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and I’m probably going too, for laughing at this.

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From reading a few blog comments and e-mails, it has come to my attention that I am an ignorant, insensitive, jaded, callous lout, altogether poorly educated on the subject of chronic pain.

*sob*

You people are damaging my self esteem. I may need counseling. In fact, the horror of the psychological damage you have inflicted upon me with these unwarranted attacks may preclude me from living a productive life ever again, and indeed, may render me a psychological invalid.

I need a Xanax and an application for Social Security Disability, STAT. While you’re at it, call me a waaaaaambulance and take me to the ER, because oh, the humanity!

I am neither callous, nor jaded. Neither am I uneducated or ignorant, or intolerant of the views of others. (Wipe the spittle off your monitor before reading this, BlackHawk. In the IQ Derby, you will always finish out of the money if I am in the field).

I offer this as proof of my overall sunny personality and compassion for my fellow man. I cried when Old Yeller died. I even dig the occasional – gasp – chick flick. I like puppies, long walks on the beach, sunsets and children.

I’m also a firm believer in adequate pain management. A good friend will be delivering a pain-management lecture at the Texas EMS Conference this fall, advocating far more aggressive pain management than most EMTs currently practice. I contributed in small part to the development of that lecture.

Lest you think I know not whereof I speak, I’ll share a couple of personal details with you.

I used to have these symptoms. I’m not the only one. Turns out, my problem wasn’t chronic fatigue syndrome, it was sleep apnea. But before I was diagnosed, I knew all about chronic headaches, muscle pain, severe fatigue and walking around all day in a mental fog.

Hell, I fell asleep at red lights, people. I used to arrive at work, and have absolutely no recollection how I got there.

Luckily, I discovered the source of my problems, and got effective treatment. I’m no longer a menace to the highways, despite the opinions of the legally sanctioned extortionists at the Woodworth, LA Police Department.

I also have a condition known as meralgia paresthetica. Imagine having the lateral aspect of your left thigh feel numb, yet also feel as if someone has scrubbed it with a wire barbecue brush, then doused it with kerosene. Then set it aflame. Maybe tried to beat out the flames with a Louisville slugger wrapped in barbed wire. Want to start a fight with me? Just slap me on the left thigh. If you want to win the fight, all you need do is just lightly brush that area with your fingertips.

This condition was caused by my big fat gut pressing on my lateral femoral cutaneous nerve. There are things you can do to help alleviate the symptoms, like avoiding restrictive clothing and tight belts, and doing more sitting than standing.

I work on my feet all day long. When I worked full time on the rig, I wore a Batman utility belt with various EMS accoutrements, and they held up those oh-so-soft EMS cargo pants we wear. Pain is as much a part of my daily landscape as shaving in the morning.

Now you can imagine my daily life. I tell you this not to arouse sympathy, but to give you some perspective on my stated opinions. I’m lucky, in that my two maladies were easily identifiable and treatable: wear a CPAP machine, and lose weight.

I don’t go to the ER to seek help for these conditions, because they are not emergencies. They are chronic medical problems, just like fibromyalgia and chronic fatigue syndrome are chronic medical problems.

If you have fibromyalgia or chronic fatigue syndrome, you have my sympathies.

If you insist on using EMS or the Emergency Department as the primary means of treating those maladies, you have my everlasting scorn and disrespect. If YOU want sympathy, you will find it somewhere between Shit and Syphilis in the dictionary.

For every patient who truly has chronic fatigue syndrome or fibromyalgia, there are twenty others who have either self-diagnosed or been handed the diagnosis by a compliant doctor as a panacea for constant whining.

For every child truly afflicted with ADHD, there are twenty others on Ritalin and Strattera who actually suffer from Chronic Hickory Deficiency.

I propose a new syndrome for addition to the ICD-9-CM, or perhaps the DSM IV, one much easier to prove or disprove than fibromyalgia or chronic fatigue syndrome. I think I’ll call it COWMAS: Chronic Oxygen-Wasting Malingering Asshole Syndrome. It has a certain ring, don’t you think?

On my Emergency Department nursing assessment form, the blocks for drug allergies and the pain scale come well before the block for past medical history.

If I have written Toradol, Tylenol, Ultram, Ibuprofen, Aspirin in the Allergies section and entered a 10 on the Pain Scale, 90% of the time I know what I’m going to be writing next in the Medical History section: fibromyalgia.

That’s just the way it is.

Some people got my point in the previous posts. Others didn’t. Some of the private e-mails I got did nothing but reinforce the drama queen stereotype.

So I’ll say this before I immolate the corpse of this dead, battered horse and scatter the ashes:

If you suffer from chronic fatigue syndrome or fibromyalgia, your efforts would be better served by writing an open letter to your fellow sufferers rather than whining on my blog about my insensitivity. I’ll even get you started with a title:

Fibromyalgia vs Chronic Oxygen-Wasting Malingering Asshole Syndrome: The Differential Diagnosis

If you go the to ER once a month or more for your symptoms, it ain’t fibromyalgia.

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Normally in these situations I’m tempted to tell someone to pull up their big girl panties and deal with it, or accuse them of being humor-impaired, but in this case I’ll refrain from calling a waaaambulance and address the offended party with tact and reason.

Yeah, I know. Not my strong suits.

Tbeck was somewhat offended by my post making fun of fibromyalgia:

I know an LPN that has the condition. My WIFE also has the condition. There is no doubt in their minds that it is real. Like others, she manages to live a fairly normal life with OTC medication as her primary source of pain mitigation. She is not a junkie and has worked hard not to become one. The temptation to go with something stronger is tremendous but she resists it because she has seen where that road will inevitably lead.

Anecdote does not equal evidence. Their certainty of the diagnosis simply amounts to two opinions. Now keep in mind, I’m not discounting their opinions, but that’s all they are. For that matter, the physician who diagnosed them with fibromyalgia is also offering an opinion disguised as a diagnosis.

The problem is, fibromylagia and other nebulous disorders such as chronic fatigue syndrome are diagnoses of exclusion – conclusions reached in the absence of any reliable evidence pointing to another identifiable disorder. In layman’s terms, it means “I can’t find anything wrong with you but your symptoms seem real enough so we’ll make up a name to call it.”

Your post was uncalled for. It’s hard enough to get a good diagnosis without the doctor’s own preconceptions and stereotypes getting in the way. The doctor rolling his eyes is the problem, not the solution.

No, the person coming in to the ER or calling an ambulance at 3 am for their fibromyalgia symptoms is the problem. Even accepting your premise that fibromyalgia is a legitimate disorder, coming to the ER seeking narcotics is neither appropriate management of the symptoms nor appropriate utilization of emergency services. My post was poking fun at the people who abuse emergency services using fibromylagia as their excuse, not at any specific person or disease process. Perhaps the distinction was lost on you.

Most people who come to the ER with fibromyalgia complaints exhibit none of the signs of being in pain. While I know that pain is subjective, physical discomfort produces certain physiological responses. Your adrenal glands secrete catecholamines (epinephrine, norepinehrine and the like) which activate your fight-or-flight response. Pupils dilate, heart rate, breathing and blood pressure all elevate. You sweat. You get anxious, fidgety and restless. You may even get a little queasy.

All of these things can be physically observed. But when someone tells me they have fibromyalgia and rates their pain as a 10, all while chatting calmly on their cell phone with a blood pressure of 110/70 and a heart rate of 64, and they just happen to be allergic to Tylenol, Motrin, Toradol, Ultram, Naprosyn and aspirin, I reserve the right to call bullshit. Any medical provider with a functioning synapse would do the same.

Interestingly enough, all of those symptoms I mentioned also scream “narcotics withdrawal.” Guess what? If there is any doubt in my mind, I give the pain meds. I’ll give sedatives to the withdrawal patients, too. Withdrawal is unpleasant. Heck, I give so many analgesics compared to my EMS co-workers that I’ve been called The Candy Man. If you read some of my old posts, you’ll find that I’m a strong proponent of aggressive pain management.

In any case, I applaud your wife’s ability to manage her symptoms without narcotics or frequent ER visits. If she’s not already doing it, tell her that regular physical exercise also appears to alleviate the symptoms dramatically. Whether there is a physiological reason for this, or whether the relief is purely psychosomatic from endorphin release, has yet to be established. In any case, the people I know who claim to have fibromyalgia swear by regular exercise.

Telling someone who cannot get a good night’s sleep and lives with chronic pain that “it’s all in their head” is right up there with ridiculing the germ theory of disease because you can’t see the critters with a naked eye.

