Paramedic

by Peter Canning

  Meg gives me a warm good morning, then tells me to check out the rig, while she gets us radios. The ambulance is a van type, smaller than the large box ambulances favored by most volunteer corps, who carry crews of up to four people. The van ambulance is built for twenty-four-hour, seven-day-a-week abuse. In the back there is room for a stretcher tight against one wall, and a bench seat against the other with about a foot of room in between. At the head of the stretcher is another seat where a rider can sit, facing the patient’s head. It is the preferred seat to manage a patient’s breathing. Under the bench seat are two longboards for spinal immobilization, a metal scoop stretcher that comes apart in the middle and is used to fit under somebody who needs to be lifted up but doesn’t need spinal immobilization, a traction splint for isolated femur fractures, a Kendrick Extrication Device (KED) to help stabilize the spine of someone trapped in a car, a urinal, and a bedpan. By the back door on the stretcher side is the collapsible stair chair for carrying patients down from the second, third, and hopefully not much above the fourth floor, and a wooden short board. The cabinets on the stretcher wall are filled with linen, cervical collars, IV supplies, trauma dressings, bandages, oxygen masks, and cannulas (a plastic tube with two prongs that fit under the patient’s nose to give them a richer oxygen to breathe than what exists in room air). At the head is the oxygen outlet and in-house suction unit. By the side door is a rack that holds the cardiac monitor, the pediatric box, and three spare portable oxygen cylinders. The portable suction is on the inside of the door. It is used to clear mucus, blood, or vomit from a patient’s mouth and throat. The cabinet between the back and the driver’s compartment holds the military antishock trouser (MAST) pants, a spare advanced life support (ALS) supply box, and run forms, on which we document our treatment of each patient. The main gear we take into the house in addition to the monitor includes the blue in-house bag, the airway kit, and the biotech.

  The in-house bag has a portable oxygen cylinder, airway supplies, blood pressure (BP) cuff, obstetrics (OB) kit, burn sheets, trauma dressings, ammonia inhalants, and spare run forms. The airway kit holds the laryngoscope, and the various sized and shaped metal blades that attach to the handle. The blades have tiny lightbulbs on the end that illuminate the patient’s throat as you search for the vocal cords through which you will pass a clear plastic endotracheal tube that again comes in various sizes—from a tube for the tiniest baby to the Andre-the-Giant-sized ten tube. The biotech is a hard black suitcase that holds the emergency drugs and IV supplies, except for morphine and Valium, which are kept above the monitor shelf in a lockbox. The heart monitor displays the patient’s electrocardiogram (EKG) on a small two-inch screen when attached to the patient through three wire leads—the white lead on the upper right chest, the black lead on the upper left, and the red on the lower left side. “White is right, smoke over fire,” I say to myself to keep the order straight. The monitor also has detachable paddles, which when applied to the patient’s chest and activated can deliver an electric shock of up to 360 joules (Js) to a patient’s fibrillating heart in hopes of stopping it cold, so it can hopefully restart by itself with its normal rhythm. The newer models have hands-off pads that can be applied to the chest, one on the right sternum, the other on the left apex, so the shock can be delivered without having to be in such close contact with the person.

  “Ready?” Meg says, coming back and handing me the company portable radio as she clips to her belt the portable that connects us to the Hartford police dispatch and to CMED, an operator who can connect us to local hospital emergency departments.

  “Yeah, I guess.”

  With my stethoscope around my neck and a pair of trauma shears sticking out of my back pocket, I climb in the passenger seat.

  “Nervous?” Meg says as we head into Hartford.

  “Yeah, a little,” I say.

  “Good, you should be.”

  I look at her.

  “Just kidding,” she says. “You’ll do fine, I’m sure.”

  Easy for you to say, I think.

  Shootings and Stabbings

  We get a call for “shootings and stabbings” at the High Street Liquor store. We have three priorities. Priority one means imminent life-threatening, full lights and sirens, and pedal to the metal. Priority two is possible life or serious health threat, use lights and sirens, and get there expeditiously. Priority three is no lights, no sirens, obey all traffic signals, and if your radio dispatches you while you are in the rest room, go ahead and finish your business. This call—“shootings and stabbings”—is a priority one.

