“I just need to give the patient her medication. I’m sure you won’t mind waiting.”
The patient is a sixty-seven-year-old woman with brain cancer. She has a feeding tube in her nose. We hook her up to our oxygen and heart monitor. As we go to transfer her by rolling up her sheets and lifting her across onto our stretcher, I see that she has diarrhea in her bed. I don’t say anything.
As we walk down the hall, the nurse walks ahead of us carrying the patient’s chart; I notice a streak of shit on the back of her white sweatpants at calf level.
The new Cancer Center is just across the street. When the new addition to the hospital is finished an ambulance won’t be necessary. They will be able to wheel patients over by the sky-walk. But for now we have to transport them and wait with the patients while they get their radiation, then transport them back.
Outside, we lift her into the back of the ambulance. The nurse climbs in, then I get in. The nurse says to me, “It’s so close, yesterday I asked the ambulance driver if I could drive.”
“Do me a favor,” I say. “Don’t call us ambulance drivers. It’s like calling you a bedpan changer. I’m sure you understand.”
She looks very taken aback. “Oh, what should I call you?” she says.
“Paramedic would be good.” I am tempted to tell her how well trained we are. How I run codes by myself, perform intubation, needle decompression, intraosseous lines, cricothyrotomy, and can administer over thirty emergency drugs, but I don’t.
When we bring the patient back to her bed, I go to disconnect her from our monitor by pulling off the three wires from the electrodes on her chest. I pull off the red wire and the black wire. My hand is on the white wire and I am about to tug, when I realize I am holding the thin white feeding tube that is running into the woman’s nose. I let go gently and pull off the proper wire.
Close to being an asshole.
The Park
It’s lunchtime. We get together with another crew at Bushnell Park and throw a Frisbee. State workers buy hot dogs and taco salads from the lunch trucks lined up along the street and sit on the park benches or walk to the downtown for some quick shopping or a meal at one of the lunchtime restaurants.
I see a woman I knew from the health department and she does a double take on seeing me. “I thought you went to Washington,” she says.
“No, I quit when the administrations changed. I’m a paramedic now. I work three days a week, twelve-hour shifts. I like it. I have the rest of the week to myself to read, write, and take it easy.” I am tempted to say, “You mean you didn’t see me on the front page of the Hartford Courant? Above the fold? In color?”
“You look tired,” she says.
“I get plenty of rest on the weekends.”
“Well, if that’s what you like doing.”
“I do like it. Every day’s different.”
She pauses, and I sense she feels an awkwardness toward me. We chat a little bit more about nothing in particular, then she says, “Well, nice seeing you.”
“Good seeing you, too.”
I watch her walk off through the park. I don’t think I convinced her how much I really do like what I do. I’m not stuck in that drab building with the stale air and dirty carpets and mountains of unfiled paper. Still, her reaction depresses me.
Now in the park I wonder how others on their lunch hour see us—four EMTs in boots and uniforms with radios on their belts. We are somewhat of a motley crew. Alex is barely five feet tall and stocky as a fireplug. He works seven days a week for two different ambulance companies. Ray is a young man with a wild past, who through EMS has gotten his life back together. Glenn is just a country boy come to the city looking for work. He wants to be a cop. For now, he’s an EMT by day and a bartender/bouncer by night. I’m six foot seven or eight depending on my mood, my hair’s a little shaggy, and I have trouble keeping my shirt tucked in because my long-tailed shirts are still on order.
Of the four of us, only Glenn throws a Frisbee well.
EMT SPORTS PAGES
Trauma
Many people in EMS are trauma junkies. All the medicals, transfers, and drunks are just fillers, as they wait for the big bad one—the shooting or the head-on crash at eighty miles per hour. The call where, heart pounding, you race the clock to get the patient, lights and sirens wailing, to the trauma room, and, surrounded by gowned doctors and surgeons, give your report as they descend on the patient. It is the call that leaves you exhausted and your ambulance a mess, but afterward, sweaty and bloody, you shake hands with your partner or crew and say good job. It’s the call you’ll talk about for days, and other people will ask you about when they hear you were on it. You’ll see yourself on the news and read about it in the paper. Even though trauma—particularly broken bones—gives me the creeps, I’d rather be telling the story than hearing it from someone else.