Specious argument, Tbeck. The fact is, medical science has found NO causation for fibromyalgia. No one knows what causes it. No one knows what cures it. It’s a set of symptoms desperately searching for a disease.

And the ugly truth is, it actually may be all in their heads. Don’t be so quick to discount a psychiatric cause. Saying so doesn’t make the sufferer crazy, and should bear no stigma. It doesn’t even mean their symptoms aren’t real. It just means there is no identifiable physical cause for the disorder.

Frankly, until there is legitimate scientific study that discovers a causative relationship between fibromyalgia and an identifiable, measurable factor, we will neither have an accurate diagnostic test for it, nor a viable treatment.

Until that day, it remains the province of charlatans and shamans, and lazy doctors all too willing to give you a catchall diagnosis as a panacea for your problems. What masquerades as “proof” of fibromyalgia is merely a collection of junk science, anecdote and questionable testimonials. People who advertise “cures” for fibromyalgia are unconscionable snake oil salesmen preying on the gullible.

Using your analogy, the current “research” supporting the existence of fibromyalgia is the 21st century equivalent of belief in the homunculus.

Anyhoo, thanks for your comments and your readership. When or if the day comes that science actually legitimizes fibromyalgia, I look forward to continuing the debate with you here and eating my words.

If that happens, bring some Tabasco, would ya? I hate bland words.

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There are few things more dismal than an ICU waiting room. People gather in familial clusters, keeping vigil against the specter of death. Books and blankets abound, snacks and cups of stale coffee cluster on tastefully appointed end tables, and the soon-to-be bereaved seek to mask their uncertainty and seek diversion in months-old editions of news magazines. Huddled together for support and security, they share the fear among them, as if spreading it around lightens the collective burden.

But there is always enough fear to go around.

And here I sit in an ICU waiting room, keeping my own vigil. Privacy is something I can only wish for, even here. Some of these familial clusters I have met before, in different circumstances; living rooms, bedrooms, breakfast nooks. Their fear was more visceral, more raw then, not the kind of settled-in dread they’re feeling now. Some of them come over to say hello, perhaps to thank me, only to realize I’m here for my own personal reasons, and so they beat an embarrassed retreat back to their own clans. Others keep their distance, looking at me with accusing eyes.

I sit here surrounded by the members of my family, alone yet not allowed the comfort of solitude. I am not one of these people any more. I divorced myself from them long ago. My sisters are here, and their families. My oldest sister is sobbing piteously, a crying jag that has lasted for three solid days. Sometimes it seems as if she has been crying for most of her forty-four years. She has always been ruled by her emotions. My father is here as well, looking forlorn and feeble. He sits there next to my aunt, lost in his own private Hell. His hands sit limply in his lap, trembling with Parkinson’s disease.

Inattention tremor, my education and training tells me. Inattention tremor, bradykinesia and hypophonia, all caused by loss of dopamine-producing cells in the substantia nigra. Replacement therapy with Sinemet or similar drugs will only slow the progress, not cure the disease. Eventually, he’ll become bed bound and rigid, and the disease will settle a blank mask over his features.

A different part of my brain tells me that he’s not there yet, because the fear on his face is palpable. He’s wondering what he’ll do once Mom is gone. That part of my brain is wondering where my Daddy went, the Daddy of my childhood, the Daddy that used to quiet my fears. That man isn’t here any more, either.

I want to go to Dad, to comfort him in some way, but doing so would only bring on more crying, more unwelcome histrionics from my sisters. I want to get Dad out of here, if only for a little while, but that will have to wait until Terry gets here, if he indeed gets here in time.

My mother is dying.

My mother has been dying for thirty years, if you listen to her talk. Throughout my childhood, it was her children who were killing her. Occasionally, it was her grouchy husband. Other times, it was life in general. Mom was an extraordinarily persecuted woman. She was, among other things, a Professional Martyr.

But this time it’s for real. My sister Sheri had called me a month ago, breaking the news. At the time I had chalked it up to Sheri being Sheri. Like I said, she has always been ruled by her emotions. Genetic traits in my family are strengthened with each successive generation, not diluted. In the case of fucked up X chromosomes, my oldest sister rolled snake eyes in the DNA craps game. Every bad trait of Mom’s, she inherited in spades. Mom was worse than Grandma.

I suppose we should be thankful Sheri has birthed only boys. A daughter would be too frightening to contemplate.

But a second call from Sheri three days ago made it real. Aside from being an unwelcome second phone call in a one-year span, it also bore the unsettling news that Mom had been admitted to the ICU.

Okay, so apparently a doctor also thinks Mom is sick. Sick enough to need intensive care.

I walked into the ICU maybe 12 hours after Mom had been admitted following her lung biopsy. The Missus and I walked right past the waiting room, avoiding my family gathered there. I knew the security code to get into the ICU, so I let myself in even though it wasn’t normal visiting hours.

“Well hello there, AD!” one nurse greeted us cheerily. No one even questioned my presence there, despite the fact that I was not in my uniform. Several nurses asked about upcoming ACLS classes. Everyone was perky and cheerful.

“Actually, I’m here to see about my mother,” I told them. “She’s in Bed Six.”

“Oh. I’m…I’m sorry. I didn’t connect the names,” the charge nurse stammered, embarrassed. No one else said anything, and an awkward silence followed.

“Can we go in and see her?” I asked politely. “I know it isn’t visiting hours…”

“No, go right in,” the nurse interrupted. “I was just going to bring her a popsicle, but I’ve got some charting to do here…you can just bring it to her yourself. Take all the time you need.”

If it can make an ICU nurse somber and solicitous, it’s bad.

“Well, look who’s here!” Mom greeted me with a grin. “My prodigal son and my favorite daughter-in-law! How long has it been since I’ve seen or talked to you, five years?” Despite the hearty greeting, her voice was harsh and strained, muffled by the oxygen mask.

More like three years, Mom.

“How ya’ doing, Mom?” I asked softly, pulling a chair next to her bed. I stole a glance at the telemetry monitor mounted above her bed.

Atrial fibrillation. Since when did she have atrial fib? Pulse oximetry is only 84%, despite the non-rebreather mask. BP only 90/50.

“I’m dying,” she said matter-of-factly. “I won’t make it out of this hospital. You kids have finally killed me.” The last sentence delivered with a wink and a grin.

“Want something cool to wet your whistle, Mom?” The Missus asked tenderly, sitting beside her on the bed and unwrapping the popsicle. Mom nodded weakly and The Missus gently slid the mask up onto her forehead and fed her tiny bites of the popsicle.

She leaned close to Mom, winked mischievously and whispered, “Remember the first time I ever saw you eat a popsicle?”

Mom’s eye snapped open wide and she chuckled. The laughs began as the big, rolling belly laugh that I knew so well, and ended with painful, wracking spasms of wet coughing. A suction unit gurgled quietly in the background, and I could see a chest tube draining bloody pus into a collection chamber.

I remember that day. It was maybe thirty minutes after you met her for the very first time. She was the first, and only, girlfriend I had ever allowed to meet my parents, and then only because she insisted that my parents be a part of our wedding. In ten minutes you were cackling like old girlfriends, and then you proceeded to show The Missus how a wife pleasures her husband, using a popsicle to demonstrate. The Missus had been shocked at first, then you both dissolved in a fit of giggles. She told me later that now she knew where I had inherited my sense of decorum and my internal censor.

“I won’t be doing that any more, I’m afraid,” Mom had answered hoarsely after the coughing fit had passed. “I’m too old for that, anyway.”

“What did the doctor say, Mom?” I pressed. “Sheri didn’t make much sense when she called me, and she doesn’t understand medical terminology.”

“He said I’m dying,” Mom repeated, as if I were still a child. “I believe his exact words were ‘advanced pulmonary fibrosis of a particularly aggressive nature’ or some such bullshit.”
/>“Did you get a second opinion?” I asked desperately. “Maybe another doctor might – “

“Charge me money to tell me I’m dying, but using different language? No thank you. I know I’m dying. I’ve felt it for the past month.”

“Maybe another doctor somewhere else, Mom,” I argued. “Somewhere with better hospitals. I can arrange an ambulance to take you to Houston – some of the best hospitals in the country not eight hours away. Hell, I’ll go with you myself…”

“Listen to me.” she scolded. “I have less than 30% of my lung capacity left. I’m taking steroids in doses that would kill a horse, they have my stomach so irritated I could shit through a screen door, and I’m only getting worse. So grow up and accept it. I. Am. Dying. I’ve already signed a DNR, so it’s out of your hands.”

