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.

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

It’s her birthday, and she’s only got two years on me. But her eyes are world-weary, and in the slump of her shoulders lies a thousand different disappointments. Pancreatitis, she tells me. Acting up again.

We talk about the outward manifestations of her functional health, as I run down the assessment steps. We stand in the confidential location of a woman’s shelter. The curved bannisters arch gracefully up and out of sight somewhere above. Stained glass windows filter the light falling in through them, dim on this gloomy day yet warmed by the colors of the old glass. Pocket doors slid behind us as we entered, preserving some semblance of privacy here in this gentle embrace of a genteel old home. Women and children pass through here in a never ending stream, and we meet some of them. I wonder now, as always, where they go, what happens to them, did this house of kind strangers afford them a new start, a fresh beginning? Or did the familiar pull to old unhealthy relationships win out? Did they return to the abusive partners from whom they sought shelter here? And the children - do they fall victim to the cycle or do they emerge strong down the line and find fierce ways to ensure they do not allow such treatment in their adult lives? How many fall one way - or the other? The awful sadness is the never knowing.

Her hands are kind, and soft. Her mouth seems to have a hard time remembering how to curve upwards. I work at it, establishing rapport and extending gently honest respect to this woman who is before me. Something in her tugs at me. Maybe it’s the way she is in pain, maybe it’s the way she seems surprised when I realize her date of birth makes today her birthday and I exclaim, “Happy birthday to you!” It almost seems as if no one has been that exuberant about her birthday in quite a while. Maybe they haven’t. Maybe she just didn’t realize what the date was today.

Her boy will ride with us, and the stranger who is the helper at the house today disappears in search of him. Soon they reappear, the child just under ten. His speech leaps and bounces from topic to topic as we make our way outside and towards the truck waiting at the curb. His eyes never linger long, scanning up the street and then down again. He surveys the ambulance and announces his desire to ride up front. My partner looks at me with a shake of his head and I guide the boy towards the back with promises to ride by mom. He shrugs. Climbs inside. Resists the seatbelt but caves when I stick firm to following the law. Mom is silent, docile, amidst the verbal stream coming from the boy. He asks about computer privileges at the hospital, will they have something to eat, what will he be able to play with? My patient speaks up then, quietly, asks him isn’t he worried about her, she’s sick. Again, he shrugs.

Her eyes drop. The shoulders round even more somehow, as her chin nearly touches her chest. The shirt is worn. The boy’s shirt isn’t new but it’s in much better shape than hers. He rambles on in complete disconnect or disconcern for mom and her pain, mom and her fears about her health. She seems unsurprised yet saddened.

I wonder as I give report to the receiving facility via radio regarding the outward, measurable data - who last made this kind, quiet woman a birthday cake? What man or men taught the boy that a woman’s fears and illness are so easily dismissed? Who models for him that his needs take such utter precedent? Or is this simply age appropriate egocentricity? Is he scared too and thus the chatter is a nervous avoidance of his fears about mom’s health? Who has he lost? The same person who left mom such a saddened husk of a lady?

I walk them in and I give report to the receiving facility staff. I shake my patient’s hand, and looking in her eyes I let my heart shine visibly outward as I softly wish her a happy outcome ot this ER visit, and many happier birthdays to come - that I believe they will come. Her eyes flicker with surprise and a smile finally - finally! - lifts that mouth. Her eyes drop to her lap. I shake the boy’s hand too, and tell him to be a good man and take care of that sweet mama of his. That it’s ok to be scared, that kids can’t fix everything but my friends here in the ER will help with that. He just needs to love mama while she gets feeling better. His head cocks up at me and he nods vigorously.

The entirety of my body is not yet through the doorway when I hear his querulous voice asking the patient care tech for a computer to play on. I look back at mom, framed by the doorway and placidly lifting her arms into a gown - and wonder what happens to the light in people when they don’t get loved enough. Do you suppose it goes out for good eventually, or does it lie dormant, waiting for the warmth of the right person to bring it to light again?

Happy birthday, dear lady. I hope next year finds you happy and laughing - and loved.

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

He was a year ahead of me in school, a joker and a clown and for awhile we rode the same bus until he got his license. I hadn’t seen him in a few years but here he was now. We didn’t speak. I didn’t know what to say, but I was too busy anyway. It didn’t matter even if I could’ve thought of something to say because he wouldn’t have heard me.

I got there in my private vehicle soon after the others, so I didn’t catch the whole story. I just joined the mostly silent group, stepped in and relieved the responder doing compressions. The patient was slight, a young and pretty slip of a girl. She might’ve been a year or two older or younger than me. It was tough to tell. I tried not to think about the crepitus beneath the heels of my hands as I started in on the age-old rhythm of compressions. Tried not to think about the connection to my younger years as he stood with bowed head and slumped shoulders, weeping.

We got her to the ambulance outside, the yard redolent in the heat with cicadas singing as we carried her to the truck. Got settled and then we headed down the winding country road. The siren seemed vulgar to my ears. I had been a volunteer a little less than two years at that point, I think. I remember I was wearing blue jean shorts and a white tank top with flip flops. I’ll get to why I remember that in a minute. For now, I rotated with the others, giving respirations with the bag valve mask thru the Combitube, then rotating back to compressions. There wasn’t a lot said. I knew him, but the rest of the first responders knew both of them. I hadn’t seen him in a few years, this was his girlfriend. One of the other responders told me he came home, found her. Still warm and apparently it may have been a recent code, or maybe it was the heat? Anyway, they started to work her and here we all are now. Going down a beautifully green leafed back road, winding our way down the rural landscape they must’ve driven together many times, laughing certainly – or maybe listening to the radio. But now she’s so little, and pale, and I see his pickup truck following behind us with the flashers on.

