field of hon·or

1 – a scene of a duel

2 – a region where a battle is being, or has been, fought

3 – the scene of the final battle between the kings of the earth at the end of the world

—

Polo strategy on hitting: Get your hand high for a long shot. Hit through the ball. Keep your arm straight until it passes forward and above the shoulder. Give yourself space hitting the ball – not too close to the horse. Take your time on the ball. Ride your horse before your hit the ball. Set your horse up for the shot.

Jamie Le Hardy – Polo Champion

—

He lays in the field of battle next to his trusty steed, writhing in pain and struggling to breathe; diaphragm spasming to the point that the lungs can’t function. Other combatants stand around him swaying in the awkward forward and backwards rocking motion that is unique to their mode of transportation. His polo mallet lays nestled in the grass next to him after causing the accident. His steed lies nearly lifeless just a few feet further away.

—

The origins of Polo date back to the 5th century BC in Persia where elite calvary units of the king’s guard used the game as simulated horseback battle.

—

As I walk up to the players on the polo field they canter away in their awkward little leaning motions to give me more room to inspect my new patient. We arrived with the fire fighters so our little entourage is trudging across the field while we carry bags and push a gurney to the crumpled man in the middle of the “field of honor.”

As with any injury of this nature one of my first concerns are the integrity of the neck and the neuro-function of the extremities. I run my patient through the battery of simple neurological tests while one of the other polo players recounts the events leading up to the injury.

—

Sultan Qutb-ud-din Aibak, the Turkish Emperor of North India, ruled as an emperor for only four years, from 1206 to 1210. He died accidentally in 1210 playing polo.

—

“Jim was shuffling the ball towards the goal and one of the defenders started to crowd him. It was totally legal and everything, he was just defending. So Jim went to score and took a big wind up with the mallet. When he took the shot his mallet got caught in the undercarriage of his mount and he got thrown. He didn’t pass out or anything but it looked like he couldn’t breathe so we called you guys.”

After all the neuro tests come back with no issues I sit Jim up and assess for any obvious abrasions, bruising, or swelling that would indicate a problem. Nothing really looks out of place until I encircle his rib cage with my hands and have him take a big breath. Jim practically jumps out of his skin with painful sensations shooting from his flank to the middle of his back. A closer inspection shows that the ribs are stable enough but it’s very likely that he separated some of the cartilage where the ribs connect to the spine. It’s not a critical injury but it’s worthy of some x-rays and sign-off by a doctor. Once I listen to his lungs I’m satisfied that the injury is probably localized to the ribs and not involving a collapsed lung – I’m ready to transport. I’m just worried about his poor steed laying in the grass, barely moving, with pitiful whimpering noises coming in small gasps.

To the fire lieutenant as we’re loading up the ambulance, “Can you please call PD and have the poor steed put out of his misery.”

—

Military officers imported the game of polo to Britain in the 1860s. The establishment of polo clubs throughout England and western Europe followed after the formal codification of rules.

—

stag·na·tion

1 - the condition of being stagnant; cessation of flowing or circulation, as of a fluid; the state of being motionless; as, the stagnation of the blood; the stagnation of water or air; the stagnation of vapors

2 – in acupuncture: a pattern of excess that occurs when the smooth flow of Qi is stuck in an organ or meridian – the primary symptoms are pain, soreness, or distention, which characteristically change in severity and location

3 – in western medicine: the retardation or cessation of the flow of blood in the blood vessels, as in passive congestion or occlusion

—

“My mind rebels at stagnation. Give me problems, give me work, give me the most abstruse cryptogram, or the most intricate analysis, and I am in my own proper atmosphere. I can dispense then with artificial stimulants. But I abhor the dull routine of existence. I crave for mental exaltation.”

Sir Arthur Conan Doyle – Sherlock Holmes

—

Officer Leung arrives at the Chinatown police sub station early every morning. He has a personal sense of ownership in that he opened up the station sixteen years ago and he’s been walking the streets of Chinatown ever since. After checking last night’s crime reports he sets out on his morning rounds of getting out to interact with the community. He’s a familiar face to the locals and he can’t walk more than ten yards at a time without saying hello to someone. Being a native Cantonese speaker he easily communicates with the locals and they feel the ability to approach him with everything from neighborhood concerns to telling him about the birth of a son.

It’s an experiment in community policing that started decades ago and is only now beginning to take hold and show results. Many people living in ethnic enclaves of our mostly urban city seldom venture outside of their comfort zone. They may have a mistrust of police and authorities and an inability to easily communicate in English. Because of this they are many times the victims of crimes that go unreported. The community policing model is an attempt to put a familiar face on the authorities and give the people in these areas the ability to thrive in a safe environment. Officer Leung is that face in this community and he loves his job – he feels he gives back to his community every day.

Chinatown is in the midst of its morning wake-up routine: produce trucks double parked and offloading fresh goods, vendors stacking baskets of fruits and vegetables partially in the sidewalk, succulent looking roasted duck and pork hanging in windows. Quickly following the produce trucks are the professional recyclers – men in small pick-up trucks, stacked high with cardboard, providing a service to the vendors and a small income for their family.