  As we race down Albany Avenue, Meg gets on the radio with the Hartford Police Department (HPD). “Is it shootings or stabbings?” she asks.

  “I don’t know,” the dispatcher says. “It came in as shootings and stabbings. We have officers responding to the scene.”

  I put on my latex gloves. It is not too cool to put on your gloves until you get to a scene, but I want to be prepared for “shootings and stabbings.” I have only done one shooting and one stabbing before and never both together. The shooting was in 1993 when I was doing my internship in Bridgeport. There we found a woman in the backyard holding two Dobermans by their choke collars. The dogs had barked and slowly dragged the woman across the yard toward the back porch where the shooting victim was. The cops hadn’t arrived. Mike MaGoveny, a former noseguard who had had NFL tryouts, and I ran into the yard and found a young man leaning against the back door by a set of open basement stairs, shot in the thigh and unable to move.

  “The shooter’s down the steps!” a neighbor shouted.

  We looked down the dark stairway, then at the barking Dobermans who were slavering at the mouth as they dragged their handler closer toward us. It was a Commander McBragg moment. (McBragg was one of my favorite Saturday-morning cartoon characters who used to say, “There I was, lion in front of me, rhino to the right, a band of savages to the rear …”) Mike and I picked up the kid, each grabbing a leg and a shoulder, and ran for the gate. We set him down on the stretcher, and lifted him into the back, and slammed the doors. The dogs broke loose and ran at us. The ambulance lurched forward as Mike floored it. When we got out at the hospital, I checked the door handles for Doberman jaws.

  The stabbing was in Hartford during my paramedic class ride time. We found a guy who had been slashed vertically up the throat—probably with a razor, exposing but not cutting an artery. “He done fell against the dresser,” his girlfriend claimed. The others in the room nodded quickly in agreement. “That’s right, he fell against the dresser.” Though he bled a great deal, it was not a life-threatening wound. On that hot summer night we carried him down three flights of stairs and out into a crowd on the street that numbered close to two hundred, drawn by the red lights. It was like being in a Hollywood movie with Public Enemy blaring on the soundtrack.

  I am sure the scene ahead will be like nothing I have seen. I picture bodies and bloody carnage. Surely a lead story for the six o’clock news, maybe even Dan Rather, the cover of Newsweek, an urban massacre that I will be right in the middle of—a horror story to share for years.

  Another ambulance arrives simultaneously with us. In front of the store, I see a police officer putting a handcuffed man in the backseat of his cruiser.

  “False report,” another officer says to us when we get out. “The guy’s girlfriend’s not feeling well, so he made up a story to get an ambulance here quicker.”

  I feel both relief and letdown. I want action, but I also fear it.

  Just then I notice a tall impassive woman in a soiled light blue snow jacket standing against the side of the building. She is holding her side.

  “Are you okay?” I ask.

  “My side hurts when I breathe,” she says quietly.

  I inspect, half expecting a stab wound, but see none.

  “I’ve been sick for a while,” she says. “I need to get warm.”

  Her lungs are junky, and she says she’s been coughing up brown phlegm most
of the winter.

  “You want to go to the hospital?” I ask.

  She nods. This will be a priority three.

  As we walk to the ambulance, I see her boyfriend press his face against the window of the cruiser. He bangs against the glass. She never once turns to look at him.

  For me it is a lesson in the unexpected, the quiet drama of the streets.