Someone had called for an intercept with the paramedic service about 45 minutes north of the residence, maybe before I arrived on the scene. It seems like so long but eventually I can hear a second siren and we are pulling into the parking lot of a fish hatchery, and parking. Our siren stops; so does the second siren.

The back doors open and a very serious man’s face appears. Brisk and businesslike, he begins asking questions. His hands are busy working on removing supplies and medications. I don’t remember what his partner looked like, or what was said for a bit. I kept rotating between compressions with another responder while both of the paramedics attended to the airway. The first man is younger than me, but the professional appearance of both made me suddenly aware of the shorts and white tank top – and flip flops. Time to transport, and the second paramedic gets back out. The first one, the one with close cropped hair, rapid speech and precise movements – he stays in the truck with us.

As the second paramedic gets out, I see my schoolmate pacing, weeping quietly. We begin to transport again. I’m watching intently as the paramedic in our ambulance takes out a device I’ve never seen. He selects a site, and to my horrified fascination, and with A DRILL places a bizarre needle in the patient’s leg, just distal to her knee. He connects IV tubing, and hangs a bag that is inside a sleeve. He pumps up a bulb attached to the sleeve, much like the pump on a manual blood pressure cuff. He gives medication thru the IV line.

About this time, he notices me for the first time, as a person it seems rather than a fellow body passing objects back and forth – and he meets my gaze. He’s serious but his eyes are kind and he asks me if I’ve ever seen the IO before. I shake my head, look down and say I’m a newer first responder, and this is only the 3^rd code I have seen. He asks, “do you want me to tell you about what I’ve done?” and I reply in the enthusiastic affirmative. Horrible as the circumstances might be, it was evident from the moment he stepped foot into our ambulance that help was here, and help knew exactly what to do.

He begins to walk through everything he did – layman’s terms but not insulting, outlining the indications for each and the expected outcome, the hopeful outcome. He explained what he was doing as he rechecked interventions, rechecked rhythms and what the medications he had given were for. I drank in every word, fascinated in my tank top and sweaty hair. I don’t remember if he ever had a visible droplet of sweat, but I do remember to this day how he made me feel drawn to the medicine despite the fact that the small pale form on the cot was not far removed from my little world at home. She looked like my small best friend, and that bothered me too. I focused more on the medicine. I told him I knew of her, went to school with and rode the bus with her boyfriend. He shook his head and said that was too bad, went back to his medications with not much more emotional response.

I’d never heard a radio report like the one he gave; I was impressed by the succinct way he summarized this whole experience. Walking into the city ER, I tried to be as small as possible next to these two uniformed paramedics in their competence and calm. Standing outside shortly after, putting our ambulance back together, they emerged again. I asked how it was going and the paramedic that rode with us said briefly, “they called it.” I remember sagging against the ambulance, somehow just feeling like a balloon with all the air whooshed out. I had hoped that somehow all these people who were so far beyond my knowledge would fix things. I remember them explaining how the disease she had often meant patients didn’t live much past their early 20s. They were kind, explanatory and collected. Then they were gone.

On the way home, I just sat, the details swirling around in my head like an out of order kaleidoscope. I had never seen my schoolmate diminished like that, head bowed, weeping. I kept thinking of their little home, and of him returning to it alone. Thinking of what I didn’t know how to do and if I had known all those interventions, would she have had a different outcome? Looking at my sweaty street clothes with embarrassment. Wishing I had thanked that paramedic with the rapid speech and professional competence. Remembering what he took the time to teach me.

Wishing I could be like that.

~*~*~*~*~*~*~

Years later, I’m a dispatcher for that same paramedic service in the city and that rapid speech replying back on the radio becomes familiar to me. Later, and I’m a paramedic student; he’s one of my preceptors, teaching me still with that medicine-based professional air and I try to remove the emotion from my approach to patients, to be so matter of fact like he is.

It’s 2018 and I just graduated nursing school and I can tell you there is still so much to learn from this quiet and decisive educator. He watered a seed that was already in me, and his demeanor of efficient movements, ready to teach with equal respect both co-workers, students and those on the periphery of emergency medicine like I used to be.

As I’ve been around emergency medicine now for 14 years, I’ve seen many alpha males and females, many Monday morning quarterbacks. I think we need a lot more of the seed waterers, the educators, those who teach and lead by example.

His name is Nick. I think we need a lot more Nicks. I’m sure glad I met him, glad he ignored the tank top and flip flops and explained intra osseous intravenous access to me with as much deliberation and gravity as if I’d been a young medic. He was just promoted to program manager of clinical education of that paramedic service, very well deserved,

Be a Nick. Light that fire in someone, show them what you do, include them.

“See one, do one, teach one.”

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

He’s the center of attention and he’s trying to be brave. It’s hard to be brave though when you’re lying on your back on a shiny brown cot in the nurse’s station and the room keeps filling with more grownups. All of the grownups are gathered around him when I add my uniform to the room, and they’re all peering down at him. He’s valiantly trying to lock it down, but the hiccuping kind of sigh/crying kids do when they’ve been at it awhile is going on. The sad noise out and the kind of inhale that’s short and sad; sometimes the lower lip gets involved. His face is red and splotchy, and if I didn’t have the dispatch information, if I saw him sitting in a chair somewhere without the accouterments of grown up people, I might’ve chalked up the discoloration to long-term crying.

But we are all gathered here today in the presence of Mom and the school nurse, and I do have the dispatch information. So I come in with the knowledge that he has a tree nut allergy and he’s eaten walnuts in a muffin. The very capable and kind hosting nurse tells us he was given an EpiPen prior to any EMS arrival. She produces it and gesticulates with it, punctuating the close air for emphasis as she tells the story – or at least what she knows of it.

