listened to the day shift at all so I have no idea what kind of a day they had. I don't know much about what is in store for me tonight except that it is supposed to be in the high teens F tonight and after a warm(er) day and some snow melt that could make the roads pretty interesting.

Well, the day got interesting with the cancellation of school. I ended up home with all three kids and as much as I tried not to I ended up dozing off and on for a good portion of the day. I still managed to keep them fed, amused, dressed and not have them trash the house but I also spent time dozing in various chairs, sofas, and once on the floor.

By midafternoon I was rested enough to get up and start moving along with the chores that I had to do. Laundry, housework, dishes, ironing, all got done on the afternoon and early evening. The house looked pretty good, if I do say so myself.

My wife was stuck at the hospital with various patients in labour, or having other gyn problems that I was glad I don't have to know anything about. I'll see her in the morning sometime.

By 2000 the kids were so wound up and bickering after being in each others hair for the entire day that I told them to just go to bed. What surprised me was that THEY DID! No arguing, no cajoling, no yelling, they just went to bed on their own. Very cool, lets see if it ever happens again.

With the kids in bed and me fairly wide awake I did some decadant things with my time. Well, decadent for someone with kids, a full time job, and loads of responsibilities. I watched some TV, The History Channel, of course, I read some of my book, surfed the web for a while, sent out a lot of email that was long overdue, and generally got myself caught up.

Now it's almost 0400 and I am starting to get tired again and thinking of heading to bed. Most of the rest of the day will probably be spent asleep getting me ready for my Medic 2 shift tonight.

Not a very busy night, only 4 responses but one of the calls kept me stoked for the entire night.

***Note to the squeamish: Just move along, you don't want to read any further.***

"Medic 1 respond in the city with Engine 1 and Ambulance 224, Main and Liberty for a stabbing, PD on scene". Being a pretty small city this is not a dispatch we hear all that often. I followed the ambulance down Main Street and before I had gotten more than halfway the engine company was calling to find out my ETA. That's enough to get me on edge. These guys are good at what they do and they don't ask for an ETA often. That is usually a sign that something bad is happening.

When I pulled into the parking lot where the PD and the engine were parked I found everyone surrounding a middle aged black male who was *squirting* blood out of a single puncture wound in the center of his chest just left of the sternum. It was quite impressive, the blood was pulsing out in a 10-12 inch stream.

First thought, "Cool! I've never seen that before". Second thought, "Holy shit! Time to rock and roll".

He was still standing up so while the FD applied a dressing to the wound and applied direct pressure the BLS ambulance slid the stretcher up behind him had him lay down on it. The PD have me what little information they had at the time, stabbed once in the chest with a steak knife during an altercation, weapon had not been recovered yet but they were searching. I told them we would be heading for the trauma center about 20 miles north of us. The cop looked at me kind of strange but I didn't hang around to talk.

Once the stretcher was in and secure I looked at the EMT driving and told him to head out and not to wait for anything. The patient was still holding his blood pressure but had a heart rate in the 150-160 range. This made me pretty nervous and for a breif second I considered diverting to the ED at the local hospital I worked for. Nah, this guy really needs a thoracic surgeon and that was not something that was likely to be in house at this hour. We were 30 seconds from the highway and about 15 minutes from the trauma center, it was a better choice.

I put in two large bore IV's on the move and ran the fluids in wide. His pressure was still holding and his heart rate started to come down after a few hundred cc's of fluid but the was still bleeding profusely from the chest wound even with direct pressure, just bubbling up through the trauma dressing and running off both shoulders onto the stretcher and down onto the ambulance floor.

I alerted the ED as soon as I was in radio range, of course they asked me lots of silly questions like "are his pupils reactive?" and "are you sure he was stabbed?" and "why aren't you going to a closer facility?". I admit it, I got a little testy and hung up the radio and refused to answer anymore. I really didn't have time to play these kind of games.

Shortly thereafter we rolled off of the highway onto surface streets in the city. Everytime we turned a corner, braked, or accelerated the pool of blood on the floor had visible movement as it oozed from one side to the other. Wow, that was impressive.

We backed into the ambulance bay and unloaded the stretcher. There was still a large amount blood running off the patients chest onto the stretcher and then onto the ground.

Triage was unimpressed. She wanted the EMT to remove the pile of blood soaked trauma pads so she sould look at the wound and got snippy when I refused. "Well how an I supposed to know if he needs a trauma activation or not?" All I did was looked over my shoulder at the river of blood pooling underneath the stretcher and the heavy trail that ran from the ambulance bay to where we were standing. "Oh, go to Room 1 and I'll activate the team."