Jin has been doing this for years and he knows all of the vendors on his street. As he methodically breaks down the cardboard boxes and stacks them in the back of his truck his shoulder continues to hurt from the strain and the cold morning. He’s thankful he wore extra layers of clothing as it’s a cold day but he seems to be working up a sweat faster than usual today. as each layer of cardboard gets added to the pile in the truck the strain on his shoulder increases. Finally he drops to one knee, holding on to the side of the truck, and grimacing in pain as he sees Officer Leung stop next to him.

—

I really don’t like running Code-3 through Chinatown. The public cliché about Paramedics and EMTs is that they are adrenaline junkies who love to drive fast and live for the blood and guts of a gory scene. In truth, just about every co-worker I know is really happy when a call gets downgraded to Code-2 and we get to shut down the lights and drive slower. We get far more satisfaction from a complex medical call than a bloody trauma.

But running Code-3 in Chinatown is its own special kind of hectic. Putting aside the normal stereotype about Asian drivers, the real problem is the one way streets with delivery trucks double parked on either side and the intersections where pedestrians can cross in all directions at the same time. It’s a very confusing place to drive – much less Code-3. Fortunately, my partner is handling it pretty well and I just have to help keep an eye out for the random jaywalker.

When we pull up to the scene I open the door and I’m hit with the smell of Chinatown. It’s not unpleasant yet it is unique in the city. The fresh pastries from the Chinese bakery have a sweet smell that blends well with the roasted meat from the next storefront. Layered on top of the food smells is pungent odor of Chinese medicinal herbs that waft from the herbalist’s store. All of this mixes in with the closest and least appealing smell: burning brakes from our rig.

I walk over to the officer and the man sitting on the curb. “Hi Officer Leung, what’s going on today?” Over the years I’ve seen Officer Leung walking the Chinatown beat. He’s a refreshing fixture of the Chinatown landscape.

“Not really sure. Jin collapsed while stacking his truck. He said his shoulder hurts and he saw a doctor for it yesterday but it’s worse today. He only speaks Cantonese but I can translate for you.”

“Okay, how about we move into the rig so I can check him out. Ask him to have a seat on the gurney. Thanks.” The rig has plenty of room and Officer Leung is able to sit at the foot of the gurney without getting in the way. He’s easily able to translate all of my questions pertaining to the onset of symptoms as I try to figure out what’s going on and my partner sets up the monitor to take vitals for me.

Jin has the skin signs that scream MI: pale/cool/diaphoretic, wincing in pain, holding his left shoulder, respirations coming in small gasps. My priority is to set up the 12-lead and have a really good look at the heart. Yet as I open his shirt I’m surprised to see evidence of trauma – he has bruises all over his chest. I’m a little confused as this was presenting like the perfect MI; I remove his shirt so I can fully appreciate the bruises.

As I step back to get the overview of his condition it all comes into focus. He looks as though he was just attacked by a giant squid. He has maybe a dozen circular bruises on the front and back of his left shoulder – they look like giant hickies. Turning to Officer Leung, “Can you ask him to clarify, did he see a doctor yesterday or an acupuncturist?”

After a quick exchange of Cantonese I can rule out the giant squid theory and replace it with the likelihood that he is the recent recipient of fire cupping. It’s an acupuncture technique where a piece of flash paper is lit inside of a bulbous cup which is quickly placed on the skin. The fire sucks the oxygen out of the interior of the cup which then pulls the skin into the cup as it creates suction. The result is a number of circular bruises on the skin that look like a giant squid attack. The theory is based on the principlel that stimulating areas along a meridian will release the stagnation of energy and restore normal circulation. It’s a treatment that’s been around for millennia yet as I look at the results of the 12-lead ECG printing out of the monitor I can see it’s not the treatment he needs right now: ***ACUTE MI SUSPECTED***

post·script

1 - a paragraph added to a letter after it is concluded and signed by the writer; or any addition made to a book or composition after it had been supposed to be finished, containing something omitted, or something new occurring to the writer

—

As it turned out, Missy was a WUS. That’s not a disparaging comment about her intestinal fortitude – it’s a classification of stroke known as a “Wake Up Stroke.” According to a recent article in the American Heart Association / American Stroke Association entitled Thrombolytic Therapy for Patients Who Wake-Up With Stroke, approximately 25% of all strokes are WUS. Given that people may sleep 25%-30% of their life it can only be expected that a stroke will happen during that time in a proportionate number. EMS currently deals with a short (4-hour) window of time to rush a patient to a stroke center for thrombolytic therapy – if a stroke has a known onset of four hours or less, the patient is eligible for thrombolytic therapy. Outside of that window it is considered a “cold stroke” and thus ineligible. If the onset time of the stroke cannot be verified, such as in the case of a WUS, the patient is automatically ineligible for thrombolytic therapy. This latest article, however, states that the therapy may be safe in longer periods of time from onset of symptoms. Further studies are being conducted to explore the possibility of an extended time period for this treatment.