We’re at Hartford Hospital when the call comes in. “Eight-forty, respond to Charlotte Street on a one for a shooting.”
We sit up straight, haul our shoulder belts on. Charlotte is all the way across town in the deep north end. Glenn hits on the lights and sirens and we lurch forward.
“Eight-forty, an update for you—shooting to the chest.”
We have a rider with us, a young female paramedic student from New Hampshire named Vicki. “This is the big one,” Glenn calls back to her. She is buckled into the captain’s chair. All day long we have been doing drunks and homeless people—giving her a view of city life but nothing medically challenging.
I put on a pair of large latex gloves.
Glenn speeds across town.
“Let’s get him on a board and in the back of the ambulance as soon as we can,” I say.
Another ambulance has cleared Mount Sinai and is sent to assist us. As we hit Charlotte Street, they swing in right behind us.
The police department is on scene. A cop stands on the sidewalk and directs us to the curb.
I grab the green bag, which has the oxygen, airway, and bandaging supplies.
The cop directs us to the backyard, where another cop points me toward the back door. Glass is on the porch. The window of the door has been shattered. I enter the house and go through the kitchen, through the living room, and into another room, where a forty-one-year-old man lies on his back. His eyes are open and he is breathing. His color is poor and he is sweating. I set my bag down and kneel over him. He has a rapid radial pulse. I pull up his shirt and see a round bullet hole, smaller than a quarter but bigger than a nickel. There is no air sucking out of the wound.
Jeff Quinn, another paramedic, hands me a stethoscope. I listen to lung sounds, which are clear.
“Let’s cut his shirt off,” Jeff says.
I slice the front of his shirt open with a seat-belt cutter, a small plastic device with a razor blade in a slit. Jeff cuts his right sleeve and Vicki the left sleeve.
“Let’s get him on a board and get him out of here,” I say.
Glenn hands me the board as we roll the patient on his side.
“Exit wound under the scapula,” Jeff says. Glenn drops a trauma dressing under it as we set him back on the board. Vicki puts an oxygen mask on him. Glenn hands me the oxygen tank, which I put between his legs. Jeff’s partner, Chris Bates, and I strap him to the board. Vicki tries to take a blood pressure, but Jeff says, “Later.”
Chris and I lift him on the board and backtrack out of the house.
Glenn has the stretcher set up in the backyard. We lay the patient down and wheel him around to the ambulance. Glenn and Jeff are in the back setting up IV bags. We lift the patient into the back.
“Drive,” I say to Glenn. “Drive!”
Vicki holds his head stable. Jeff puts an IV dressing over the bullet wound. He takes a blood pressure of 140. I am going for an IV line. We are hurtling down the street. Glenn patches to Saint Francis, telling them we are four minutes out with a shooting victim. Chris is following us in the other ambulance.
The man has no veins
visible or palpable in his AC joint. I take an eighteen gauge needle and go in blind. Nothing. I try again. I fish around. Nothing. Jeff is trying for an IV in the other arm. He’s not getting anything either.
The man’s lung sounds are decreased now on the right side. His chest cavity is filling with blood. He is still with us. He is sinus tachycardia on the monitor at 120. His respiratory rate is 26.
We’re at Saint Francis now. The back door opens and another crew pulls the stretcher out. A doctor gowned in green is standing by. With Chris, Glenn, Jeff, and Vicki, they race the stretcher through the ER doors, down the hallway, and into the trauma room, where eight or nine nurses, doctors, and assistants, all in green and wearing paper masks over their noses and mouths, wait. The board is lifted from our stretcher onto the bed. Jeff, who is only twenty-one, known as “Doogie” after Doogie Howser, the boy MD of TV fame, rifles out a crisp verbal report when I hesitate.
The trauma team descends on the patient.