“You’re giving up, Mom. Don’t give up. Not while you’re still strong enough to bitch at me like I’m a five year old.”

“What should I do,” she coughed, “Wait until I’m too weak to make my wishes known, and rely on my kids to make the right decision? You might be perfectly willing to let me die, but Sheri won’t. You know it and I know it.”

I said nothing. She was becoming angry, and all too many of our conversations for the past twenty years have been angry. I just held her hand and sat by her bed until she dozed off, and then The Missus and I slipped quietly out of her room.

I made my entrance into the ICU waiting room, greeting relatives with whom I felt no kinship. I was struck by how frail and tiny Dad felt when I hugged him. I hugged or shook hands with everyone, pretended to be interested in family gossip, and prayed for it all to be over soon so I could get away from these people.

I settled into my own isolated niche with The Missus at my side, who was wise enough to leave me alone with my thoughts. She stayed next to me, squeezed my hand occasionally, and allowed me my silence.

Later that first day, Bodie, Mike and Reggie showed up. I was comforted by the fact that my family was there – the family I had chosen. My wife, and my partners. They spent the next three days keeping vigil with me, missing work and family commitments, losing salary money. God I loved those guys.

I spent those days sorting through my feelings for my mother, and by extension, my entire family.

You see, as my mother went, so went our family.

My father worked long hours at his small business when I was growing up. He always came home tired and cranky. In my teen years, we rarely got along.

My mother was the one who taught me how to catch a baseball. My Mom taught me how to ride a bike. My Mom taught me how to swim.

My Mom also taught her children that mediocrity was acceptable, and that excuses were more valuable than doing the work. She taught us that our failures were always someone else’s fault, and in so doing, taught us how to repeat those failures for the rest of our lives.

I made straight A’s throughout school. When I was a kid, Mom used to reward me for those A’s – a dollar here, a quarter there, more when Dad’s business prospered – until one day in the fourth grade when the rewards stopped. She needed the money to reward my twin sister for B’s and C’s. Her reasoning? “It comes so easily for you, and you don’t need the motivation.”

She was right about that. There would soon come a time when everything I did was entirely self-motivated. I craved neither my mother’s approval or even her acceptance.

She taught us how to laugh. There was much joyful giggling in my childhood.

She also taught us emotion without reason. That lesson crippled my sister Sheri, who learned it all too well.

My Mom taught me how to stand up to a bully. When I was eight, the neighborhood bully beat me up and stole my new Boy Scout knife. It wasn’t the first time he had beaten me up. I still bear an inch-long scar on my right temple as testament to his cruelty.

“You go over to his house, and you get that knife back, or you will deal with me,” Mom had ordered. “You better decide who you’re more afraid of.”

I marched tearfully over to the bully’s house, knocked on his door, and dealt out the worst fear beating I’ve ever administered. How bad was it? I beat a ten-year-old unconscious, that’s how bad it was. But I got my knife back, and I was never afraid of David Young again.

My Mom was also the one who invited that enemy into our home and gave him the opportunity to steal my knife in the first place. She invited him to join our Cub Scout den, and this after he had left me with seven stitches in my temple.

My affinity for people and my love of medicine, I got from Mom. I inherited those gifts from her. She was a fifty-year-old housewife with a GED who decided to go back to school and become a nurse. I used to proofread and edit her essays when she was in nursing school.

I learned CPR by playing hooky from junior high school and tagging along with Mom to LPN class. The nursing students used me as a practice assessment dummy for an entire summer.

When I was a high school sophomore in 1984, I used that knowledge to help revive a man who had choked and arrested at a hotel restaurant. It was my very first save, and the very first time I saw paramedics in action.

When Mom took her licensing exam that year, back in the days before electronic testing, she got a perfect score. One of only eight people to have ever done so in this state, I might add.

Mom also taught me the value of sarcasm. Our car stalled once at a red light in rush hour traffic. A jerk in the car behind us kept leaning on his horn while Mom vainly tried to start the car. Eventually, she got out, walked back to the man’s car and knocked on his window.

“Sir, I was wondering if you could help me,” she said politely, in her best helpless Southern belle voice. “You see, my car won’t start…and I was wondering…if you might come up and see if you can get it started…while I sit back here and honk your fucking horn for you.”

The guy apologized for being an ass, helped Mom push the car off the road, and stayed there with us for thirty minutes in the July heat until we got the car started.

Mom could also be a profane, shrieking harpy who could be heard cursing like a sailor throughout the entire neighborhood.

She rented a house trailer to a black woman in the 70′s, and then stood up to our all-white neighborhood association who demanded that she terminate the lady’s lease.

When I was seven, she caught me with a Chick O Stick I had stolen from the neighborhood grocer. She marched me back down there and made me confess my crime and promise to sweep his store after school for a week to make restitution.

When I was fifteen, I also watched her purloin the seat from a toy tractor at Wal Mart, because the one she had bought for my nephew was missing the same part.

My cousins always adored her because she was the crazy Cool Aunt who let them get away with stuff.

To her kids, she’d deal out syllable whippings when we misbehaved. Ever had a syllable whipping? Imagine someone grabbing you by one arm, and whipping you with a switch with the other hand, all while you run in a circle, desperately guarding your hindparts and trying to get away. She’d swing with every syllable, and when Mom was mad, she had a bad tendency to get long-winded.

Many was the time I ran in a circle through the disciplinary equivalent of Hamlet’s Soliloquy – “Don’t-you-e-ver-do-that-a-gain-do-you-hear-me-you-lis-ten-to-me-while-I’m-talk-ing-to-you-I’m-your-moth-er-damn-it-and-I-will-be-o-beyed…”

There were also many times where I had to intervene for fear she’d beat my demonic twin sister to death.

She told riotously funny jokes until we
‘d collapse in giggle fits, laughing until our stomachs hurt.

She’d also sit alone in the dark for days on end, eating white bread and staring vacantly at soap operas. And some days, she’d contemplate suicide.

My mother was the Barbara Mandrell of psychiatric disorders. She was bipolar before bipolar was cool.

She’d let my twin sister get away with murder, because she was a Troubled Child.

She also had an aggravating tendency to walk in at the culmination of hours of torture at the hands of my twin sister, at just the precise moment I’d finally snap and retaliate.

“Oh, so you two wanna fight, huh?” she’d muse. “Well, I’ve got the cure for fighting. When you get done, you won’t wanna fight any more, believe you me!”

She’d then proceed to the hedge and gather three diabolical switches, test them for proper flexibility and tensile strength, and then hand one to each of us.

“Go ahead and fight,” she’d exhort us. “Work out all that aggression. And if you don’t fight, you get a whipping from me.”

I’d spend the next five minutes getting lashed by not one, but two psychotic females.

She would mortify me in front of my friends with her mouth and her antics…

…but they kept coming back because I had the coolest Mom in the neighborhood.

She taught my Cub Scout den how to dance. We were at that socially awkward age where you first start to notice girls, but still haven’t figured out how to approach them. We had a school dance, and all of us were stressing because none of us knew how.

“Dancing is easy,” Mom had said, “just pretend you’re drying off after a shower.”

“Huh?” said a dozen eight-year-old boys.

“You just do The Towel,” she explained, and then proceeded to demonstrate, to my utter mortification. My five-foot-nothing, 300 pound mother grabbed an imaginary towel, stood up and showed us how.

“You pretend you’re drying your lower back, like this,” she said, while shimmying her hips.

“Mom, please don’t…”

“And then you pretend you’re drying your shoulders,” she said, striking a disco pose straight out of Saturday Night Fever.

“Okay Mom, I think we get the idea…”

“And then you dry between your legs,” she’d say, doing a pelvic thrust.

“MOM!”

Mom was also a noted philosopher, quoted by no less an American luminary than Paul Harvey:

Joyce in Louisiana writes:

“I’m just a simple woman, unable to grasp the nuances of science, geopolitics or world affairs. We are embroiled in a war in Vietnam that I do not understand, and we are impeaching a President whom I no longer trust.

Yet this I do know: Why, in a country that has been able to land a man on the surface of the moon, must we continually be forced to purchase hot dogs in package of ten, while hamburger buns come in packages of eight?”

Who says all the world’s great philosophers are dead?

My Mom said it first, folks. And she changed the world. You can now get hot dog buns in packages of ten.

Three years earlier, my Mom took me out for dinner on my birthday. We didn’t talk much even then, but after dinner she took me for a drive. She had something to say.