I recently attended a lecture series by a panel of neurologists on strokes and the latest trends in therapy. During the session the extension to the thrombolytic window was explained in greater detail. To paraphrase four hours of lecture, in the event of an ischemic stroke there is a proportion between necrotic (dead) brain tissue and the surrounding ischemic (under-perfused) brain tissue which can be visualized with a Functional MRI. With a proportion of 80/20 thrombolytic treatment would have very little effect. With a proportion of 25/75 thrombolytic treatment may have a greater effect and the potential benefits of extending the window would then outweigh the possible risks. The ramifications of this line of research is that every patient has their own personal window of opportunity for thrombolytic therapy which can only be viewed once that patient reaches a stroke center. This same research is showing that an extension of the window to as long as sixteen hours may be safe in some situations.

In the case of Missy I took her into the hospital running Code-3 because of the smoke inhalation and potential for an airway that may be in the process of closing. Yet I transported her to a stroke center, bypassing a regular ED with no specialties, to ensure that neurologists would be on hand to quickly evaluate her recent stroke symptoms. Unfortunately the extension to the thrombolytic window is still in the research phase and has not progressed to cover the WUS scenario at the local hospitals. The deficits from Missy’s stroke did not immediately resolve and she was not a candidate for thrombolytic therapy. She will undergo extensive physical therapy in an attempt to regain some of her left-side functionality.

Meanwhile, Stacy, the fire medic/RN who got caught up in the excitement of the fire to the point that she missed an obvious stroke in her patient, has since been promoted to Lieutenant…

back·draft

1 – a reverse movement of air, gas, or liquid

2 – an explosion that occurs when air reaches a fire that has used up all the available oxygen, often occurring when a door is opened to the room containing the fire

—

Missy woke up a little early and from the start she knew something was wrong. She just didn’t feel right and the world seemed just a little more confusing than usual. She tries to get up out of the bed but the weakness is just a little more pronounced than usual and she never makes it all the way out of bed. Thinking maybe it would help to bring the world into perspective Missy reaches for a morning cigarette with her left hand, but finding she can’t quite make that work she finally reaches across her body with her right arm, grabs the cigarette, puts it between her lips, and lights it while laying in bed. With the smoke inhaled deep into her lungs she starts to relax again and nod off.

There’s shouting from outside the house – someone is yelling at her. She opens her eyes and sees the flames overhead – gently rolling across the ceiling with the smoke starting to burn her lungs on every breath. She tries to get up but again the weakness is stopping her from getting out of bed. Suddenly there is light in her bedroom, as the door opens, this is quickly followed by intense heat as the flames erupt as if seeking the oxygen from the open door. Strong arms grab Missy and start to drag her out of the house. Once on the front lawn she can see the flames well above the roof as firefighters are breaking windows and drenching her house with water.

—

As we roll into the neighborhood my partner and I stop following street signs and just follow the smoke to the location of the medical call. We have to park a block away as the small residential street is full of fire apparatus and supply lines. We roll the gurney closer to the house, avoiding the standing water and six inch fire hoses that snake across the road. Sitting in front of a burned-out house is my patient, leaning forward in a tripod position, sucking hard on an oxygen mask, with both arms being held out to either side.

Stacy, the fire medic, is supervising two Explorers who are simultaneously taking blood pressures, one on each arm. Our county has a Fire Explorers program for youth who someday want to be firefighters – it gives them the opportunity to volunteer with a local fire unit and learn the basics of the job. Both of the Explorers seem distracted by the commotion of the fire; they glance repeatedly from the blood pressure dial to the flames. It’s obvious they would rather be squirting water than taking care of this woman.

Finally, Tracy has had enough and asks each of them for their findings – she knows I’m not going to hang out here all day waiting for kids to check a vital sign that I’m going to recheck regardless of their findings. The kid on the left gives us a report of 90 over 60, the kid on the right tells us it’s 180 over 110. I have a dead pan stare on my face as I wait for Stacy to give me a report.

Stacy is writing the two sets of blood pressures on the patient care form and handing it to me. “Yeah, I know, you’ll have to check the BP again. Basically she was smoking a cigarette in bed and fell asleep. The blinds caught fire and the whole house went up. She got caught in a backdraft when they went in to get her. She had moderate smoke inhalation without any visible burns. That’s about it. Are you good?” Am I good? Hell no I’m not good. But I’m absolutely ready to leave.

Having moved Missy onto the gurney we start the long trek back to the ambulance. We have to double back a few times because of standing water creating small lakes in the street and fire hoses blocking our way. Throughout the ordeal I’m grumbling to myself about the poor treatment of Missy. Yeah, great, they got her out of the fire, but her treatment stopped there. Stacy knows better, she’s also an RN at a local Emergency Department, yet she released her helpers to let them fight the beast while the Explorers tried in vain to take vital signs. She didn’t have a history and knows almost nothing about this patient except she was in a fire.