Standing back against the wall is Dr. Morgan, the head of trauma at Saint Francis Hospital. As a member of the health department I sat in his office and he in mine to discuss regulations to implement a statewide trauma network. But here and now I am just a paramedic and he is a legend to paramedics in the street. A former gang member, who was once knifed and another time jailed, he has risen to become one of the top trauma surgeons in his field. He is an extraordinary man whose approval I desire. The paramedics who work the city’s streets love the man because he takes time to educate us. He treats us like professionals and demands our best. He drills it into us—trauma patients need a surgeon. Get to a scene, get the patient on a spinal board, intubate if indicated, get a line en route if you can, get to a trauma center, and get there fast.
He watches the team work. The man’s pressure is down to 90. “Let’s go, people,” he says. “You’re moving in slow motion.”
They start two central lines, do a chest tube to drain blood from the chest cavity, then rush the patient off to surgery.
“You drove like the wind,” I say to Glenn.
“Way to be quick on the scene,” Chris says to me.
“You guys were great,” I say.
We call dispatch for our times. Response: four minutes. On scene: seven. Transport: five. Total call: sixteen minutes.
We slap high fives.
Skip
Those who have been in EMS the longest are the ones who no longer wish for trauma. I remember once returning from a fatal accident in East Windsor with Skip Woodward, a man not yet fifty who’d been responding to calls in that town for over twenty years and had the small-town volunteer’s burden of knowing many of the victims. A truck driver had fallen asleep at the wheel and drifted across Route 5 on a curve, slamming into a car driven by a young girl headed home from a night out. It was pouring rain. Half her body lay out of the car, her leg trapped by the crumbled steel. She’d been killed instantly, but still we worked her, pumping on her chest as the rain hurtled down and her lifeless eyes bulged almost out of their sockets, and the fire department worked to free her with the jaws of life.
Driving back, still pitch-black out but the rain lighter, Skip said, “I don’t care for it,” meaning trauma. A few weeks later, I was on I-91, headed home. I had my portable radio on when I heard Skip clear from an accident scene at the intersection of Routes 5 and 140, where one patient had been declared dead and another helicoptered out in critical condition. I swung by the ambulance bay and saw him. He looked whipped. He said nothing to me. He just shook his head. He looked old.
Do Not Resuscitate
We’re sent for a person not breathing in West Hartford. The police are on scene doing CPR. The woman is cold. She is flat line on the monitor. Her arms are still limber, but her neck is too rigid to intubate. Her husband returned home to find her on the floor. The last time he saw her alive was four hours ago. He is distraught. Meg Domina, who is on scene with me, makes the decision to keep working the code. Cardiopulmonary resuscitation had already been initiated, and it seems like the right thing to do for the husband’s sake—to give him the feeling that everything possible is being done.
When we arrive at the hospital, the doctor looks at the patient and calls her dead right on the stretcher. The next day Meg brings in another code to the same hospital. “At least you brought us a warm one this time,” a nurse cracks. Meg has too much class to tell him to get bent.
The job of EMS personnel is to respond and to save lives. There are three rules for not initiating lifesaving care for a person without pulse and breath. Death may be presumed in the following instances: advanced decomposition; injury incompatible with life, meaning decapitation, body transection (cut in half), or body consumed by fire; and rigor mortis with dependent lividity, which means the body must be stiff with a purple hue where it is touching the ground from blood pooling in the skin. Any other person found not breathing and without a pulse must be subjected to resuscitation efforts. While there is a good reason for this—evidence the occasional news stories about people waking up on the coroner’s table—the decision to work or not to work a cardiac arrest is one of the toughest situations an EMT can face, particularly when the patient’s death was expected and the family either panicked or didn’t know better and called 911, initiating an EMS response.