Someone brought a snack, and when you’re 7 years old, you like snacks. Honestly, when you’re a tall human you love snacks too but I drag my mind back to the gesticulating nurse and resolve not to think about how many double digit hours since my own last meal. My abdomen grumbles but I prevail.

So the snack was wrapped up and store-bought and (here he interjects) there weren’t any visible nuts. But as nuts sometimes do, they were hidden by their small size within the muffin and when he realized this fact, he was maybe four bites in. I’ve seen 7-year-olds eat snacks, so I know no assumptions can be made about the size of the bites. I hunker down by the small hiccuping sniffling miserable person on the cot and gravely introduce myself, shake his hand. I tell him he’s the star of the show, that nothing is going to happen that he won’t know about first, that I will explain anything he wants, and that he gets to choose what order we do things in. He’s intrigued but a tough sell. I press on. I am impressed that he didn’t cry from the shot, per the nurse. She nods and punctuates the air again with the depleted device. He nods. I ask him if he’d like to sit up so all these tall people aren’t looming over him, and we open the door and pretty soon he’s upright and looking like he feels a little more on even footing with the situation.

Vitals. Assessment during all of the above, because it’s reflexive and interacting with him affords me his mentation, his lack of drooling, his speech is clear, he stops being red and blotchy and turns out yep, it was long-term crying. Or at least somewhat.

Next step; Mom. Mom is at the feet of the man of the hour, and has been watching all of this with grave interest and no small worry. I establish with her number of times he’s been exposed to nuts (once before), and what happened (swelling, face and throat). Negative intubations, excellent response to medication. In fact, so good that there is no EpiPen with him at school. It might be at home but she isn’t sure. We all turn to look at the device which has been passed on to the first responders. It is expired. Is it the school’s? Unsure. The nurse is gone. To where, I’m not sure but I don’t see her again until we are exiting through the office.

Soon inside the ambulance, transport is beginning. I’ve let the patient choose whether he wants the blood pressure cuff on first or the light on his finger for pulse oximeter. It doesn’t matter which is first, what matters is that he is calm and is beginning to have a small rapport with me. He’s perked up, he giggles when I complement his bright and busy coat and matching boots. He’s acting like a regular 7 year old.

Mom and I chat on the way in. She’s a little frustrated that despite the numerous papers she filled out, there was this series of events. Little man’s brow furrows at this and he hangs his head. A lightbulb that thankfully no one can see goes off, and I put some of the nursing training to work – this is a teachable moment. So we discuss the honest way a tiny ground up amount of nuts could be in a banana muffin packaged from the store without anyone knowing. We aren’t even sure if the muffin was consumed in class or shared in a hallway in a free moment between structured times. She nods, shoulders relax.

She asks why I wanted to know how many times he’s eaten nuts and reacted, genuinely curious. I explain the initial response, the subsequent responses and the need for hospital evaluation even after an EpiPen is administered. We talk about reoccurrence of symptoms, the window of time in which they may return and need immediate treatment again. She is struck by all of this and we go on to have a productive dialog.

During the dialog I ask the patient questions both to keep him interested and so he understands the importance of telling someone each time he feels a symptom, even if he has been treated already that day or night. He is bright, asks appropriate questions, and throughout the conversation I am able to monitor his continued swallowing, breathing, as well as the pulse ox level, heart rate and blood pressure.

I give radio report maybe five minutes out. He says his throat is itchy and his belly hurts. Mom is asking about an EpiPen, she’s not sure where theirs is. I advise the ER physician can help with that, and she nods. Her shoulders slump though, and her face clouds. I tip my head and she tells me in a hushed voice that her husband’s company recently downsized and his position was eliminated. She doesn’t have $600, or insurance. I suggest an area free clinic, wondering aloud if they may have some resources with which I am unfamiliar. I am matter of fact, careful to keep any sympathy from sounding like pity to this proud, sad mama. My hands are busy, too, letting the patient pick which 18G needle he wants, which small syringe. I’m getting out our epinephrine vial, and he’s watching me with interest and some concern. Mom mentions the name of the doctor at the free clinic, whom I know well, and I tell her so. She’s struck by how small a world it is, and I’m able to explain to the patient that we might need to give him some more medicine. I remind him again though that he will know if I am and that he is the boss, applesauce. He grins. We’re stopping, now, and I realize we are in the garage bay.

Mom hops out, my partner comes around and we take the patient out. He is jacked up, riding the automatic cot lift and I see no signs that worry me. We go inside, walking with Mom I ask her permission to approach the staff inside about options for covering the cost of that oh so necessary EpiPen. She agrees, and then we’re in, I’m giving bedside report and the small human is checking out the inside of this new environment. I see a red spot by his ear, and point it out to the nurse.

Leaving the room, I find the most senior ER nurse I see, and quietly fill him in. He directs me to the social worker, who nods during my tale, then reassures me that I shouldn’t worry – the EpiPen can most likely be added to their ER bill for today. Which they aren’t going to be able to afford either, I think to myself. I ask if there are any programs, and she repeats that they will work it into the bill. I meet the eyes of another ER nurse who was once a street medic in my same uniform, and she smiles sadly. I nod, mutely, and head back to the truck in the garage so we can clear and enter the system, ready for the next call.

The whole way there I had pulmonary edema on the brain. Dispatch information wasn’t very alarming; “70s male, shortness of breath, coughing up blood.” But as soon as my boots hit the garage floor, that’s all I kept thinking. I’ve had three calls before with pulmonary edema – and two of those times it was the same patient. I’ve never been to this address, and despite nothing screaming clearly in the dispatch information, my gut says its pulmonary edema. 3am thoughts or gut instinct?