She told me that night that my twin sister and I were not our Dad’s biological children. Our father was her teenage sweetheart, a man whom she had an affair with after she married Dad.

My twin sister had known for fifteen years. My entire family had known, except me. And now she wanted me to build a relationship with this man.

“There’s no hole in my life he needs to fill,” I told her nastily. “I know who my father is – the man who fed me, clothed me and disciplined me when I needed it. The man who has been here for thirty years. Don’t expect me to feel some kinship with a man just because he fucked another man’s wife over thirty years ago. I don’t even feel a kinship with you.”

We didn’t speak again until that moment by her hospital bed, three years later.

I spent the next three days reliving every memory of my childhood – good and bad. I found some forgiveness in my heart, and mom granted me her own. In the balance, the good times outweighed the bad.

The day before she died, she had my Dad and her teen sweetheart to her bedside, and made them reconcile their differences. She told them she wanted the only two men she had ever loved to find some common ground with each other, to harbor no bitterness after she was gone. Because they both loved her, they agreed.

Mom grew steadily weaker, but kept her sense of humor until the very end.

In one moment when we thought she was too far gone to hear, Terry and I stood on either side of her bed holding her hands, both of her estranged sons come back home. Terry whispered, “Mom, I sure wish I could switch places with you.”

Mom cracked one eye open and whispered back, “Yeah, I wish you could switch places with me, too.”

Those were the last words I heard from her before she died.

After her funeral, The Missus and I took her nieces skiing on the lake. The eldest of them was celebrating a birthday, and I couldn’t see canceling a birthday party. The kids deserved their fun.

“Are you sure you’re okay with this?” The Missus had asked me as we lay there on a beach towel, basking in the sun.

“Yeah, I’m okay with this,” I assured her as I watched the kids trying to dance to some hip hop music I’d never heard before. “Mom would roll over in her new grave if I canceled a kid’s birthday party.”

You’re sure?” she asked, squeezing my hand.

“Yep, I’m positive,” I replied firmly, getting to my feet. “and I don’t know about you, but I’m tired of watching those spastic nieces of yours try to dance. You really are some countrified white girls. Somebody needs to teach them how to do The Towel, and I’m just the man to do it.”

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I still use View From the Porch as a blogosphere portal of sorts, and I suppose others do the same. One of her links has shown me a little linky-love, one whom I’ve visited frequently through VFTP, so welcome The Smallest Minority to the Blogs I Read Every Day. If you like insightful social and political commentary with a healthy dose of snark, give him a read. You’ll not be disappointed. There are a few new entries to the Reciprocal Blogroll as well.

In other news, Matt, Babs and I have a little treat in store that we’ll be posting in the next few days. Stay tuned…

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Either I’ve been channeling Jeff, or he’s been channeling me.

Heh.

Come to think of it, I have had this inexplicable urge to climb things lately…

“The hardest part about not having a soul is remembering a time when you had one.”

Tom Clancy, Without Remorse

Phlegm Fatale witnessed an ugly scene the other day, and I left a comment on her blog about how violence scars everyone it touches, even peripherally. I was reminded of a particular call long ago that made me to examine the scars on my own psyche. The revelation of what I was becoming was not comforting.

I have discovered that within any organizational hierarchy, you will invariably find a certain percentage of assholes. In EMS, they are usually found near the top of the organizational chart, having risen to their particular level of incompetence through management’s misguided attempts to get them off the streets and into the office where they can’t kill anyone. Corporate Greed EMS has an overabundance of assholes however, assuring that as soon as one arrogant, incompetent jerk gets promoted, another will take his place. Lance Bidwell is just such an asshole.

The only reason I’m working today is because Lance insisted on swapping shifts, rather than just coming in to relieve me on the night I got the Valium squirted in my eyes. Hank Williams Jr., David Allan Coe and Lynard Skynard are playing a show in East Lake Podunk tonight. Future Missus and I had tickets, and now I have to miss Redneck Nirvana because my relief has not learned to work and play well with others.

To top things off, I have to work with Mike Treme, a man with the personality of a cinder block. He seems to think that his job on scene is to stand around with his thumb in his ass until I tell him to do something, and his primary topic of conversation around the station is boasting of his sexual conquests among the local Corporate Greed groupies. Tonight, Mike seems intent on entertaining yet another groupie in the privacy of his bedroom.

She’s a real catch, too – about one hundred-seventy pounds, all acne and bad teeth, with an annoying habit of snorting like a pig when she laughs. Fortunately, before I am subjected to the trumpeting of mating elephants in the next room, the scanner crackles with the urgent voice of an East Podunk Police officer. “East Podunk, this is PD 12! Send fire department and an ambulance right away!” Tom Tate radios breathlessly. “MVA north of town on Highway 26, just past the skating rink! Pickup truck in the trees and on fire!” The wreck is less than a mile away. I immediately jump up and pound on Mike’s door until he answers.

“Get your clothes on and say goodbye to the lady,” I tell him curtly when he opens the door. “We’ve got a bad wreck just north of town.” I turn around and walk away before he can frame a reply.

It takes him three and a half minutes by my watch to emerge from the station. The groupie follows him out the door and waddles across the street to where she parked her car.

“So where is this damned call?” he snaps irritably, slamming the driver’s door of the rig and snatching at his seatbelt. “I didn’t hear our pager tones.”

My, aren’t we testy! You should thank me for interrupting you when I did. Otherwise, right now you’d be screwing Acne Girl.

“The pagers didn’t go off,” I explain patiently, “because we haven’t gotten the call yet. I heard it over the scanner. Now let’s go,” I order, pointing to my left. “It’s just north of town.” Grumbling, Mike turns north on Highway 26 as I call dispatch with the particulars.

“Holy shit!” Mike blurts not thirty seconds later. Tom Tate is desperately hosing down a blue Dodge Dakota pickup that has left the road and struck several trees. The fire is creeping out from under the ruined hood, and growing steadily larger. Standing too close to the fire for safety’s sake, Tom doggedly tries to extinguish the flames. Mike and I bail out, each grabbing one of the two extinguishers we carry on our rigs.

“Thank God,” Tom gasps as we draw nearer. “My extinguisher just ran out.” He drops the empty canister on the ground and bends over, coughing and trying to catch his breath. Between Mike and myself, we manage to beat the flames down enough to get close to the wreck, and Mike finally puts the fire out for good by dumping the full load of his extinguisher on the source of the flames, a ruptured fuel line near the rear of the engine compartment.

“Mike, check the passenger side,” I cough as I move to the driver’s door. “And be careful!” I add. The driver’s door is sprung open, and the driver’s left leg is hanging out, clad in a yellow paisley pair of stirrup pants. Her shoe is missing. As I reach in to check a pulse, I notice that she has been decapitated, with the top of her skull and most of her brains lying in the bed of the truck behind her. “The driver is DOA!” I call out to Mike.

“So is the passenger,” he answers, walking around the back of the truck, grimacing in distaste and wiping his hands on his pants. “He’s hanging out of the window over there. I ran right into him.” Mike puts his hand to his mouth and retches.

“You okay?” I ask, concerned. He nods, swallows hard and spits on the ground. “Yeah,” he says shakily. “I couldn’t see anything through the smoke and extinguisher chemical, so I bent down to see better, and wound up face-to-face with him. He’s pretty torn up.” “Dispatch, be advised we have two fatalities at this scene,” I radio. “Please notify the state police and the coroner’s office.”

“Ten-four, Medic 306. We’ll notify LSP and the coroner,” dispatch replies. I walk over to check on Tom, who has finally managed to catch his breath. He is walking the ditch bank, shining the beam of his flashlight over the broken ground.

“They passed me hauling ass, all over the road.” Tom says, shaking his head. “I got them on radar at ninety-four. By the time I got turned around, they had wiped out. Looks like they left the road here,” he indicates a set of tire marks with his flashlight beam, “went airborne here when they hit this culvert,” pointing the beam at the spot where the tracks end, “and then hit the tree sideways.” It is nearly a hundred feet from the point of impact to the spot where they left the road. “Are they dead?” Tom asks, already knowing the answer.

“Yep, both of ‘em.” I answer as we walk back up to the truck.

From the rear of the truck, it looks as if one of the red bucket seats has broken loose from its mount and split wide open from the impact. There is pale yellow padding visible through the split fabric. As we get closer and the smoke and fire extinguisher chemical dissipate, we are horrified to see that it’s not a bucket seat at all, but the back of yet a third victim. She was pushed upward by the impact, erupting through the roof of the truck.