Once we’re back in the rig I can start over and give Missy a proper check-out prior to going to the ED. Looking her over I can’t see any obvious burns but I’m more concerned with her breathing and airway at the moment. I slip the oxygen mask off and shine a flashlight in her mouth and nose and find singed nose hairs with soot extending the visible length of the nares – not good. Soot in the mouth and on the lips – not good. Oxygen saturation of 86% on room air – not good. Wheezing in the apex of each lung with a stridorous noise starting to come from the throat – really, really not good!

As my partner prepares the Albuterol and Atrovent nebulizer to affix to the mask I put an end tidal carbon dioxide nasal cannula on her nose so I can keep a good record of her respiration trends and quality of breathing, but looking at her face something just isn’t right.

“Missy, we’re going to give you a breathing treatment to help you breathe a little better but I have to ask about your medical problems. First off, have you ever had a stroke?” I’m seeing the telltale facial droop on the left side with an eyelid that looks like it’s being pulled down in the corner.

“Yeah, I had me a mini-stroke a while ago. They said it’s because of the A-fibs. But I all better now.” Now that I hear her speak I can tell there’s a bit of a slur to her speech.

“So you’re saying you didn’t have any lasting deficits from the stroke; like facial droop or weakness on one side?” My partner just finished setting up the nebulizer but I need to finish this line of questioning before putting it on and obscuring her face with a mask. He moves up to the front and starts getting us out of the neighborhood; I haven’t given him a destination yet – we both know that destination will be critical with this woman – yet we need to get moving.

“You know, now that you say it, it feel kinda like that mini stroke right now. I could’t get out of bed and my arm jus’ seem like it don’t want to move like it should.” That’s enough for me. I run Missy through a series of stroke tests; facial droop, slurred speech, left side weakness, change in sensory appreciation from left to right side and minor cognitive disassociations (how many wheels on a tricycle, what color is an orange, that kind of thing).

I glance out the front window as I place the mask over Missy’s head and see that we’re just exiting the neighborhood. Rechecking her blood pressure I discover that the Explorer on the left was closest – she’s 84 over 48. I start to set up the Sodium Thiosulfate drip for the IV.  “Okay, you ready for this?” I yell up to my partner.

“Yeah, go ahead, where we headed?” He yells over his shoulder as he lights up, turns on the siren, and heads for the freeway.

“Well, you already guessed we’re going Code-3. We’re going to Hilltop ED; 44 year old female, moderate smoke inhalation, hypotensive, tachycardia, tachypnea, Albuterol/Atrovent/Sodium Thiosulfate running. She’s also got a cold stroke, unknown onset time, left side weakness, with a history of.”

“Seriously?”

“Yeah, seriously, that’s what started the fire.”

post·script

1 - an extra piece of information about an event that is added after it has happened

—

The patient in question did in fact have a massive pulmonary embolus known as a Saddle PE. Because the embolus lodged in the pulmonary artery at the bifurcation between the left and right branch, much of his lung capacity was not actively engaging in gas exchange. He was not able to offload the EtCO2 or fully oxygenate the blood. His altered state was actually a hypoxic event even though his lungs were clear and had perfect tidal volume. The EtCO2 reading was the only finding, other than skin signs and oxygen hunger, that pointed me in the right direction.

Upon turning him over to the MD at the ED I concluded my report with my findings and a differential diagnosis of PE. This bought me a raised eyebrow from the MD as a PE is a very difficult thing to diagnose without the help of a CT. That same MD seemed a little more on board with my findings when the patient flat lined ten minutes later and subsequently three more times before they pushed thrombolytics to dissolve the clot.

Later that night he was moved to the ICU and extubated the next day. He recovered with no lasting deficits yet he remained in the hospital for two more weeks as they continued to administer blood thinners and observe for any reoccurring emboli.

The bifurcation of the cherry tree is a beautiful analog for the inner vasculature of the lungs. Nutrients are carried along the trunk to the blossoms where gas exchange occurs and photosynthesis creates energy that is then carried back along the trunk. When a branch is injured the blossoms die and create a dead space. The cherry tree has the advantage of many bifurcated branches to continue the cycle – we only have one.

—

Dead Space

A decrease in perfusion relative to ventilation (as occurs in pulmonary embolism, for example) is an example of increased dead space.[3] Dead space is a space at which gas exchange does not take place, such as the trachea. It is ventilation without perfusion.

Saddle Pulmonary Embolus

A large thrombus lodged at an arterial bifurcation, where blood flows from a large-bore vessel to a smaller one. The ‘classic’ saddle embolus—which occurs at the bifurcation of the pulmonary arteries in fatal pulmonary embolism secondary to a centrally migrating venous embolus—is distinctly uncommon.