So the trip out to the country road consists of me, all the way awake in a way you understand if you’ve ever seen pulmonary edema – bonus points for the pucker factor that is flash pulmonary edema – I’m chattering. My partner is an EMT tonight and he’s still waking up. He bears with me though. I explain what we will need to do in a short period of time if it is pulmonary edema. He gets it, he’s a great partner and I know I can concentrate on what I need to do. Knowing he will do what needs to be done and he isn’t the sort of partner who requires a lot of hand holding and validation.

We arrive on scene, he puts it in park and I hop out the passenger side, round the side corner and spy a man approaching. He’s well dressed, fully dressed, and walking spryly. Coat neatly zipped up to the chin. Dapper hat atop his head. He looks like a retired cowboy, tan skin and western button up shirt. I ask if he’s the patient and he nods. I’m able to get the side door open and my patient is loading himself right up the steps before I can say much.  Climbing up after him, I catch my first auditory of my patient.

Pucker. Factor. Right there. Right now. Yep, we’re about to do medicine. I nod at my partner, and we go to work in the choreographed steps we worked out while the truck winked and blinked its red and blue strobes down this back road and across the corn still waiting to be harvested.

Sublingual nitro – check. CPAP – check. IV – check. Nitro drip – check. Furosemide – check.

My patient is working to breathe, and working hard. The telltale wet sounds of crackles and rales are screaming the alarm for me, for anyone, to notice this man is attempting to exchange gasses at the alveolar level through liquid. Sternomastoids, scalenes, and intercostals – they’re all desperately doing their level best to move air in and out. The air is going in and out. The problem is that the air can’t pass into the blood through all the liquid filling the lung fields. He’s breathing fast, tachypnic, and blood pressure is high. His body is trying to compensate and from the looks of things, it has been for a while. There is no pink frothy sputum, and while acute, I’m not sure this presentation paints a picture of sudden, flash pulmonary edema.

Transport begins. We’re maybe eleven minutes out and we need to be at the ER yesterday. He needs a tube, but out here on this pitch dark country road I’m the only paramedic in the county. State law states intubation is a dual medic skill and so we get to work. We’re making the pavement disappear between us and the ER with all of its equipment and people. I’ve always been one of those medics who is not fond of transporting emergent, and I do so seldom. Given the amount of medications and procedures we can perform in the patient compartment of our trucks, the due regard we need to demonstrate in driving, the aggressive protocols under which we operate, we are able to enjoy the ability to do many of the things on scene that the ER would do. There is not often a need to endanger ourselves, our patients, or the general public with the heightened level of adrenaline that comes with lights and sirens. Not to mention the effect on my patient, quite often the heart rate and blood pressure increase if we need to use the sirens and lights. Evidence-based practice is what we have learned, and we have learned to take the time to manage our patients before and during transport, driving non-emergent towards definitive care rather than just throwing them in the truck and “apply diesel therapy” as we used to say.

But when my partner asks me if I want him to transport emergent, I consider it, then say yes if there happens to be any traffic, use the lights and sirens to move them, then just lights. It is the wee hours of the morning in this farming community and there is no need to awaken every coon hound between here and the ER.

My patient seems determined to ask me questions and speak beneath the CPAP mask. It’s not as loud as the model we used to have, but it’s loud enough that I can’t hear him. PEEP is between 5 and 8 mmHg, the nitro is blurping along and the Lasix should be starting to kick in. His SpO2 shows oxygenation in the gutter though, and falling. He’s tiring out. I lean forward and speak quietly in his ear. I always do this and it seems to help them in their soundless mask, to feel less alone. I start with the basics; is he having pain, does he understand what is happening, has this been going on for more than a little while? He denies pain, indicates understanding and answers in the affirmative that this has been going on longer than a bit. Yes’s and no’s get me worked around to, he’s been up most of the night, he thought it would get better, he used inhalers, and he’s had this before. Then the big question I have to ask, has he been intubated before? He nods. I ask him, in the hospital? And he shakes his head, points to my gold patch. “By EMS?” I ask. He nods again, eyelids closing. He’s so tired, still hypertensive, still tachypnic. I keep speaking, verbally coaching him to remain awake. We cover that he is a former smoker, lots of years. He lives alone. It must’ve been a long night before 0300.

I wonder if he wonders at my inactivity after the flurry when he first got in the truck. I explain to him what the nitro under the tongue – and now in the IV – is doing to help his breathing by reducing the workload on his heart. I tell him about the injection of Lasix, and its role in pulmonary edema management to begin to move the excess fluid out of the lungs. I promise him that the CPAP mask is helping push the fluid out, too, with positive pressure. He nods weak thumbs up. SpO2 is 74%. I give radio report. 71%. This is killing me. He needs a tube.

ER. Bright lights. People. So much help, now. Handoff report at bedside. Remain and watch the C-MAC and Bougie make short work of the tube placement. Confirmation, tube is good. X-ray comes, lab. RT. I get a facility acceptance signature, accept the face sheet registration hands me. Walk out to my truck.

There’s his hat and coat. Can clothing look forlorn? These did. Take them back inside.

Hours go by. Flight team comes for him; he’s not hypertensive anymore now that the respiratory drive isn’t so desperately triggered. The ventilator is sedately moving air in and out of lungs that are much more baseline. RT tells me “his lungs were full”. I nod. Guess this nursing student does still have a medic’s gut instinct.

Shortly after, I watch the EC145 spool up. The horizon is ever so faintly light, and somewhere over my head now, the hat and coat are dutifully following their owner.