What we thought was the seat back was actually her torso showing through her red sweatshirt. She is literally split in half from pubis to sternum. Her left arm is amputated and is lying on the roof of the truck. The woman’s torso burst just to the left of her spine, spilling all of her chest and abdominal organs onto the floor beneath her. I can literally look right through her at Mike Treme walking around on the other side of the wreck.

Whoa, cool! You don’t see that every day.

“Oh my Lord,” Tom breathes, playing his light over her body. “Is that what I think it is?” he asks fearfully.

“Yup, that’s what you think it is,” I confirm, then key my radio microphone once more. “Dispa
tch, Medic 306. Uh, be advised that’s three fatalities at this scene.”

“You advised ‘three fatalities’, Medic 306?” our dispatcher inquires sweetly, in a voice that communicates quite clearly that I should learn to count.

“Yes, three fatalities,” I confirm. Beside me, Tom whispers a prayer and crosses himself.

“Hey Mike!” I yell. “Found another one!” He comes trotting over, looking all around the truck.

“Check it out,” I grin, handing him the flashlight. Mike points the flashlight beam at the truck, squints and does a double take. His reaction is pretty much the same as Tom’s – shock and horror. By the time East Podunk Fire Department arrives, there is no fire to suppress, no living victims to extricate. The smoke has cleared enough to show every gory detail, starkly lit by the halogen lights the firefighters have set up. Their men and their extrication equipment sit idle, waiting for the moment when they will be asked to pull the bodies from the wreckage.

The curious and the bold have all long since satisfied their morbid curiosity, and the only ones poking around the wreckage now are the state trooper and the parish coroner. They are shooting photographs, documenting the scene from every conceivable angle. The state trooper straightens from where he has been kneeling near the passenger side of the truck and beckons me over.

“Thanks for the film,” he says, handing me my camera. “I thought I had enough.”

“No problem,” I grin. “Just make a set of prints for me, too. I’ll blur the faces when I use them in class.” The trooper nods in understanding.

“Check that out, would you?” he says, pointing to the body of the passenger. Unlike the other two, his body is remarkably intact, especially considering the fact that he was closest to the point of impact. He is hanging from the waist up from the passenger window, partially wedged against the tree. I bend down to get a closer look, and see that this guy is still holding an empty Miller Pony bottle clenched in his left hand. I grunt and straighten up, shaking my head in amazement.

“Pretty damned weird, huh?” the trooper asks rhetorically. “I got a couple of good pictures of it. You see some of the damnedest -…”

“Hey, Corporate Greed!” the coroner interrupts. “We’re ready to get the bodies out now,” he calls.

The trooper and I walk over to the coroner’s Ford Explorer, joining the fire captain and the coroner, who is rummaging around in the back. He finally emerges with three body bags. “Here, take these,” he says, handing them to me. “I’m pretty much done here, so I suppose we need to get the bodies out and transported to Big City.”

“Any particular way you want it done?” the fire captain asks.

“Not really,” he shrugs. “Just do your best to keep from tearing them up any more than they already are.”

Easier said than done, pal. Will you settle for all the parts in the right body bag?

The fire captain calls his extrication crew over and tells them, “Look, we’re just gonna cut the roof off and get ‘em out as best we can. You two,” he points at two young, fuzzy-cheeked firemen, “line up the body bags over there, where they can’t be seen from the road. You can help the Corporate Greed boys pull the bodies out.” These two kids don’t look really enthused with their assignment, but they obediently take the body bags from me and line them up behind the truck.

“What’s your name, man?” I ask the firefighter with me. I have to consciously resist the urge to call him “kid.” He looks about fifteen, and I suddenly feel old.

“Carey,” he answers nervously. “I just joined the Fire Department.”

“Is this your first time to see something like this?” I ask him. He bobs his head like a schoolboy.

“Yes sir,” he says, swallowing hard and licking his lips. “I’m supposed to take your First Responder class next month.”

“Well good!” I beam. “Look, just relax. You and I will get in the back of the truck once your guys remove the roof. We’ll pull them out as best we can. There’s really nothing to it.” He nods absently, only half listening.

Jesus Christ, this kid is going to puke any minute now. How did I get saddled with this pussy?

Presently, the extrication crew cuts the roof away and gingerly manipulates it around the mangled torso of the third victim, leaving what is left of her body slumped over the guy in the passenger seat.

“Okay, Carey. That’s our cue,” I tell him grimly, climbing into the truck. “Spread that body bag open in the back of the truck. I’ll get under her shoulders, and if you can get her hips, we’ll see if we can pull her out.” Carey clenches his teeth and gamely takes a hold.

Pulling her out requires some doing. There is nothing pinning her now, but the impact has done more than split her torso in half. Both of her thighs are essentially deboned; both hips are dislocated, and the femurs have burst from the flesh all the way down to her knees. Getting her into the body bag in the bed of the truck turns out to be a messy proposition. By the time we are through, Carey is gagging. Mike and the rest of the firefighters remove the other two victims without much trouble, and Carey and I line our body bag up next to the others.

“Hey AD,” the coroner calls out to me, “make sure everything is out of the truck. I’m calling the wrecker.” I nod my understanding and scan the inside of the truck for personal effects, money and meat. There is something lying in the floorboard under the jump seat.

“Carey, open that first body bag for me,” I order. He is standing with his back to me, taking deep shuddering breaths. Reluctantly, he turns around and kneels next to the bag, unzipping it and spreading it open. He turns his face away and closes his eyes. I grab a double handful of the driver’s brains and dump them unceremoniously into the bag. Carey groans, rolls over onto his hands and knees and vomits into the grass.

What a pussy! I think cruelly. If you can’t handle the sight of a little blood and guts, you’re not gonna last long.

An hour later, we’re back at our station. Mike is asleep, but I’m still keyed up, so I walk across the street for a breakfast sandwich and a soft drink. The sun is just coming up, and the parking lot is filling with early morning commuters. The wrecker driver is there with the Dakota secured to his flatbed, sipping a cup of coffee and holding court before a small crowd of gawkers. I sidle over closer to hear what he is saying.

“Musta been a bad ‘un,” he grunts, pointing with his coffee cup into the cab of the truck. “There’s blood all in it. Cops said three people got kilt. To tell the truth, I dunno what there is to be salvaged,” he shrugs, idly picking up a piece of floppy, translucent looking plastic from the floorboard and examining it as he takes another sip of coffee.

“Well, first of all,” I tell him as I reach over his shoulder and take the piece from him, “that isn’t part of the truck. This is cartilage, probably from one of the victims.”

He immediately spews most of his coffee onto the truck, followed by the rest of his breakfast.

“Secondly,” I continue, looking at him contemptuously, “you don’t need to be out here showing off the truck to every Tom, Dick and Harry. You never know who might be in the crowd.” I toss the piece of cartilage back into the truck and walk away, to the shocked stares of the gawkers.

Back at the station, I crawl into bed and stare at the ceiling for hours.
<
br />What in God’s name is wrong with you? You thought that was funny. Three people dead, and all you take from it is the opportunity to make two people toss their cookies? You used to not be that way, AD. You used to have compassion. You used to have empathy for people. Yeah, but you can’t identify too closely with every patient. You can’t bring it home with you, or it will just eat you up. That’s what Richard and Randal taught you from Day One in EMT class. But you’ve always said that you’d quit before you became one of those burnouts who didn’t care about people. So why don’t you just quit, Mr. Chickenshit? Dear God, what are you going to do if you’re not a paramedic?

When I finally drift off to sleep, I have a nightmare about Frankie Maryland. He blames me for killing him.

John, a faithful reader, posted a request that I am loathe to refuse. John and his wife are splitting up, an amicable divorce, thankfully, but wrenching nonetheless. John requests:

Would you get the word out for a brother for prayer that God’s will will be done- and no one would get terribly hurt?

I have my misgivings about using my blog for so public a request. This place is my creative outlet, my venting place. It’s my confessional.

But it’s also a place where people come to share a little of my experiences and perhaps find the odd chuckle here and there. Your blog too, in other words.

You see, I’ve been where John is.

I know from hard, first-hand experience that relationships die without nurturing. I came home from a trip almost three years ago and found my wife gone, with nothing but a note for explanation. I was hurt, and confused, angry and bitter. The experience nearly wrecked me, and the lives of a couple of others.

At the time, I was too wrapped up in work and commitments to see my wife’s pain. I was blissfully unaware that the love I thought would last a lifetime was flickering out for lack of fuel. We let life blind us each of us to the person that made it worth living.