When we got in the trauma room most of the team was already there, the resident undressed the wound and almost jumped back when the blood made a 3" high geyser off the patients chest. then she stuck her finger in the hole like the little dutch boy plugging the hole in the dike. While this may be a dramatic thing to do it is not something that I have felt comfortable since I watched a surgical resident at another trauma center lacerate his finger on a broken rib doing the same thing. Well, I suppose it's not my finger and not my decision.

Five minutes later the patient had a couple of units of O negative blood hanging and was on the way to the OR to have his chest cracked and find out where he was bleeding from. The surgeon didn't sound too hopeful, "but you never know for sure until you get in there".

The police officer investigating the incident arrived just after the patient left for the OR. He was taken by surprise when I told him the patient was in the OR already. It seems he had been told that this had been a superficial wound and he headed for the phone quick to call for the detectives when I mentioned that the patients survival was far from certain.

It took quite a while to decon all my equipment, blood had gotten on everything. I managed to do a rough decon and bagged all the stuff that couldn't be cleaned right away so I could do a heavy decon when I returned to my ED.

I hate to admit it but this was a somewhat enjoyable call. I know that sounds kind of sick but it was. Since I stopped working in the larger cities this kind of trauma is just not something I see everyday. My urban colleagues would have found this to be "routine" but for me it was a rare occurence.

After midnight the detectives came by the ED to take my statement and deliver some information that made me have to think hard about the whole situation. It seems that the patient was a convicted pedophile awaiting sentencing and he had gotten stabbed in an arguement over a prostitute. A fine upstanding citizen, the lowest of the low.

A small part of me wished I had known this before we started treatment but then the professional in me took over and I realized that in reality it can't make any difference. It's not my place to be judge, jury, or executioner no matter how dispicable I find the patient to be personally. All I can hope is that the justice system exacts an appropriate punishment. Well, that and that my experience with the prison community holds to be true. While there is no honour among theives, even theives dislike pedophiles and his term in prison will not be easy.

Around 0400 it started to snow again. I'm getting pretty sick of snow. At about 0530 school for all my kids was cancelled and so was my chance to get any sleep today. *sigh*

Total calls for the night: 4
1 ALS turned over to the ALS ambulance
1 ALS transport
1 Cancelled enroute
1 Cover assignment

Total milage: 104

CD for the night: "Night Train" by Oscar Peterson

Another day that was not very productive. I had a very hard time falling alseep this morning and it felt like I had just fallen asleep when the alarm was going off to get me out of bed so I could meet the school bus. A half day of school is great for the kids but not so good for me. But they were pretty happy when they got home and I was able to lay down for a couple of hours sleep during the afternoon. So I was not completely exhausted when I had to get up, just somewhat exhausted.

It was my wife's birthday today and we had thought that it might be nice to take the family out for dinner to celebrate. I had to work tonight so we planned on an early dinner with the idea that I could leave for work directly from dinner.

What a disaster. Started bad and just continued to get worse. While we were driving to the restaurant the older two kids were with me in the car and it was clearly evident to me that they were starting to get cranky with some bickering and sniping at each other going on for most of the trip. When we arrived at the restaurant and met my wife and youngest daughter it was obvious that all three kids were getting cranky. Still, rather than just packing everyone into the car and going back home we pressed on.

Everything might have been OK if the service had been better. Things just didn't work out well. The kids meals all came about 15 minutes before the adults meals came. I know, I know, some people like to do it this way thinking that once the kids are fed they will be happy and let the adults eat in peace. Unfortunately it doesn't always work that way and by the time the adults meals arrived the kids were done and the bickering had started up again. They were ready to go home. Of course my wife and I had problems with both our meals, mine was just plain not what I ordered and my wifes was cold and it took almost 15 minutes more for them to be made right. By that time I had about 5 minutes to eat and get on the road to make it to work.

So I find myself on the way to work with none of my family particularly happy with our celebration. I just hope the night gets better for all of us. The weather reports are conflicting and it I really hope that the optimistic reports are correct. Right now the temperature is a balmy 34 F and while some reports are calling for snow, sleet, and freezing rain by morning, the optimistic reports are not saying that with their timetable not having bad weather until later in the day, well after I get home. Still, either way it's not the bitter cold that it has been and even though I am dressed for the cold (wearing my brand new long sleeved shirts for the first time in close to 10 years) I'd be just as happy if it never got colder than this until spring.