Segen’s Medical Dictionary. © 2011

Massive pulmonary embolism

As a cause of sudden death, massive pulmonary embolism is second only to sudden cardiac death. Massive pulmonary embolism is defined as presenting with a systolic arterial pressure less than 90 mm Hg. The mortality for patients with massive pulmonary embolism is between 30% and 60%, depending on the study cited. Autopsy studies of patients who died unexpectedly in a hospital setting have shown approximately 80% of these patients died from massive pulmonary embolism.

The majority of deaths from massive pulmonary embolism occur in the first 1-2 hours of care, so it is important for the initial treating physician to have a systemized, aggressive evaluation and treatment plan for patients presenting with pulmonary embolism.

dead

1 – having lost life, no longer alive

2 – having the physical appearance of death; a dead pallor

3 – not circulating or running; stagnant: dead water; dead air

space

1 – the infinite extension of the three-dimensional region in which all matter exists

2 – an empty area which is available to be used

dead space – a calculated expression of the anatomical dead space plus whatever degree of overventilation or underperfusion is present; it is alleged to reflect the relationship of ventilation to pulmonary capillary perfusion

—

Walking back into the ED room to get a signature from the nurse I’m momentarily surprised at the level of commotion surrounding the man that was my patient just a few minutes ago. I look up to the overhead monitor that displays his vitals and see the obvious cause for excitement – asystole, the most stable heart rhythm in the world, is marching across the screen and slowly erasing the beautiful complexes of normal heart beats as it fills the screen with the flat line of death. The Paramedic Intern pulls a short step stool out from the corner just as the attending MD makes the call for him to begin CPR. Well, I guess my differential diagnosis was correct, small comfort considering he’s dead now.

—

There’s a question in paramedicine that is useful to the Paramedic in deciding a course of action on any given call – is this person big sick or little sick? The speed at which we can determine the acuity level of any given patient helps us in determining how fast we move through the call. On occasion the first look at a patient can tell you everything you need to know in terms of acuity. As I walked into the bedroom I could see that this is one of those times. My new patient looked up at me from the bed and it’s obvious that this is big sick and I’ll be moving fast today.

The firefighters arrived just a few seconds before us so they’re still attaching the monitor  leads and trying to get a blood pressure. I know what they’ll find based on the patient’s skin signs alone. The term – pale/cool/diaphoretic – gets overused in our business but it still surprises me when I see these skin signs manifest on a patient. A man of his ethnic background would be hard pressed to look pale so the fact that he looks ashen tells me all I need to know. My first thoughts on a call like this are about extrication. I want to get this guy out of here, into my ambulance, and start driving. Everything else can be figured out on the way to the hospital but the main priority is getting him from the bedroom to the ambulance. The problem is that he’s over two hundred pounds and there are three flights of stairs between me and my ambulance.

I send my partner back to the rig for a stair chair as I start to take in the vital signs and patient history to see if I can paint a picture of the last few hours that led to this big sick presentation. It seems that he and his wife were out running some errands and he started feeling sick about an hour ago. He vomited once and now he’s presenting with an altered mental status, very low blood pressure (72/48), fast heart rate (118 bpm), clear lung sounds, and skin signs that are screaming “heart attack” at me. Of course that was until I ran the 12-lead for the second and third time. The results keep showing nothing even remotely concerning in the cardiac department. In his altered state the only intelligible uttering I can make out from him is, “I…can’t…breathe…”

I put a non-rebreather oxygen mask on him and start the trek of three flights of stairs to the ground floor and the relative comfort of my ambulance where I can start to figure this thing out. The new stair chairs with the revolving treads make quick work of the stairs while preserving our backs in the process. It seems we’re on the ground floor in just a minute or two and headed towards the ambulance.

Finally inside the ambulance, I have decent light and all of my tools at hand so I can try to analyze his condition while driving to the closest hospital. I’ve already ruled out the possibility of a STEMI (S-T elevation myocardial infarction – a.k.a. heart attack), which would require a cath-lab, so I am free to head to the nearest hospital. As I check his 12-lead a fourth time – on the right side this time, still looking for the elusive STEMI – the firefighters decide it’s a good opportunity to leave. Figures. Looks like I’m on my own on this one.

With lights flashing and the siren singing a duet with the air horn I bounce down the road while starting two IVs in my quickly fading patient. Once that’s done I set up two bags of warm saline flowing wide open to drop as much fluid on him as possible and try to keep that blood pressure out of the double digits.

I slip the non-rebreather off of his face and put on a nasal cannula that has a receptacle for reading the exhaled breath and measuring the end tidal carbon dioxide (EtCO2). I actually do a double take as the reading comes back as 8 when the normal reading should be between 35 and 45. Hell, I’ve stopped CPR and pronounced people dead with higher EtCO2 readings!

A number this low just doesn’t make sense. I listen to lung sounds again and they are still coming up clear. I check his blood sugar to rule out a DKA (diabetic ketoacidosis)  presentation and it comes up perfect. Sepsis could possibly take the reading this low and explain the presentation but not with an onset of just one hour. There’s only one other differential diagnosis that is making sense to me right now and when that flashes into my head I’m more relieved than I can admit to see the bright lights of the ED out of the back window as my partner backs us into a spot by the double doors and I prepare to give my findings to  the doctors on the other side.

