By Crystal Wallin, NREMT-P, CCEMT-P, Gundersen Tri-State Ambulance

We're sitting at the designated posting area. It's just past the middle of the night; that time when the boisterous crowds have filtered to their respective homes and a different kind of silence settles over the town. Because there are different kinds of silence; anyone who's rolled through the dark streets, in and out of puddles of yellow streetlights can tell you that. There's the lull as the bar scenes and theaters, restaurants and gatherings come together. There's the diminished sounds once the respectable crowds of a certain age or temperament head home. This is the next kind of silence, when the city is dark and silent, spent of even the loud partiers who spilled out last into it's streets after bartime, finding rides and partners to keep the loneliness of night time at bay. 

It's that kind of night, past the fun time of the wee hours of the morning and into the hours where figures seen appear lonely. The sounds that do pierce the night seem intrusive, as the sleeping city hunkers down and all who have somewhere to be, are there. We're winding down too, my partner and I. We started the night catching up; it's been months since I worked a street truck and he was telling me about his day. Then we ran a few calls and the hours settled into their groove; before we know it, we've pushed through to the silent lonely side of 3am. We'd like to see the inside of our eyelids but that hasn't happened yet. 

We are the last truck available for a number of square miles that is higher than you'd think one truck could cover. But we do, and the other trucks will become available shortly in a staggered fashion as they transport their patients and clear the hospitals. It's the dance of system status management, and we are all well versed enough to know it all works out. I remember when I was new, though. One night my partner rested their eyes and I sat in this same parking lot, contemplating the number of square miles that the two of us were responsible at that time. That was a poor choice; I remember being very wide awake after thinking down that path for a few minutes.

But now the radio comes to life and the ambulance last dispatched to a call requests a second unit at their location. Their initial page was for a non responsive female. Now the female paramedic on the call is requesting a second unit for an RSI - rapid sequence intubation. She's with an EMT tonight and needs a second paramedic on location in order to intubate. We come to life, activate the lights and siren and are soon pulling up at the curb behind the first truck. Two squad cars and a first responder unit complete the ruination of the serene neighborhood's slumber.

Inside, we are directed by family standing in the living room towards the far back bedroom. Why is it always a complicated or extended call seems to be in the far nether regions of a residence? Inside the back bedroom are three first responders, two police officers and our other crew. Everyone looks moist, they've clearly been at this awhile. IV access is in place, cardiac monitor is applied, CPR is ongoing and report begins. Complex patient, bradypnea upon arrival, unable to arouse. Bradycardia on the monitor. Pulses present and absent by turns. Naloxone ineffective. 

Three paramedics in the room now, three dedicated first responders, one EMT who is working so rapidly and smoothly as we go down algorithms and protocols that she seems to be two people. Consultation with medical control by phone. Intubation by my partner who was most likely born with a bougie as I push drugs and the small cramped bedroom somehow continues to hold all of us. The patient is bariatric, and very sparsely clothed. She has been incontinent of stool, and the precious real estate that is the minimal floor space is taken up by her girth and her incontinence. We persist. Extrication approaches are considered, discussed, attempted, abandoned, re-grouping and finally thru massive human effort and loss of sweat, she is moved to the living room. Patient is rechecked there, interventions and vitals rechecked. From there to the cot, to the truck belonging to the first crew. Re-evaluation again of all interventions, medications evaluated and refreshed as necessary. An officer brings me one half of our scoop stretcher, fecal matter intact down the front. He asks me, "this yours?" I consider this a minute and then with a guilty, grateful grin I reply, "nope. Theirs" and wrap it in a sheet, slide it into the other truck's patient compartment at their rueful, accepting direction.

The two crew members are getting things settled in the back, we ask if there is anything else we can do, and return to our truck. I stop at the door, pick up my feet in turns. Resting first one, then the other on the opposite knee, I inspect them for any souvenir fragments. None. I climb inside, shut the door, slide on the seatbelt and turn to my partner. Senior medic to me by at least a decade, he is grinning. "That's a good call. Do a lot of medicine, get back in a clean truck." Shaking my head, I have to agree.

We turn off all the lights, wheel wide of the curb, head back toward the city and our station. The sun is brightening the intersection of horizon and cityscape, and I'm getting hungry for breakfast. House lights are winking on and the people are once again helping the city to waken.

I missed this. The rhythm of the night and the imperfect reality of street medicine. This is where the pulse of the city lives.