I wonder how many people would’ve put down their last cigarette and never picked up another – if they could’ve seen him, valiantly moving air in and out – and essentially drowning in front of me. I wonder what he would tell them, if he could.

His VFW jacket is deceptive on his small frame, and the corresponding ball cap on his head is similarly boxy. He’s currently occupying a ditch alongside a small pickup truck where a few moments ago he was a passenger. Now he’s meeting my partner and I, so obviously his day has gone downhill. Literally.

They go up this hill every day, he’s telling the passerby who is seated next to him in the tall summer grass, keeping him company before all the sirens went from distant to loud, then finally silent here at the scene. The garish lights are strobing up the countryside but they are held to a dim minimum on this sunny summer day. Him and his buddy go down this hill every day to see another buddy, and then back up the hill to the ridgetop they call home. He never thought this would happen today. They were headed up the hill when the gentleman in the VFW jacket thought the engine sounded funny, “Like it was slipping gears, ya know”. Soon the driver told my patient, “I got some bad news for ya. I think we’re gonna crash.” My patient thought it best then to click on the seatbelt he’d removed to access his smokes in an inner pocket of the VFW jacket, and no sooner did the seatbelt click home than the engine did die. Within short order the steering and brakes left as well and they ended up somehow going back down the hill backwards. As my patient tells it, “after about five minutes, we rolled over. Just once I think but it’s hard to say, ya know.”

More turnout gear is accumulating next to me in the ditch throughout the retelling of this saga. I’ve taken report from the passerby who turned out to be a nurse driving by on her day off, I’ve attached the three leads and assisted an arm out of the jacket to place a blood pressure cuff and I’ve got the pulse oximeter on a nicotine stained finger. But I’m not having much luck slowing the flow of words, or guiding it. All of us are wearing grins and all of the data my equipment is supplying is pleasing, however. So I ask the firemen to bring the cot if they would be so kind. My partner reappears and states that the driver is refusing all medical evaluation and treatment, and she returns to him for a refusal signature AMA. Through sheer force of will, though I cringe at the necessity of interrupting this intriguing gentleman, I manage to evaluate him for injuries, perform palpation and range of motion checks and all the usual things we do for an MVC.

The firemen and I get my patient seated on the cot and secured with all the straps. We encounter a concerned looking lady on our way to the back doors of my truck, and he calls out to her by name. He starts the story one more time for her, adding that he left his cell phone at home and would she mind calling his daughter? She reassures him she will and after a short time I’ve managed to verbally edge my words into his dialog with a gentle reminder that we really must get him inside and start working our way towards transporting. I assure her we will take very good care of him.

Once inside the ambulance, secondary assessment reveals no additional findings. I start an IV as he tells me about Vietnam, and I thank him for his service as I connect the tubing. Inspecting his shoulder where he indicates “just a little soreness, ya know, just a little, just starting” I see no visible injuries. My partner returns and we begin transport.

Up the hill for the second time in a short while, he expresses his relief that this trip was successful. He tells me of his years after Vietnam, after the head injury saw him live out a few decades in a “VA home, cuz the USAF owns me, ya know” he left Chicago for the beauty of the ridge in the Coulee Region that he now calls home. He’s in love with the breezes, fresh and smelling of sweet hay, and the lack of mosquitos. He tells me with dead earnest eyes that he’s seen some pretty bad mosquitos in his day but this third summer on the ridge has him believing there’s no mosquito that could fly in the ridge wind.

He tells me of his children, his grandchildren who are the loves of his life and as we wind our way from the rolling fields of the ridge into the concrete and traffic of the city, I realize that as much as I can talk – and it surely is a lot – I have nothing on this sweet veteran who is now clutching his VFW coat under his elbow as he tells me about how good his life became after he gave up alcohol. He tells me stories as we wait and then proceed through stop lights, as I get repeat vitals, as I switch the IV bag from the hook in the roof to the pole on the cot. As I give radio report to the receiving facility the stories continue to swirl around my head in the air as his quiet voice patters on. We park in the garage and I explain the privacy act notice, offer him his own copy (“now why would I want that? Those politicians, ya know I think they are behind all of this paperwork everywhere. Well, them and lawyers, ya know”), explain that his signature will allow billing of his insurance company (“well the VA will get it I guess, the USAF owns me ya know”). He signs while telling my partner about that hill they go up every day, who would’ve thought that today of all days…

We walk in; give the name and DOB to registration who is waiting for us at the door. Stories continue to spool still unimpeded as we walk to the room, give report to the staff there, transfer him from my cot to the ER bed, and finally I interrupt again as I offer my hand. He breaks off, mid story, shakes it. “Thanks girlie, keep a listen on your engine, won’t ya”. I assure him I will. The nurse signs my prehospital care sheet, takes her copy and I head out the door with my copy in hand. Up ahead my partner is wheeling the cot. My boots squeak, always on this floor. It’s the only sound I hear. For a moment, it’s a beautiful thing.

I think of the young man who would’ve made that coat seem small. I think of hurtling backwards down a hill, then rolling over, a slight man in a big coat unable to see what was coming. I think of the small pickup. I’m sobered by what might have been, and I’m glad I got to meet this veteran, that he was here to tell his many stories. Such a vibrant soul might’ve been lost and I am certainly grinning as I walk to the truck, spirits lifted by this loquacious veteran who I realize may very well have made my day.

Don’t ya know?

The first thing I register is the officer’s words as he gives report to my partner. “…hasn’t taken meds in six months…hasn’t been out of the apartment in six months…hasn’t eaten in three weeks…” The officer continues to fill in the blanks, that she lives with a roommate but that he is bipolar and hadn’t thought these things were concerning. The report complete, my partner and I enter the residence.