—

In these days when science is clearly in the saddle and when our knowledge of disease is advancing at a breathless pace, we are apt to forget that not all can ride and that he also serves who waits and who applies what the horseman discovers. 

Dr. Harvey Cushing

post·script

1 – a note, paragraph, etc. added to the end of a letter or at the end of a book, speech, etc. as an afterthought or to give supplementary information

—

Three days after leaving my mostly urban county by helicopter the young man in question was extubated and regained consciousness with no lasting deficits. The trauma surgeons in my county trauma center made the right call in sending him to the specialists at University Hospital. And, as much as I may have some misgivings about the use of an air ambulance in an urban setting, I believe it was the right choice of transportation.

Most forward thinkers in the pre-hospital setting are fairly skeptical of the use of helicopters for all but the extended transport times in rural settings. A flight time of twenty minutes can easily be extended to over an hour when all factors are taken into consideration; travel time to the scene, landing and unloading, assessment and loading the patient, landing and unloading the patient at the hospital. In many cases where the benefit may be minimal the right answer is to drive the patient and get to definitive care faster.

In this case I believe the use of the helicopter was warranted given the time of day and general unstable nature of the patient. In the midst of morning rush hour the normal drive time of 48 minutes would be extended to nearly two hours even with the use of Code-3 lights and siren. The geographical choke points of bridges and waterways create near gridlock traffic situations where an ambulance literally has no place to push the traffic out of the way.

It’s easy to get jaded in a busy urban environment like this. My initial impression of this escapade was that of skeptical acquiescence. The decisions about where and how this patient is transported are very far beyond my control once the doctors put things into motion. It’s also easy to lose a little bit of feeling or caring for someone who intentionally put themself in danger to satisfy the cravings of an addiction. Violence and trips to the ED are unfortunate byproducts of the environment for people who engage in this lifestyle. Just as a Paramedic may have very little sympathy for an injured drunk driver – we may have the same lack of compassion for someone who intentionally drives into the hood at four in the morning to score drugs. As a byproduct of their misadventure lives are put at risk while driving Code-3 and flying helicopters in a very busy airspace. That is a risk we will take when an innocent life is on the line yet it’s hard to justify when we are put in that position by someone’s poor choice of lifestyle.

Yet my impression of this patient changed a few days later when an officer involved in this case told me that the patient had bounty hunter credentials on him at the time of the shooting. Was he actually trying to clean up the streets rather than contributing to the problems in the hood? I don’t know, I will likely never know, but it does serve to remind me that it is not our job to judge people. We are here to fix who we can, keep them alive as long as we can, and deliver them to definitive care with all haste. That’s what it is to be a Paramedic.

flight

1 – a swift passage or movement

2 – the motion of an object in or through a medium

3 – the action or process of flying through the air; a bullet in flight

fan·cy

1 – not plain; ornamented or complicated

2 – requiring skill to perform; intricate

3 – the power to conceive and represent decorative and novel imagery

flight of fancy

1 – an idea which shows a lot of imagination but which is not practical

—

The back doors to the helicopter swing open to expose a passenger compartment where a flight RN sits in a jump seat and kicks a metal sled, loaded with medical bags, towards me. The sled slides free of the helicopter and we ease it onto our gurney and strap it down with seat belts. Pushing the gurney across the mostly empty tarmac of the airport my partner and I load it into the ambulance as the two flight RNs jump in the back. I take a seat in the front to help my partner navigate to the trauma center.

The morning rush hour traffic has the freeways reduced to parking lot status and the side roads are only marginally better yet it’s our best bet so it takes both of our attention on a constant vigil – on the lookout for the motorists who forget what to do when sirens come up behind them.

We pull into the Big City trauma hospital and I jump out to back my partner into the closest parking spot next to the door. As I stand behind a backing rig, annoying beeping sound assaulting my ears, the ER attending doc approaches me. We have had a cordial familiarity over the years.

“Why’d they send you guys? The patient is on a vent and five drips!” He knows I can’t transport a patient like this as we don’t have a drip machine or vents and I’m not authorized to transport someone who is likely on medications that are outside of my scope of practice.

“It’s okay,” I smile, “I brought a flight crew of RNs with me.” He looks a little surprised as two crimson jump-suited RNs fling open the back doors to my rig and jump out.

—

The flight crew is getting a history on the patient who’s laying in the trauma bay as my partner and I hang back – we’re pretty much sherpas on this call – we’ll leave all of the patient care to them. While they get up to speed on the patient my partner and I talk to a few of the trauma RNs and police officers that we know.

“So what’s a clean-cut white boy like this this doing in the hood at four in the morning?” It’s somewhat of a rhetorical question and I can’t even ask the question with a straight face. The most obvious answer is that it was a drug deal gone bad. At least that’s what everyone involved is thinking until proven otherwise.