Thankfully, my wife and I were grownups, and for the sake of our friendship and our daughter, we kept things civil. We’re still friends. Heck, she’s even my direct supervisor at work.

But it could so easily have gone the other way. That’s where John and his wife are right now.

So if you are the praying sort, think about saying one tonight to the deity of your choice, that John and his wife find peace apart from each other, and remain friends along whatever path they choose. If you’re not of a particularly religious bent, just send a few good wishes his way. A little support from your fellow man (or woman) goes a long way.

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Tomorrow, May 12, marks the first National Fibromyalgia Awareness Day.

In related news, emergency nurses, doctors and paramedics will also be observing National Roll Our Eyes and Chalk You Up As A Drug-Seeker Day.

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If you bring me a patient whom you have chosen to immobilize simply because “she fell,” who denies the presence of any neck or back pain whatsoever and exhibits no neurological deficits, I will think much more highly of you if you actually get the patient on the board.

Bringing in a half-assed immobilization job on a patient with no indication for it does not speak well of your abilities, or the EMS profession in general.

That is all.

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In not announcing the addition of Mostly Cajun to the Blogs I Read Every Day. He’s got a quality blog there. Give him a read, you’ll not be disappointed.

I’ve also added a few blogs to the reciprocal blogroll. Folks, if any of you have me on your blogroll and I haven’t reciprocated the linky-love, drop me an e-mail and I’ll get you added.

Also, many thanks to the folks who have dropped an e-mail to the Publisher today. Keep the feedback coming, but remember to be nice! He’s a lovable old coot even if he is technologically inept.

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Yes, I’ve asked you this before. Most of you know that I have written a book. Many of you have read some of the stories here in this blog. I constantly argue with publisher of said book about my little screed here in the blogosphere.

Don’t worry, the blog ain’t going anywhere. But my publisher is of the opinion that “Why should people buy the cow if they can get the milk for free?”

AD: “But Lou, you don’t understand the blogosphere! These people do both – read the blog and buy the book, even if they’ve seen the stories before. Tom Reynolds has a successful book called Blood, Sweat and Tea that is a compilation of his blog posts. He even got a TV deal for it!”

Publisher: “I don’t believe it. People are not gonna pay good money for something they’ve already seen before. If they like your blog, if anything they just give a friend the URL so they can read the blog, and then you’ve lost another sale.”

AD: “Peter Canning has a blog, Lou. His readership ain’t suffering on either front – book or blog. One complements the other.”

Publisher: (sticking fingers in ears and squinching his eyes shut) “Naaa naaaa naaa naaa I cannot hear yoooouuuuuu…”

AD: “Fine, you big baby. I’ll let them tell you, if you won’t accept it coming from me.”

So that’s where I am. He also holds the opinion that the blog is costing me speaking appearances because people will not take me seriously. This from a man whose entire business comes via the Internet, people. He’s an EMS pioneer, but he’s also a dinosaur that still doesn’t fully get it where the internet is concerned.

So I ask you this one teensy weensy favor. If you would personally buy a book compiled of things you’ve already read in this blog, drop the Publisher a line here. If you’ve already bought the book after learning about it on this blog, tell him that too.

Sitemeter says I’m averaging over 800 hits a day now, so I expect to see 800 supportive e-mails in the Inbox within the next 48 hours. Chop chop, people!

And if you haven’t already bought the first book, what are you waiting for? The Double Wide Fund needs an infusion, people!

Here endeth the shameless act of self-promotion. If you’ll excuse me, I feel like I need a shower.

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My 50k Visitor!

You may not know this, but Podunk General Hospital, Nail Salon, Tire Repair and Crawfish Hut also houses its own inpatient psychiatric unit. It’s a real cash cow, and apparently a very popular destination for the well-to-do unhinged among us. People are just crazy to get in there.

Now I’ll confess that I’m somewhat ignorant as to the inner workings of our own little asylum. Typically some poor soul walks into the ER, totally bereft of all hope because the lawn is infested with dandelions or they can’t get those pesky talking spiders to go away, or Sanjaya got booted from American Idol, and Life Just Cannot Go On. I listen to their story, suppress the urge to write WTF??? as their chief complaint, and tuck them in a room. I take their clothing and garb them in one of those oh-so-flattering hospital gowns, and call the psych intake coordinator. He takes it from there.

Aside from the occasional foray into the secured area whenever they have an emergency situation requiring the assistance of anyone large and beefy, I tend to stay away. The place gives me the willies. Frankly, sometimes the only way to tell the difference between the patients and the staff is that the staff wear scrubs and know where the bathrooms are.

Who knows what goes on behind those double-locked, reinforced doors? Not your humble scribe. I have vague notions of group therapy, finger painting, Rorschach tests and other psychotherapeutic hooey aimed at helping people reaffix their mental cheese firmly to the cracker, but I don’t know what goes on. All I know is that unearthly howls and eerie screams of the mentally tortured often resonate through our hallways, and it’s not always coming from the administrative staff meetings.

Well, tonight I got a peek behind the veil. I was informed that on certain nights of the week, they herd all the residents not already in a Thorazine fog out onto the patio, and they all…

…sing karaoke.

I. Shit. You. Not.

Well, now I know where the tortured screams and unearthly howls are coming from. And all this time I suspected it was the Ex-Missus trying to get another box of gauze approved in the budget meetings. I keep picturing Jack Black singing the Immigrant Song in School of Rock.

So as Laid Back Male Nurse and I pondered the concept of a large group of the mentally deranged clustered on a concrete patio under a bug light (think disco ball), butchering Shania Twain songs, he said what both of us were thinking:

“Dude, that is so bloggable.”

“Yup. You know, we’ve been doing it wrong. Instead of restraints and Haldol, all we need is a Mr. Microphone. Nothing soothes the savage beast like crooning a little Barry Manilow.”

“Heh. Copa Cabana.”

“Nah. Mandy. Definitely Mandy.“

SING IT WITH US NOW!

“Oh Mandy, well you came and you gave without taaaakin‘, and then I sent you aaaway, oh Maaaandy…”

If you found that soothing, we have a room reserved just for you.

The ER clerk abruptly stuck her head in the door to see what all the racket was, and left just as quickly, shaking her head and muttering. No doubt she was horrified by our off-key rendition of a timeless American classic. After we got through giggling, LBMN was struck by an idea:

“Dude, you should come up with some good karaoke songs for different psychiatric disorders!”

Heh. The boy may actually have a blogger lurking inside him.

So without further ado, I present to you the musical stylings of the mentally challenged and pharmaceutically gifted, sorted by psychiatric disorder:

Paranoia: Who Can it Be Now?, Men At Work

DTs/drug withdrawal: Shook Me All Night Long, AC/DC

Narcissism: I’m Too Sexy for My Shirt, Right Said Fred or The Greatest Love of All, Whitney Houston

Obsessive Compulsive Disorder: Over and Over Again, Nelly and Tim McGraw

Multiple Personality Disorder: Cult of Personality, Living Colour

Social Anxiety Disorder: Don’t Stand So Close to Me, The Police

Megalomania: The World’s Greatest, R. Kelly

Agoraphobia: Solitude, Edwin McCain and Darius Rucker or All by Myself, Eric Carmen

Oppositional Defiant Disorder: Burning Down The House (because Mom made me turn down the stereo),Talking Heads

Schizophrenia: Change Your Mind, Sister Hazel

Chronic Depression: Paint it Black, Rolling Stones

Delusional: No Such Thing (as the real world), John Mayer

Autism: Rockin‘ Robin, Bobby Day

Manic: Bouncing Off the Walls, Sugarcult

Self Mutilation: Pinch Me, Barenaked Ladies or Cuts like a Knife, Bryan Adams

Personality Disorder: It’s My Party and I’ll Cry If I Want To, Lesley Gore

Borderline Personality Disorder: Impulsive, Wilson Phillips

Amnesia: How You Remind Me, Nic
kelback

Premenstrual Dysphoric Disorder: The Bitch is Back, Elton John

Gender Dysphoria: I Want Your Sex (any sex but my own), George Michael

Post in comments if you think of any other song titles. If we build a large enough album, I smell a new reality show for the fall lineup.

How does Thorazine Idol sound?

Bonnie took up the meme in her blog, and in it she writes:

I’m of the firm opinion that, if an action is taken in which the only person who is harmed is the person undertaking the action, then that action is not to be regulated by the government. You know what I call rampant drug use? Natural selection.

Heh. Good one.