Well, I am making up for yesterday. Lots of stuff getting done and I even have some time to practice my trombone. For some reason my music just isn't hitting the groove today. I don't know what it is but it is really frustrating. I'm just going to take a break from the horn for a while and just play some loud music on the stereo and hope that things get better.

I don't know why but I am feeling a tremendously disconnected from the world today. Maybe if I had made it to the synagogue for the minyan this morning I woudl feel better. I don't like feeling this way and hope it doesn't last much longer.

As I said Monday, I finally finished the book I was reading. I have always been interested in history both what actually happened and the theoretical, "what if" kind. The Years if Rice and Salt falls into the later category.

The premise of the book is how would history have changed if the plague that ravaged Europe in the mid 14th century had killed 95% of the population instead of the smaller, yet still staggering, 33% that actually died. With European civilization in ruins and all but extinct what cultures would dominate the world and effect the course of history. It is an interesting question that Kim Stanley Robinson addresses by telling the stories of a number of people spanning almost 2000 years.

While Robinson is most definitely not a historian the book does seem to bring many of the widely accepted theories into play and concludes European culture and civilization destroyed the world would be dominated by the Islamic world and by the Bhuddist/Chinese world. Later in this history other players on the world stage would come from the Indian subcontinent, the Native American civilization, and the Incan Empire in South America. It is interesting to note that the Native American population suffers the same decimation from diseases brought from the Old World as they did in the European dominated history we live in.

The unifying premise of all the stories told across the entire alternate history is the reincarnation of charecters from early stories in the book as characters in later portions as well as some exposure to the interaction between these souls in the "bardo" while they await judgement by the gods and being sent back to earth in their next form.

I am not a believer in reincarnation and I felt like too much time was devoted to the discussion of it. However, it did not detract from the overall ability of the book to hold my interest. The reincarnation discussion was most prevelant in the early chapters and became less frequent as the book went on. I suspect that this may have contributed to the difficulty I had getting through the first few chapters. What also made it easier after the initial chapters was the familiarity with a new history and orientation of the world.

All in all it was an enjoyable and thought provoking book. Be warned, however, it is not a light read and definitely not a book that can be read without concentration. Unless the reader makes an effort to grasp the orientation and history of this alternative world it can be difficult to follow. It is also not a book to be read if you don't want to be rocked back on your heels every once in a while, even hours after putting it down, by the thoughts of how the change of a single fact can alter the course of the history fo the world.

When all is said and done I would give it a 4 star rating with the proviso that readers that don't want to think or that can't approach history with an open and inquisitive mind should just move along to something else.

I can't put my finger on a reason why but today was one of those days where nothing got accomplished. I don't know why, I had plenty to do, I had plenty of energy, just nothing got accomplished. I suppose that is OK and happens to everyone once in a while, I hope to be back on track in the morning since I do have a lot to get done before I go back to work Thursday night.

I am also hoping that my wife feels better in the morning. She came home from work not feeling well and went straight to bed. Wednesday is her day off and, at least this week, a day that we can spend together so it would be nice if she felt OK.

I did get some time to think about my future and possible career moves. I really don't want to make any move right now but most of the people I have talked to feel it is prudent to have a plan in case my department is eliminated and I find myself looking for a new job. Certainly in the short run I could go work for one of the commercial services in the area but I just don't think I would do as well in a restrictive environment now that I have been in the kind of situation where trust, responsibility, and high expectations are the usual order of the day. I also think it would frustrate me to no end to work somewhere where my coworkers, or at least the majority of them, are not as dedicated to doing the best job they can do as I am. (Yeah, I know, pretty conceited opinion but experience bears this out.)

The fact of the matter is that no decisions HAVE to be made right now and none WILL be made now. My plan is to hold tight until my departments funding issues are resolved one way or the other and then decide. I figure as long as my timecard still works I have no reason to move.

I am so glad that I upgraded my Movable Type installation to 2.661. Tonight I got what an email with this subject:

"[The MacMedic] IP Banned Due to Excessive Comments"

The message?

"A visitor to your weblog The MacMedic has automatically been banned by
posting more than the allowed number of comments in the last 200 seconds.
This has been done to prevent a malicious script from overwhelming your
weblog with comments. The banned IP address is

80.58.46.235

If this was a mistake, you can unblock the IP address and allow the visitor
to post again by logging in to your Movable Type installation, going to
Weblog Config - IP Banning, and deleting the IP address 80.58.46.235 from
the list of banned addresses."