I have had other EMTs tell me about arriving at the scene of a departed cancer patient and finding themselves in the midst of a family fight. Half the family is yelling at them to stop resuscitation efforts, while the other half is yelling to continue. They have no choice in those situations but to work the call. A worse case is when the entire family is demanding that you cease efforts. It is not as simple as just yielding to their wishes. Who is to say that maybe the patient wasn’t about to rewrite his will, leaving everything to his youngest daughter, who has gone to the grocery store, prompting the rest of the family to apply a pillow over the dying man’s face? An option an EMT has is to call their medical control, detail the situation, and get orders to cease their efforts, but not all doctors will take responsibility for terminating efforts based on a phone call, particularly if the EMT is not well known to them.
The state of Connecticut has instituted a program where patients with terminal illness can wear an orange Do Not Resuscitate (DNR) bracelet, which must be signed by their physician and is valid for six months. If an EMS responder finds a person wearing a valid bracelet, they can withhold efforts. The program has not yet met with widespread acceptance and there has been some foolish controversy as to whether the bracelets are demeaning to the patients. I encountered a young man—a terminal leukemia patient—who wore a bracelet. His family, who had last talked to him at eleven-thirty the night before, found him in the morning no longer breathing. They called 911. When I got there he had rigor mortis in his neck, but the rest of his body was warm, even sweating due to the heat in the house. While the family wailed around me, urging me to do something, I put him on my heart monitor, confirmed a flat line in all three leads, then called the hospital, reported my findings to a physician, and asked for permission not to work the code, which was granted. “He is dead,” I told them. “Departed.” If he had had any activity at all on the monitor, I know the weeping family would have fought me to the death had I done nothing. As long as people call 911 when their loved ones breathe their last breath, there will be tough choices.
Back in 1992 when I was working my weekly Thursday night 6:00 P.M. to 6:00 A.M. shift in East Windsor, I spent the night sleeping on the couch at the ambulance bay. I was tired because we’d gone out at three-thirty for an old woman vomiting. I was awakened at seven-thirty by the tones going off. This was one of the days East Windsor did not have a scheduled crew and relied on a commercial service two towns away if it could not raise a crew with the “all call.” While my shift had ended, since I was at the bay I felt I had no choice but to respond.
The call was to view a body and presume it dead. I was told not to go lights and sirens. En route I picked up Colleen Woodwar
d, a nineteen-year-old EMT and the daughter of Skip Woodward. The address was an old farmhouse on the outskirts of town. Two police cars were there. We walked in and found the officers talking with an old woman. She was saying, “He went so peacefully. He called me at four o’clock this morning and said, ‘Flo, bring me a cool glass of water.’ I brought it to him, then he said, ‘Take me off this contraption.’ The sound of the oxygen machine and the tubing in his nose bothered him. He took a drink of the water, then laid the glass down and said, ‘Now I can rest.’ When I found him this morning, he was gone.”
I nodded respectfully. The police officer pointed to a room off the living room. “In there,” he said.
We went in. A bony old man lay on his back, with covers up to his chest. His mouth was open, his skin an opaque white. He was not breathing. He was as still as stone. It was clear his spirit had left him.
In the other room, I could hear his wife saying, “He lived a good life. This last week in the hospital was hard on him. They resuscitated him once. He was in such pain. At least he made it home to die.”
I felt the carotid artery in his neck for a pulse. For a moment I thought I felt one, but knew it was just the throbbing from my own fingers. “He’s got a pulse,” I said to Colleen.
She hit me. “He does not,” she whispered.
His skin was cool but not cold. I felt his fingers. They were stiff, but I’d seen hands with arthritis that were suffer. His arm was on the way there, but it wasn’t completely “rigored.” You turn over some rigid bodies and they pop you with stiff left hooks that you’re not expecting.
I listened with my stethoscope. Nothing. I checked for lividity. There was none yet. I looked at Colleen. She knew what I was thinking. Our gear was out in the ambulance. If we went and came charging back in, threw him on the stretcher, started IV lines, and performed CPR on his frail old chest, we would have a major situation. The woman would be traumatized. The man would still be dead, but he would have his ribs broken. We’d have to call paramedics, who would stick a tube down his throat and pump him full of drugs. The family would get a bill for several hundred dollars. The cops would hate us for the rest of our lives in town. We personally would feel like shit.
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