The second thing I register is the haze. I’m no stranger to odors but as we walk into the apartment, my lungs physically rebel at roughly the one minute mark. The apartment is literally foggy with acrid, dense cigarette smoke. I follow my partner’s grey shirt in front of me, sizing up our surroundings as we advance. I register a synthetic “feather” duster on the stove, between the electric burner and a frying pan, but the light indicating a hot stovetop isn’t lit. The duster isn’t smoldering, and so I continue towards the back bedroom, entering just after my partner. I’m already coughing, thanks to the lung issues I’ve been slowly coming to terms with. Last December my primary care provider tells me my seventeen years of smoking have had some impact on me even now, six years after smoking cessation. Each room we’ve passed now, in this apartment, has had at least one overflowing ashtray and my lungs are registering the effects.

I can see the patient over my partner’s shoulder. There is a plethora of belongings and in the bed a fully dressed female, frail and nearing emaciated. She is older than myself but of indeterminate age beyond that. More ashtrays are heaped and packs of cigarettes, of the empty crumpled kind and one full pack, ring the bed. The fingernails and toenails of my patient are long, curved, and black with an unknown substance. On the floor next to my boot, two flat dried dark substances that may be mud but which my mind tells me are not mud. The patient’s hair is dark with white chunks. I look harder thru the fog, my face squinting up with effort. The white chunks are accumulations of dead skin, scalp tissue.

At this point, my lungs aren’t kidding around, I register honest pain. They hurt, and the coughing seems to be drawing the fog deeper into my lungs between barks. I move into action now, encouraging the patient to swing her feet to the floor, to sit on the edge of the bed, to stand up. We do these things slowly but with purpose, letting her get her bearings, letting us evaluate her for steady gait, etc. She ambulates to the middle of the kitchen with copious encouragement but that is as far as she can or will ambulate. I ask if my partner would like the stair chair, and when he nods, I flee to the corridor in relief. The officer remains at the doorway, holding the door open. Some of the fog has leaked into the hallway but it is still infinitely clearer out there than in the apartment. I place my hands on my knees and bark the deep kind of cough, the kind that hurts and makes others uncomfortable. I do this for a bit, sucking in the sweet air. The officer asks if I’m ok, then kindly tells me, “I’ve seen worse”. I don’t tell him so have I, or that I’ve come to know personally, much as some of my patients have learned the hard way – smoking is the gift that never stops giving. I just nod, and after the barking subsides, I walk outside, gulping beautiful outside summer air, and return with the stair chair.

The apartment is just as I left it, with one exception. The roommate is hovering in a helpful manner near my partner and the patient, who is now seated on a kitchen chair. As he hovers, the roommate is also smoking a fresh cigarette. I set the stair chair down and pull the red levers which drop the seat, and the tracks. Except the seat refuses to descend. Resolutely, the sweat now running down my neck from the heated, close apartment air, I try again, and again. Same refusal of mechanism. My partner tries and on his fourth attempt, the seat meekly drops open. I maneuver the chair behind the patient, encourage her slow standing and reseating, then fasten the belts and make my second escape to the hallway with her in the stair chair in tow. I bark some more. The officer tells me kindly “you’ll get used to it eventually” and again, I nod with a smile.

Driving down the street a few moments later, I rest my head against the seatback and savor the air conditioned breeze filling the cab from the vents.

In the back I hear the patient worrying to my partner about the duration of the hold she is on. She states last time she was in the hospital ten days. That she was homesick.

I think of her home. If services become involved, as our report and the chapter hold by law enforcement will surely necessitate upon hospital discharge, how long would a change last in the face of the apartment’s occupants’ life choices? How do we as a system assist positive change and support public health, combining compliance with medication regimens and sanitary living conditions? Such a front row seat we have to the inner workings of a myriad of homes. With that great privilege comes great responsibility but sadly too often the workings of the system seem as foggy as that apartment. The horizon seems full of potential growth as we strive to learn to combine street paramedic roles in collaboration with hospital personnel, identifying and implementing public health and social services.

It’s hot, and she’s not dressed for it. Sweatshirt and sweatpants, tee shirt and socks with laced up tennies. She’s currently sitting in the rear of a squad car, guzzling on a bottle of Sprite that is sweating only slightly less than she is.

Passersby found her, she was down on the ground and it was pretty clear she’d fallen. Someone helped her up, but then she fell again. So they called it in, the nice officer who responded scoped out the clothing situation and her speech, and activated EMS non-emergent. Now we’re here, and I lead my student across the street from our parking spot towards the black and white. My partner updates MedComm that we are on location, and brings up the rear. On this initial evaluation we’ve got the cardiac monitor. The bag is feet away should we need anything.

The lady was assisted out of her sweatshirt by the officer prior to our arrival. Pink and white camouflage, it’s more at home in a rural environment than here in the city but I guess you never know where people hail from originally. Little bits of home from all over converge in any metropolis, and you get what you get. The only constant is that the kaleidoscope keeps moving, the bits and pieces keep on tumbling.

Her speech is softly rounded, not in the drawl of the southlands but in a gently slurred sort of way. Her facial features are a little slack, and in the first few minutes while my student assesses her, I wonder if she has some cognitive delays. Soon we have the first vitals, she’s hypotensive and my partner brings the cot right to her side. She’s still seated mostly on that rear seat with the door open, one leg in, and one leg out. Her cane is leopard print, and I grin at her style. Pink camo and leopard print – lady’s got flair.

Securely fastened to the cot, we wheel her to our truck and the automated system whirs her into the air conditioned truck. The doors kathunk shut behind us and we survey the situation. Then she says, in that soft speech, “I believe it’s a low volume issue, I’m dehydrated and forgot my cooling shirt at home.” I cock my head and evaluate her again. She tells me she has MS.