  Lessons

  Tom Harper, my preceptor, is a tall, blond-haired, strongly built young man who works construction, building decks, roofing, and fixing farm equipment on his days off. For the next month, he will be training and evaluating me. If he recommends me for medical control to function as a paramedic on my own, Debbie Haliscak, the EMS coordinator for Saint Francis Hospital, will ride with us for a day, observing me. She will have the final say as to whether her hospital will grant me control. Because a paramedic is an extension of a physician, the hospital is liable for my performance. Granting control is not taken lightly. Not everyone who passes a paramedic course is chosen to precept, and not everyone who precepts makes it. I believe that I will, but inside is the fear I might not. My friends all assure me that I am smart and will be great at it. What they don’t understand is that just because I have a college degree doesn’t mean I can get an IV in the arm of a trapped dying man while lying under a car in a rainy ditch on a dark night. It doesn’t mean I won’t puke when I should be suctioning the airway of an eighty-year-old woman who can’t breathe because of the pulmonary edema flooding her lungs as her heart is backing up. And it doesn’t translate into how well I will be able to deal with a three-hundred-pound man having a massive heart attack on the third floor of a walk-up while his pit bull is growling at me. Many of them think this job, while interesting, is a huge step down for me. They can’t imagine that a twenty-two-year-old without a degree can do this better than someone like me. In my time riding on ambulances throughout the state, I have met many paramedics without the educational background I’ve had, who are crackerjacks, who are artists of this profession.

  Tom is a paramedic, respected by doctors and his peers for his knowledge of prehospital medicine, his assessment and practical skills, and his ability to use his head instead of just following a cookbook response to each patient. He’s put breathing tubes down the tracheas of young men with gunshot wounds to the head and had them in the trauma room within minutes of their shooting. He’s bent forceps pulling obstructions out of the throats of blue infants and breathed pink life back into them. He’s used defibrillation, epinephrine, lidocaine, and bretylium to bring people in cardiac arrest back from the dead to return home to their families. He’s been spit on and assaulted by patients and bystanders and stuck with contaminated needles. He is twenty-five years old and has only a high school diploma and his paramedic certificate. Though he is more than a decade younger, and at six three, is five inches shorter than I am, I hold him in high regard. His hero is Wyatt Earp, and in my book, he does justice to him.

  Tom teaches me to be a blank slate. “Don’t assume anything,” he tells me. “Just because the call comes in for a diabetic, doesn’t mean it’s not a stroke victim. If it comes in as not feeling well, it could be a stabbing. It could be anything. You need to do a complete physical assessment; rule out as you go along. Don’t assume anything. Don’t tunnel. Do your assessments. Don’t get caught with your pants down.”

  He tells me of a paramedic called for a “psych” patient, who had alcohol on his breath, and kept muttering, “They’re coming after me, they’re coming after me.” The paramedic took him into the hospital, where the triage nurse put him in a wheelchair in the waiting room. Ten minutes later the man fell out of his chair, dead. They pulled his jacket back and discovered he had been shot twice. “They” had already come for him.

  I know about the need for a thorough assessment, though it never hurts to be reminded. Back when I was first an EMT in Massachusetts I once did a call for a woman with back pain. We arrived at a posh house in Longmeadow where a cocktail party was underway. The hostess, who held a wineglass in her hand, led us into a bedroom where an elderly woman lay on a four-poster writhing in pain. “It’s Granny’s back,” the woman told me. “She just can’t bear the pain anymore. Her doctor wants her to be seen in the Emergency Room.” We get the medical information from the woman, while other relatives, all holding cocktails, go in and out of the room, lovey-dovey, wishing Granny well. Granny’s teeth are clenched and she is muttering as if she would take a chunk out of somebody if only she could bring her teeth apart.

  We move her onto our stretcher by rolling her sheet up and lifting her on it. She is making angry sounds like a revving car engine.

  “Don’t worry, Granny. The doctors will have something to take the edge off it for you,” a man says, leaning to give her a kiss. “We’ll save you some pie.”

  “Her poor back,” a woman says. “It’s always bothered her, but never this much.”

  En route to the hospital, I am writing my report as I watch Granny moan. I have tried to make her as comfortable as possible, but there is little I can do for her. Right before I call the hospital on the C-Med radio to tell them I am bringing in an old woman with back pain, I ask her, “Just where in your back is the pain located?” I am uncertain if she is even competent to answer.