Yes I had been spammed but since the new version of MT has a feature to reduce the automated psoting of comments there were only 6 spam comments to delete instead of the dozens that have been there from previous attacks.

If you use MT and haven't upgraded to the latest version you really should!

Another busy day at home and a change in the weeks schedule. One of the other paramedics is in school to become a radiology tech and found that his schedule was conflicting with his class schedule and asked if I would swap nights with him. He seemed pretty apologetic and I think he expected me to say no. Saying no to him was not even something that crossed my mind. He has done some swaps for me that were either not always convenient for him, last minute or both. I agreed without hesitation.

The rest of the day was spent running errands and doing work around the house. By the end of the day I had accomplished a lot and was pretty happy with the outcome.

Tomorrow promises to be more of the same. So much to do and so little time to do it in.

I would have really loved to sleep late this morning but, as is usual, the chance just was not there. My wife was on call today which meant thet she needed to be able to drop everything at a moments notice and head for the hospital. Since none of her patients were in labour she did not have to be in the hospital for a change.

The kids and I left for Hebrew School at the synagogue around 0900. I freely admit that as I drove the 20 minutes to the shul I was feeling pretty tired and even a little on the cranky side. I really could have used some more sleep. When we got there the older kids went to their classes and I took my youngest to the playgroup room. I swear she knew that I was tired because she was the most percocious child in the room and really gave me a run for my money. Willful and full of mischief I was more than ready for the morning to end and head back home to get some backup from Mommy.

After lunch we decided to surprise the girls with a trip out. My oldest was very disappointed that we weren't going shopping, my middle daughter was frantic that we might not be home in time for the Super Bowl and my youngest was just tired and wanted to nap. Funny, most of the upset went away when they saw me strapping our old tabogan on top of the car. The best sledding hill in the area is on the campus of the university just a few blocks from the hospital and when we got there we were amused to see that a few dozen others also had the same idea. It didn't matter, there was pleanty fo room for everyone and we had a great time not leaving until the sun started to go down along with the temperature. A quick stop to fill the kids with hot cocoa and we were off to home.

Now we're home, the kids have all realized that they found football totally boring and have gone on to other stuff and I am left on the sofa to doze and try to figure out what my plan is for tomorrow. I'm off, I have literally thousands of things that need to get done and I need to figure out which ones are going to get done.

We just got home from dinner and the concert. It was a wonderful and exhilarating night. I know that out of both couples that went I enjoyed the concert much more than anyone else but I half expected that going in.

Dinner was terrific with a nice meal, excellent wine, and great conversation. Every time I do something like this I remember just how much I enjoy adult (read grown up not X rated) conversation and how even though I can have more grown up conversations at work it is not the same as being totally away from the work environment. We need to do this more often. The kids were being well cared for so that was not a worry, we felt no time pressure to be anywhere and it was just totally relaxing. I even managed to stay on my diet...mostly.

We were a few minutes late for the beginning of the concert and that made absolutely no difference to any of us. We walked into the auditorium to the sound of well played jazz and I could immediately feel the rythym infecting me and the timing of my walk, my breathing, my thoughts, and even my posture. It was like coming home to a certain extent. The only thing that would have made it better would have been if I had been performing.

There is something about performing that just gets into your soul and is so uplifting. The idea that even without well defined and composed music that a small ensemble can function as a cohesive group complementing each other and making the sound paint a complete picture is just so enjoyable that I can barely describe it. It feels like doing a critical call where everyone just clicks, all the people on scene work well together with minimal need for direction fo correction and everything goes exactly the way it is supposed to go. I know that the choreography of emergency services rarely has such good synchronicity but when it does it gives a certain feeling of..of...of...peace and serenity even amid the chaos. Everything falls into place, everything works the way it is supposed to, you know what the other person is going to need before they need it and have anticipated what is coming next. That is what the feeling I get when I perform, almost a zen like peace. I love it and relish capturing that feeling even if it is just for a moment. If I cannot experience it directly the next best thing is to experience it through someone else and remember how good it felt to expereince it first hand. I truly yearn to expereince the thrill of performing again. Someday I will.

In the meantime I will continue to practice and continue to improve and strive to capture the feeling of perfect synchronicity in my work, as hard and infrequent as that may be.