She tells me she used to be a nurse. Before the disease progressed.

The remainder of our contact is wonderful. She encourages my student thru the IV start, she matter of factly discusses her evening schedule of HCTZ and why it is taken then, the need to schedule it so far apart from her diuretics. She’s a smart lady. The day didn’t seem that hot when she set out to walk for a snack. She became over heated. My student informs me after we’re in station, later, that increased body temperature in an MS patient decreases the ability of the non-myelanated sheaths to conduct impulses. So with no one to help her out of the sweatshirt, and the increasing heat making her co ordination worse, she was on a downhill sled with no trees in sight.

We take good care of her, and after my student gives report at the receiving facility, we shake her hand and inform the young nurse taking care from us that this patient is a nurse. The patient softly corrects me, “WAS a nurse.” I think of how she welcomed my student, walked her through a failed IV and told her that learning takes time. I think of her gentle patience on scene, her grace in the face of adversity of a cruel disease.

I bend down, and softly say, “you taught me as much today as my nursing instructors. You are once a nurse, always a nurse. Thank you for today’s teachable moment.”

She didn’t say much, but her eyes shined a little brighter as a smile spread across her face. I walked down the hall and thought to myself, teachable moments, indeed.

I’m 27, and I have no idea how profoundly this class will affect me. The ways in which it morphs who I am into a better version of myself. The people I will be honored to care for, the things I will witness. The ways those things I witness will impact me for months and years to come. I have no inkling that my appreciation for life itself will grow, deepen and become a nearly measurable entity.

I simply know that I am taking a class, an EMT-Basic class. It meets two evenings a week, from 6-10pm in a town roughly half an hour away from the bank at which I then worked. A nice customer from the bank also is taking the class, and we carpool. His wife is funny and kind and I look forward to those visits at their house before we hit the road, off to class. One day we get to town a little earlier than usual, and we swing by a used car lot just to kill some time. Before you can say SAMPLE, I’m the owner of a lipstick red Camaro just a few days later. In my young mind I think it’s funny to pay extra for a license plate that reads CTCH ME.

We graduate, I continue banking. But something has changed. As the pager I’m given goes off, my heart rate accelerates in a sympathetic nervous system response, and now that I mention it, I’m not certain it’s ever quite gone back to normal. The more I see, the more I am frustrated by the limited ways in which I can help. I want to learn more, I want to help more. It’s not enough, the need is too great and so soon I leave the bank. I’m working now for an interfacility ambulance company. A few years pass and I’m working in a small town ER – and dispatching for an air medical service and the largest ground transport service in our area. I’m meeting paramedics, and the more of their air I breathe, I know – I simply must learn what they know.

I’m back in school, I’m now non-traditionally old. I find it amusing then but I will find it even more amusing later. I learn more procedures, more skills, more drugs, and I drink in the knowledge like water. I can do more, I’m in heaven.

The years go by and the calls accumulate. Back in the volunteer EMT days, I once asked an experienced first responder who was a nurse, “When do your hands stop shaking?” She smiled and said, “In time.” I volunteer no more, I work 24, 36, sometimes a rare 48 hour shift. I sometimes struggle with exhaustion of the empathetic kind, and that’s when I know that the overtime needs to rest. But those mornings when you hold the hand of a spouse after pronouncing time of death, or those midnight kitchens when the patient’s lungs are struggling to move air across the alveolar membrane in spite of the obstructive fluid impeding the process – that’s when I’m more alive than I can describe to anyone who’s never dropped everything when the tones go off.

Then I’m 40 and I’m in nursing school. Now, boys and girls, I am decidedly non-traditional. Now I’m an older student, because after all that’s what non-traditional is kindly saying, all along. The calls and the years and the patients never stop coming. That old country song by one of the highwaymen has a line in it that reads, “the road goes on forever and the party never ends.” I’m used to this lifestyle and yet it’s wearing on me. I’m giving a talk one day to a group of paramedics and afterward, one comes up to me.

“You really love this job” he says, “don’t you?” Without hesitation I answer, “of course.” He asks me then, how can I be leaving it? I think about it then, and for the first time I verbalize what I guess I’d been rolling around in my mind the whole time in my nursing classes. Rolling it around like you roll a hard candy in between your teeth and your cheek. Sometimes you hold it there until it makes the skin of your cheek get all funny feeling from the concentration of the sugar.

“I’m not leaving” is what I say. “It’s who I am.” And I mean every word of it. As long as my body can respond from a dead sleep to wheels turning in under that two minute mark, as long as I can lift and pivot and hustle a cardiac monitor and backpack up three flights of stairs to an overdose at the end of a hallway, I know I can’t give away the radio. The pager is gone, now. Replaced by a nice Kenwood and a Boston strap. But the tones still activate the sympathetic response, and the drive to help, to revel in the autonomy of the street at 2am, the back roads lighting up with the red and white lights, the way the dispatch information activates the training and the street knowledge and my mind begins to run down algorithms and dosages on the way to the scene…no other profession can meet the speed at which this paramedic’s heart rate has come to love. There’s no other drug quite like the rush of a hand squeeze from an elderly patient whose breathing you’ve eased, or the never-fail feel good call of a diabetic wakeup when the family sighs with relief.

I walked out in the garage the other day. The weather has finally warmed, and I opened both garage doors to let the sun shine in and the fresh air swirl around the stale dust. The sunlight gleamed off that lipstick red Camaro parked crosswise in the rear of the garage, back behind the everyday cars. Her license plate is current, paid and valid. It still reads CTCH ME. I think of EMS like that. Lipstick red. Always another road, RPMs just begging to be elevated like a heartrate.