Update 5-7-07 Jay G. took up the meme on his blog. Lots of other good stuff there besides a tired old meme, too. A little politics and commentary, a little gun porn, and the occasional scooter trash post. Give him a read, you might like it.

…in thousands of hits, that is.

Wow, folks. This blog isn’t even five months old. Just…wow.

I am indeed glad a number of people have found this blog informative, entertaining, inspiring, or whatever it is you get from it.

Six months ago, I had never even read a blog. Then, a friend turned me on to the LawDog, and the rest is history. I found myself captured by his wit and storytelling ability, and soon I started browsing his blog roll. First I found Matt G. and then Tamara.

Then I started this blog, and to this day LawDog and Tamara are my two biggest referrers in Sitemeter. Both of you, many thanks.

This milestone will no doubt make Matt insanely jealous. Neener neener neener, big guy. My advice is to stoop to the lowest common denominator like I did. Try lots of profanity and toilet humor – worked for me.

And for Visitor 50k, from Southeastern Louisiana University in Hammond, Louisiana, you can choose the topic of my next blog post. Or pimp your blog here. Or come collect these cement bicycles that Visitor 5k and Visitor 10k still haven’t claimed. Whatever you want, pal.

Love your town, by the way. I once guest lectured to the EMT class at SELU’s athletic trainer program, and I got totally hammered at a college bar there called Razzy’s on Halloween, 1987. Got in a huge brawl that night, too.

But that’s okay, because I was tenderly ministered to and taken home by a girl named Meaghan who was dressed like Elvira, Mistress of the Dark. Rowr!

Many thanks to one and all for the ride thus far. Next stop, a hunnert thousand!

Egads, I’ve been tagged!

I’ll do this one because the tagger has been reading my blog since the very beginning, plus she nominated me for an award. Good taste like hers merits loyalty.

This weekend promises prolific posting (how’s that for alliteration?), because I’m house bound with a sick kid. In addition to Janean’s meme, I volunteered for another, plus my blog reached a milestone today that I just have to celebrate.

I know, I’m a compulsive oversharer. I’m working on it.

So without further ado:

Here are the rules: Each player starts with 7 random facts/habits about themselves. People who are tagged need to write on their own blog about their seven things and add a copy of these rules. THEN, you need to choose 7 people to tag and list their names. Don’t forget to leave them a comment telling them that they have been tagged and to read your blog!

1. I suck at math. Actually, I don’t really suck at it, but it requires a level of academic discipline that I have been thus far unwilling to practice. I can make an “A” in college math, but it requires someone standing behind me with a cattle prod to make me do the work. Otherwise, I get bored and frustrated and make careless mistakes. A “C” in calculus or physics doesn’t do much to help you into med school. If a “C” were good enough, this blog would be named A Day In The Life of An Emergency Physician. My math suckosity reaches such levels that I am the only guy I know who made an “A” in organic chemistry, but made a “C” in basic freshman chemistry. Why? Because organic chemistry didn’t have all those freaking math calculations, that’s why.

2. I have 16 firearms floating around the house, and that ain’t nearly enough. I needs me an EBR, a Glock 23 to replace the one I had, a nice custom 1911, and a new .22 target pistol, a WWII era milsurp rifle in decent condition…

Bulletin: my daughter is watching the Noggin channel as I write this, and I have just watched an animated mouse named Maizy grunt up a big turd on the toilet, wipe her little mouse hiney with animated mouse toilet paper, and go back to playing, all while merrily whistling a little mouse tune. My daughter has watched the entire Mouse Defecation Adventure with a vacant, rapt expression and a little trickle of drool in the corner of her mouth. I think I’m going to let her go back to watching Quentin Tarantino movies.

Okay, where was I? Oh yeah…

3. I was a pretty fair volleyball player back in the day, and even though I no longer have the vertical leap necessary to block or hit well, I still have enough flexibility and court savvy to be in position to make the play. Let me lose a little of this weight though, and I’ll be Louisiana’s answer to Karch Kiraly once again. Only without the matinee idol looks, or the groupies, or the money…

4. I have no internal censor. Over the years, I have developed the ability to soften some of the things that come out of my mouth with a little gentle humor. It’s all in the delivery, folks. I can say things to people and get a chuckle that would see anyone else get their ass whipped. I inherited that unfortunate characteristic from my mother, who was prone to yelling the most inappropriate things for all the neighborhood to hear. It might have been Tourette’s Syndrome for all I know, but thank goodness Tourette’s isn’t heredit – bitch! Fuckin‘ gobslobber! Whoop, whoop!

5. I am partial to 70s rock, but I listen to just about every genre of music, except thrash metal and gangsta rap. One can only stand so much dissonance or repetitive bass notes. The very first song my daughter ever sang was Drift Away, by Dobie Gray. If you want to overdose on cuteness, imagine a two-year-old, rocking rhythmically and singing “Day after day I’m more confuuuused, yet I look for the light through the pourin‘ raaaaaiiinn…”

On my MP3 player, you will find Nora Jones crooning right after Hank Jr. sings Dixie On My Mind, and right before songs by Nickelback, Staind, and Three Doors Down. Pachelbel’s Canon can be found in there right next to AC/DC. And yeah, I do a pretty decent Angus young air guitar. Michael Buble croons right next to the Georgia Satellites. I have been known to go directly from belting out Sweet Home Alabama in the car to snarling angry chick rock by Alanis Morrisette.

And while I’m on the subject – Guys, how many of you heard Alanis Morrisette for the first time, thinking “Jeez, this is one man-hating bitch!” only to catch yourself weeks later happily screeching “And I’m here, to remind yooouuu…”

Or is that just me?

6. When teaching class, I tend to use the phrases “99% of the time” and “chances are” waaaaay too much. I’m getting better, but I used to do it so often that one entire paramedic class used to sing the Johnny Mathis song whenever I did it. Picture twenty EMTs, crooning “Chances aaaare, though I wear a silly grin…”

7. I submitted a lecture proposal to a very large EMS conference for a stand-up comedy routine for evening entertainment one night, and it looks like it has been approved. Two friends and I will sit on a stage, ala Blue Collar Comedy Tour, and riff on anything in EMS we find funny. We’re calling it Two Jews and A Redneck. I’m usually very comfortable in front of an audience, but frankly, the prospect of being funny On Purpose for over a thousand people has me PETRIFIED. Now I gotta put together a routine and polish it endlessly in front of a mirror for the next six months. I have nightmares of chirping crickets.

Okay, that’s it. No more random facts for you guys. With apologies to Janean, I’m not going to tag seven other people, either. If you’d like to pick this meme up and run with it, feel free. If you get a decent blog post out of it, leave a comment here and let us know where to look.

Update 5-8-07: Our Pirate With A Permission Slip took up the meme here. If any of you are bikers, consider gathering a few of your friends together for a good cause – BACA (Bikers Against Child Abuse). Strings can tell you all about how.

A retread from the book, as a favor to Kim, who asked what was my most memorable save. I’ve attempted many resuscitations, but I have succeeded in reviving precious few, and only a tiny number (less than ten) have actually recovered to lead productive lives.

I have worked the vast majority of my career in rural EMS, where the typical response time is upwards of twenty minutes. Not often will you find a patient still workable in such an environment, but we tried, and thus every time we got a pulse back is memorable.

Here’s a story of one shift where I had the Golden Touch:

Green Acres Nursing Home isn’t too bad as nursing homes go. The prevailing stench there is of Clorox and baby powder, but without the faint essence of shit and stale urine common in so many other nursing homes.

The trend around here is to build large, sprawling “geriatric care centers” with pastoral sounding names like “Oak Lawn Manor,” or “Shady Lane Care Center,” but the only thing that really distinguishes them from the older nursing homes is that there are urine stains on carpet instead of linoleum. Other than that, it’s a wash.

I have a major problem with an industry that warehouses old people, and considers 50:1 an acceptable patient to nurse ratio. So families will know what they’re doing to their parents and grandparents, I think they ought to give them names that describe the actual living conditions, like maybe “Our Lady of the Clogged Feeding Tubes,” or “Aspiration Manor,” or my personal favorite, “Chateau of Methicillin-Resistant Staphylococcus Aureus.”

Some of these places are really grim. There is one near Lake Podunk where you see people shuffling around in a drug-induced fog, dried food on their faces, and feces and urine stains on their clothes – and that’s the nursing staff I’m describing. The patients are really bad.