  She looks at me with fire in her eyes, and mutters angrily through clenched teeth.

  “What’s that?” I say, leaning over so my ear is within inches of her mouth.

  “It’s not my back; it’s my fucking leg!” she says. You moron.

  Tom and I are called for a chest pain. The forty-one-year-old man sitting on the couch looks terrible. He is an obese man whose bottom sinks deep into the couch. He is supporting his head with his hand. He has yellow eyes and his skin is warm.

  “Are you having chest pain?” I ask.

  He nods.

  “On a scale of one to ten with ten being the worst pain you’ve ever had, how bad is it?”

  “A ten,” he says.

  His family says he was treated at Saint Francis yesterday for chest pain, but he is worse today. He has a history of diabetes, hypertension, and congestive heart failure. His blood pressure is okay, 130/80. So is his pulse of 80, but when I put him on the heart monitor, he is in atrial flutter, a rare rhythm that can cause severe symptoms. I put him on an oxygen nonrebreather mask, a face mask with an attached reservoir bag that fills with 100 percent oxygen. A flapper valve on the mask prevents the patient from rebreathing his expired air.

  “What does the pain feel like?” I ask. “Is it stabbing?”

  He nods.

  “Does it go to the left?”

  “It goes left,” he says.

  I look at Tom as if to say I think he is having the big one. Tom looks at me with an amused expression.

  We are only a few minutes from the hospital. I try to get an IV en route. I apply a tourniquet to the arm, which slows the return of blood to the heart and causes the veins in the arm to swell and become more visible. I take out a twenty gauge catheter. The needle is inside the plastic catheter. At the end of the needle is a clear chamber that collects the blood flashback to let you know you are in the vein. To do an IV you pick your spot, wipe it with an alcohol prep, then holding the arm with one hand to stabilize the vein and holding the needle between thumb and first two fingers, you make your move. They tell you in the books to go in at a forty-five-degree angle, but when I go in I go in much lower, particularly for hand veins that are right on the surface. Sometimes you feel a pop when hitting the vein. I try to go in quick and firm. I look down at the chamber and hopefully see the blood filling. I advance the catheter over the needle till just the hub is sticking out of the skin, and the one and one-quarter inch of plastic is secure in the vein. I withdraw the needle and hopefully drop it in the sharps box, because with many of the patients we care for an open contaminated needle is now a deadly weapon. A single puncture can give someone AIDS or hepatitis. Sometimes I drop it on the floor and have to remember to find it a
nd pick it up later.

  After taking the needle out I press off the vein with my fingers to prevent blood from flowing out of the catheter hub, while I screw on a vacutainer—a yellow plastic device—through which I will draw four small tubes of blood. The tubes have a rubber seal that is punctured by the needle in the vacutainer. Sometimes, if the vein is small, the vein will close down, and I won’t be able to get bloods, or if the pressure is low, no blood will flow. I release the tourniquet after the last tube is drawn, then clamp off the vein again and either insert a saline lock, which has a medication port on it, or stick in the IV line, which is also attached to a bag of IV fluid. With the lock, I flush the line with five cubic centimeters of saline in a syringe. With an IV bag, I open up the clamp on the line and watch it run. If the line is blown, it either won’t flush or run, or there will be infiltration. A large water mound will start to appear under the skin.

  Now I am ready to stick this man with chest pain. I go at a vein in his forearm. I get a flash in the chamber to show I’ve stuck the vein, but almost instantly I see a purple hematoma growing under the skin. I have gone right through the vein and out the other side causing the vein to bleed into the tissues. I quickly pull out the needle, put a four- by four-inch bandage on the wound and tightly wrap it with tape. I try again on the other arm with the same result. We arrive at the hospital without a line in place. Bad form. And a bad start to my precepting.

  I have called ahead to tell them what to expect, but when the three nurses waiting for us see the man, they say, “Oh, it’s Marvin,” and I can tell they are not too concerned, though they listen to my report politely. “A flutter is his regular rhythm,” one says.