We are here for our patients, our communities, those we know and those we’ve never met. We’re on our way when help is needed. Always – in service. Because it’s who we are, it’s more than a profession. It’s a choice, a lifestyle, a calling, a gratification, an honor and a joy.

Happy EMS Week 2017.

The children outside are curious, playing but in a sense of studied nonchalance. Not that any of them look old enough to know the nuance of the word, but innate in them as in all of us lays the gist of the word’s implication

The fire apparatus is already curbside ahead of us, lights silently announcing to anyone watching that activity is happening within this building, this day. My partner takes the cardiac monitor from me and I keep the jump bag over my right shoulder. Dropping their pretense of play, the children fall still, openly checking out our accoutrements. One brave boy calls out, “hey, whatcha got there? What’s that big bag for?” My partner returns, “helping people”. Simplified, yet valid.

Inside, a middle aged man with an air of importance around him meets us, gives us a short layman’s report.  It is remarkably succinct, and with nearly all necessary components I could’ve asked for if making a list. We continue on in the direction indicated, where ahead a small group of people can be seen gathered in the cafeteria. It’s after hours, at this school, and yet the gathering is modest. I see fire ahead, and a slight woman with grey hair barely visible in the middle of the navy shirts, suspenders attached to turnout pants, and male muscles.

I greet the lieutenant by name and make my way around the far end of the cafeteria tables arranged in neat rows. The patient has the gathering of firemen around her as well as a couple elderly ladies and amidst all of these, a few more assorted small humans, watching with grave interest. The lieutenant was a new fireman when I was a new medic and he gives report after greeting me by name.

“Patient was getting up, caught her sneaker” <I remember thinking, “Jimmy said sneaker, who says sneaker? Have to tease him later on at some point”>  “on the bench and fell, hitting her head. She did lose consciousness. Her blood pressure is low; she was very pale when we got here. Her heart rate is very slow, blood sugar is 92.”

The patient is discussing her last meal, her certainty that she is just fine, and I make my way over to her side. Seating myself on the bench of the cafeteria table so that we are near one another, I introduce myself. I speak quieter than is necessary, in this big echoing space full of people and conversations. She quiets, to hear me. Excellent. I need her to divert her attention now to the things I must know, some of them repeats of what fire have told me. This helps me to ascertain that she is remembering and maintaining not only the events about which I will ask, but that she continues to give the same version of events. I’m ruling out not only an obvious injury with this method, but also considering the all too often seen brushing under rugs of significant events by patients who fear a loss of independence. My concern in the here and now is her welfare and immediate medical issues. Independence and living arrangements, while not likely to be impacted by this event, are always concerns on the far horizon, handled by other professionals. We am mindful always, however, as this fear in the mind of a patient can result in a skewed version of events as relayed to us on scene.

She is clear on her events, clear in her gaze, and calm in her recitation of events just as the lieutenant described to me. While I ask and listen, I place cardiac monitor on her and am greeted by a sedate normal sinus rhythm out for a Sunday drive at the slow pace of 52. She’s still hypotensive, but not as markedly as fire’s initial vitals. We go over past medical history (not much to speak of, hypertension for which she is compliant with her medication regimen), and the regular familiar rolling questionnaire of intake, output, new medication changes recently, dizzy or weak before the fall, syncope of falls within the last few months, symptoms now, any pain, day, year, president and so on. She denies anything of note during all of this, her answers accurate and remaining oriented.

A few minutes later we have her on the cot, I’m handing for her purse near her when she asks me for her Bible. I spy it on the table, zipped neatly in the black leather case that is exactly like the ones in which my dad and mama always kept their Bibles. I pick it up, and the reassuring familiar heft of it is like an old friend. I grin at the familiar comfort of a memory as old as my childhood here in this moment, and ask her if they were having Bible study here. She shakes her head and with a smile, tells me as we walk to the truck about the program they have with the children here, points awarded for verses memorized. The children watch solemnly as we walk out, the man who I’m now almost certain is a pastor finalizes disposition of the patient’s car, and soon we are at the back of my truck. Opening the doors is a senior fireman who I haven’t seen in a while, and I feel the glad smile on my face. He says, “how ya doing, Crystal? Up here on the north side, tonight!” and we chat briefly while my partner loads the patient with the new power load cot. Then the back doors shut, I climb in the side door and it’s us ladies, in the back. I reattach the cables and begin another blood pressure.

She sighs, then, smiles and says to me, “all of this….” Her voice trails off. I nod and respectfully offer that we do need to think of the implications of things like a loss of consciousness after hitting a head, especially as we think of ages when our bodies don’t handle injuries as they once did. Cervical spine was cleared on scene, she has no obvious outward injuries and we pull away from the curb after she politely declines an IV. En route to the hospital, she checks in on a lady who she has taken in, tells me earnestly of her story. She elaborates on the program with the children, and when I enter the demographic data into my patient care report, I double check the date of birth in surprise. She assures me that I am correct, and with a twinkle in her eye tells me she works out.  In fact, she prefers weight training the most. I cock an eyebrow and tell her perhaps the heart rate in the mid- 50s isn’t quite as out of the norm in her case.

Report given, signature obtained, we walk into the bright lights of the emergency room, wheeling the cot. Two care techs I’ve never seen help us transfer the patient, and a nurse I’ve never met takes report. I walk down the hall a few minutes later, thinking of ladies who lift weights at twice my 40 years, and the equally preservative nature of small humans, taken once weekly, q Wednesday night. Repeat as needed for a life of service and happiness.

And wear sneakers, no matter the age.