The officer looks tired; I’m thinking he got held over to stay with the victim in case he wakes up and has anything to say. The kid has two chest tubes in him, he’s on a vent with a breathing tube, he’s got milky white paralytics slowly dripping into his veins; he’s not going to wake up for a long time – if he ever does. “We’re not sure what was going on. We just found him in the driver’s seat of a car that had a slow speed crash into a line of parked cars. When we checked on him we saw the GSW to the chest and called you guys.”

—

I’m in the back with the flight crew as we traverse the urban streets back to the airport. My partner is in the front alone and the siren and air horn are singing a duet in an effort to clear the way.

The kid’s blood pressure just bottomed out to 70/46 and his end tidal carbon dioxide level just spiked to 76. The flight crew are scrambling to reduce the paralytics and increase the vaso-constriction – yet not so much that he bleeds out faster. The bullet created a perforation to the esophagus and a tear in the aorta that’s creating a slow leak of blood into the thoracic cavity. The blood from this leak is constantly being suctioned by the two chest tubes attached to active suction. Drugs are pushed into IV tubing, IV pumps are re-set with new values – it’s a delicate balance between sustainable vitals and faster bleed out. The only thing that will fix this kid is the specialized thoracic microvascular surgery found at the university hospital. Even the attending trauma surgeons at our world class trauma center decided to pass on the surgery. This kid is well beyond critical.

When the paralytics were decreased his level of mentation starts to increase along with his blood pressure. He starts to choke on the tube – we call it bucking the tube. His eyes look as though they’re coming into focus. One of the flight crew pulls a preload of sedative out of his jumpsuit, makes a quick calculation in his head, wastes some of the sedative so that it’s proportioned to the patient’s weight, and injects it into an IV port. Ten seconds later the patient is back in his comatose state and his blood pressure is at a good level for the next phase of transport. Another unit of whole blood is pulled from the biohazard cooler and added to the many lines of tubing that are keeping this kid alive.

Driving across the tarmac we pass the parked airplanes and helicopters. It’s still early in the morning and there’s not a lot of action on this lazy midweek day in the quiet corner of the airport. We see the crimson helicopter with the pilot doing a pre-flight walk around as he opens the back doors to accept our patient.

After loading the patient into the helicopter one of the RNs is thanking us for the ride. “Hey, do me a favor, stick around until we get in the air. You know, just in case he codes… Thanks.”

—

BIG CITY, USA — It’s been an especially violent week in Big City. Police are investigating a string of shootings in different parts of the city, believed to be unrelated.

Unfortunately, gun violence is nothing new in Big City, but there has been an increase over the last couple of days and officers are doing everything they can to keep up. Big City police are stretched thin as they investigate five separate shootings in just 12 hours.

“It’s been a busy week. I think we had at least three homicides last week and then one… I know at least one working today,” said Big City Officer Jason Smith.

One shooting happened Thursday morning at First and Union streets as a high school student was riding his bike to school. He was shot by someone who was also on a bike. Crime technicians were delayed two hours getting to the scene.

“There were two other callouts this morning so that’s where we’re at,” said Smith.

One of those earlier calls took police to Lake Street near 23rd, just a few miles away. That’s where a man with a gunshot wound was found inside a crashed car.

“It has been busy. We’re doing the best we can with what we got and we handle each case. And ultimately our goal is to solve every case we get,” said Smith.

Three shootings happened on Thursday and two happened Wednesday night. It’s violence that doesn’t go unnoticed.

“It’s been a little intense here in Big City for the past couple nights,” said Jose Martinez.

Martinez works with youth at the Sojourner Center for Human Rights.

“We work directly with those young people who are involved to try to figure out what’s happening here and how we can create lasting peace,” said Martinez.

He says it will be the community coming together to create lasting change.

“What’s happening here doesn’t have to be and there’s a better way to solve our problems,” said Martinez.

He also says a bullet never solved any problem.

“Medic-40, delta level response for a seventeen-delta-three, fall-not alert, switch to fire control three.”

“Uhh, Medic-40 copy.” What the hell is a seventeen-delta-three and how do I switch to fire control three?

Having finally found the siren and switched to the proper response frequency we are following the line on the computer in hopes of finding the call location. Rolling through traffic I see the familiar landmarks and denizens of the hood hanging on their normal corners. It’s somehow comforting to feel a connection with the hood on a day that seems so different in every other aspect.

Pulling up to the corner I see my neighbor, Darren, the lieutenant on the fire crew that beat us to the scene by only thirty seconds. Sitting on the stairs in front of him is Chauntel, a frequent flyer that I recognize from just last week, and her husband standing next to her holding a huge purse.

“Hey Darren, what’s going on?” The rest of the firefighters on Darren’s crew have bailed on taking care of the patient and are poking around my ambulance to admire the equipment and new ambulance smell.

“You know Chauntel right? Looks like she took too many of her Vicodin and wasn’t able to keep her feet under her while walking down the stairs. She’s not altered or anything, just feeling a little dizzy and complaining of knee pain.”

“Cool, I got it.” I kneel down to look at Chauntel as Darren joins his crew in opening cabinets on my rig. “Hi Chauntel, am I taking you to the hospital today or are you okay to go home?”

“I best go to the hospital, you know, jus to get checked out. I don’t think my Vicodins are work’n too well cuz I still got the pain in my knee.”

I help Chauntel onto the gurney and raise it up with the push of a button. Power gurneys; finally a career-extending piece of equipment.

As my partner drives us to the hospital I continue with my assessment of Chauntel.

“How bad is the pain in your knee?”

“It’s a ten outta ten! An’ it feels sharp!” Awesome, she knows our pain scale without having to be prompted.

“Do you want some Morphine for the pain Chauntel?”

“Na, I can’t have Morphine, I allergic to it! You got any Dilaudid?” Classic!

“Chauntel, you know I don’t carry Dilaudid. And when did you become allergic to Morphine? You weren’t allergic to it last week.”

“Well, I is now!” I’m not one to judge her pain level, or her, but the drug seeking mentality is fairly transparent to us at this point. I guess some things never change.

“How do you like the new uniforms Chauntel? Did you notice the shirt’s a different color?” Just making small talk as there’s not really that much to treat on this call.

“Oh, is those new? Now you mention it you got some pretty eyes. Is you married?” Seriously, that’s what you notice. Bloody hell with the eyes again!

“Yeah Chauntel, I’m married, and so are you. As a matter of fact your husband is sitting in the front seat.”

In a conspiratorial, quiet voice. “Well, he ain’t really my husband, I jus’ call him that. You mind if I take a nap on the way? I feeling kinda tired.”

“Go ahead Chauntel, we’ll be there in about ten minutes.” I switch to the captain’s chair to try to figure out how to use the new computer.

—

Now you put water into a cup, it becomes the cup. You put water into a bottle, it becomes the bottle. You put water into a teapot, and it becomes the teapot. Now water can flow or it can crash! Be water, my friend.

Bruce Lee, TAO of Jeet Kune Do

re·flec·tion

1  :  an image, representation, counterpart

2  :  the act of reflecting or the state of being reflected

3  :  mental concentration; careful consideration – a thought or opinion resulting from such consideration

—

“The pessimist resembles a man who observes with fear and sadness that his wall calendar, from which he daily tears a sheet, grows thinner with each passing day. On the other hand, the person who attacks the problems of life actively is like a man who removes each successive leaf from his calendar and files it neatly and carefully away with its predecessors, after first having jotted down a few diary notes on the back. He can reflect with pride and joy on all the richness set down in these notes, on all the life he has already lived to the fullest. What will it matter to him if he notices that he is growing old? Has he any reason to envy the young people whom he sees, or wax nostalgic over his own lost youth? What reasons has he to envy a young person? For the possibilities that a young person has, the future which is in store for him? 

No, thank you,’ he will think. ‘Instead of possibilities, I have realities in my past, not only the reality of work done and of love loved, but of sufferings bravely suffered. These sufferings are even the things of which I am most proud, although these are things which cannot inspire envy.’ “ 

Viktor E. Frankl – Man’s Search for Meaning

—

With the top down and cool wind in my hair I accelerate on the freeway onramp to get up to speed and head for home on my last day with the company. But not my last day in the county…

It’s an emotional day, to say the least, and I have time to reflect upon the years as I navigate through the darkness to the normalcy that I call home.  Ultimately, I have an optimistic view of the future and that optimism has its origins in the accomplishments of the past. There’s a lot to be proud of in the work that my tribe of EMTs and Paramedics have done in this county. Through incredible adversity we have advanced street medicine to a finely honed machine. Though the machine sometimes throws a cog we always find a way around it to accomplish the tasks at hand. We have had outstanding leaders at the helm as well as the occasional drunken captain, but in the field we have always pulled together to bring the best possible care to our patients.

My mostly urban county has taken a toll on us yet it has given us so much more than is easy to recount in a single telling. The high call volume gives us a variety of experiences early in our careers. Those that survive the first few years have the mark of a battle hardened soldier on their foreheads. We may bear a few more worry lines and some new gray hairs, but we can also boast of relationships, forged in the trenches, that will last a lifetime. Some of those comrades will ship out tomorrow to take our flavor of street medicine to other counties. I wonder how they will be received when they finally reach their destination. Will they look back with fondness to the mostly urban county of our origin? Will they see themselves as finally having escaped the chaos? Maybe they will be ostracized in their new system and find that coming home is the only tolerable option – it’s happened already and we haven’t even started the transition.

—

The freeway takes me into the outskirts of the county and closer to home – I’m just one car in a constant stream of headlights and tail lights blurring into streaks reflected in the glass buildings in the empty office parks. As the economy fell the new buildings became empty and now stand as hollow glass blocks, devoid of occupancy; a sea of monuments showing us the economic reality that we all tried to deny until it was too late. In a real estate parody of the Occupy movement they stand idle, refusing to leave, yet their message is lost in obscurity.