There is a love-hate relationship between paramedics and nursing home nurses. We hate them because of the ignorance and apathy we see in them, yet we probably couldn’t get paid without the patients they ask us to transport. They hate us because we’re often arrogant and condescending, with no concept of how tough and emotionally draining their jobs are, yet love us because we’re trained to handle emergencies, which is not the forte of the average nursing home nurse.

I am reflecting on this relationship because Effeminate Partner and I have been called for a cardiac arrest at Green Acres. Our relief crew, Frick and Frack, have managed to alienate most of the staff at the local nursing homes, which reflects poorly on Podunk EMS in particular, and paramedics in general.

This has made my job tougher when I have to deal with these people. There is usually a distinct chill in the air when we pick up a patient from Green Acres, but not this time. This time, they’re going to be damned happy to see us arrive. This time, we’re the cavalry. The pros from Dover have arrived.

Effeminate Partner and I are directed to a room at the far end of one wing, where we find a tiny, frail little woman in full arrest. The staff is doing effective CPR, for a change. They have even removed the head of the bed and placed it under her shoulders as a CPR board. There is an equally frail little old man in the next bed, sobbing pitifully.

“Just let her go, you bastards! Why can’t you just leave her alone?” he pleads in a quavering voice. “Please just let her go!” Everyone seems to be ignoring him.

The nurse doing ventilations looks up at us as we enter the room. She’s been working hard; there is sweat dripping off her nose, and her hair is in disarray.

“How long has she been down?” I ask as I do a quick look with my defibrillator paddles. The rhythm looks like ventricular tachycardia.

“Maybe five minutes,” the nurse answers as I charge the paddles. “She collapsed while the aide was feeding her breakfast.”

“Everybody clear!” I sing out, and then light her up with 200 joules. The rhythm changes immediately to ventricular fibrillation, so I charge the paddles to 300 joules and pop her again. The rhythm changes to asystole. I pause to check a pulse, don’t find one, and put my paddles back in the defibrillator. I notice that EP is desperately scrabbling through the monitor case, opening every zippered compartment.

“No electrodes!” he says, anguished.

Well, that figures. Frick and Frack told us the truck was stocked up and ready to go when we relieved them this morning. I should have known better.

“Well, hustle out to the truck and get some!” I snap, and then turn back to the nurses. “Could you ladies resume CPR while I get her intubated?”

I quickly open my airway kit, grab my laryngoscope and a 7.5 tube, and intubate her without much trouble. An aide hands me the BVM, and I pause, looking in vain for any nurse with a stethoscope hanging around her neck. Normally, EP checks breath sounds for me while I ventilate, but he’s fetching electrodes right now.

“Uh, anybody got a stethoscope?” I ask hopefully, to which everyone replies by shaking their head.

Well, shit! Okay then, we’ll improvise.

I place my hand on the woman’s stomach. “Bag,” I tell the aide. She complies, and the stomach doesn’t rise. “Again,” I tell her, placing my hands on the woman’s chest. Both sides of her chest rise equally.

That’s good enough for me.

I grab some tape from my thigh pocket and quickly tape the tube down, wrapping the tape all the way around her head several times for good measure. I hand off the BVM to the aide, and step back over to my monitor. I do another quick look, and the rhythm is still asystole. I drop the paddles next to the monitor, pull up two milligrams of epinephrine from a multi-dose vial, and jam the needle into the side of the ET tube, just above the lips. I inject the contents, and order the nurse doing chest compressions to stop for a moment. The aide doing the ventilating takes this to mean her as well, and stops bagging. I tap her on the arm.

“Not you,” I say. “Bag like hell for a few seconds.” EP reenters the room, carrying several packages of electrodes. He is red-faced and out
of breath.

You regret those cigarettes now, don’t you partner?

He quickly attaches the electrodes and switches the lead selector switch on the monitor to Lead II. The rhythm is still asystole, as flat as can be. The old man in the next bed is just crying and moaning pitifully to himself now.

“We need a line,” I tell EP, who digs through the jump kit for a bag of saline and an infusion set. He curses under his breath and straightens up.

Shit, don’t tell me. No saline either? Frick Medic, you will roast in Hell for this!

I meet EP’s gaze, and he looks as if he’s about to cry; whether in frustration or the prospect of sprinting to the rig again, I can’t tell. I say nothing, just point at the door, and he wheels and sprints out of the room. I dig through my drug box, and manage to find a 250 ml bag of 5% dextrose and a microdrip infusion set. I hand it to a nurse, grab a 14-gauge catheter and start looking for a good external jugular vein. She’s got a whopper, so I sink the catheter and attach the line the nurse hands to me.

I tape it off securely, open the clamp and watch the fluid flow. It’s patent, so I close the roller clamp, grab pre-filled one-milligram syringes of epinephrine and atropine, and administer them both, opening the clamp briefly to flush the meds in.

“You’re doing great, ladies,” I tell the nurses as I hand the bag off to one of them. “Just keep doing what you’re doing.” The pitter-patter of little feet in the hallway herald EP’s return, and he bursts into the room with a spiked bag of saline, trailing a trickle of fluid behind him. He hands me the bag without a word, and leans over with his hands on his knees, gasping for air.

“Switch this out for me, would you please?” I ask the IV nurse, handing her the bag of saline. As she does that, I notice a rhythm change on the monitor. It’s v-fib. Charging the paddles again, I holler, “Clear!” and hit her with 360 joules. The rhythm changes to sinus bradycardia, then rapidly speeds up to the prettiest sinus rhythm I’ve seen in a long time.

Sinus rhythm at seventy; I’ll take that any day. And from the combination of relief and amazement on the BVM aide’s face, there is good news on the airway front as well.

“She’s trying to breathe through the bag,” she says wonderingly.

I’ll be damned, she is! Gagging on the tube, no less!

“Great work, ladies. She’s got a pulse,” I grin at the nurses. We take a couple of minutes to get her on the stretcher, secure her arms, and bolus her with 75 milligrams of lidocaine. As we roll her toward the door, one of the nurses stops us as we pass the old man’s bed.

“Her husband,” she explains, a fact that I feel shamed for not picking up on. He is still crying, rolled partly over in the bed reaching feebly for the stretcher legs. EP and I lower the stretcher and maneuver it as close to his bed as we can. He gently kisses her cheek and strokes her hair, his hands palsied and trembling with the telltale signs of Parkinson’s disease. I wait quietly, allowing him as much time as I dare, then reach down and gently pull him away. Her cheek is wet with his tears.

“Sir,” I tell him softly, and a little huskily, “I promise we’ll take good care of her. We’ll be gentle.” He says nothing, just rolls on his side and closes his eyes. Unsure of what else to say, I nod to EP and we lift the stretcher and roll her out the door. There is no backslapping, no exchange of high fives in the hall. If this is a save, it doesn’t feel like one.

On the way to East Lake Podunk Hospital, I take the time to hang a lidocaine drip.

What the heck, I’ve already got the right bag spiked.

At the ER, Dr. Idris takes report. He listens, nodding occasionally as I talk, then looks up at me, horrified.

“You started an external jugular IV?” he asks incredulously. “Couldn’t you find a vein somewhere else?”

“Uh, well Doc,” I say hesitantly, not sure of what his problem is, “I never actually looked anywhere else. Is that a problem?” He shakes his head angrily.

“We cannot admit her like that!” he blurts, motioning to the nurse. “Nurse, find another vein and discontinue that IV!” Future Missus complies, winking at me surreptitiously as Dr. Idris turns his back.

Our patient, Mrs. Couvillion, is moving now. She gags on the tube and tosses her head, her eyes tracking Mary as she moves around the bed. I walk back into the corridor and find a middle-aged woman and her husband standing there at the desk. Dr. Idris is nowhere to be found.

“Can I help you folks?” I ask.

“Edna Couvillion?” the lady asks me uncertainly. “Is she here? I’m her daughter,” she explains. “The nursing home told us they sent her to the hospital.”

“Oh, okay!” I say, shaking their hands. “I’m the paramedic who brought her in. The nurse or doctor should be able to let you know how she’s doing in a minute.”

“What happened?” the son-in-law wants to know. “Well, apparently she went into cardiac arrest while they were feeding her breakfast,” I tell him, then hurry on as I see the shocked expressions on their faces. “It’s okay, though. We managed to revive her in time, and she’s awake right now. Her vital signs are good, and she’s aware of what is going on around her. Keep your fingers crossed, and the doctor will be able to tell you more, but right now it looks as if she’s going to be okay,” I smile reassuringly.

“But I don’t understand,” the woman says, confused. Her husband just looks pissed. “She didn’t want any heroic measures taken. Her and Dad didn’t want to be resuscitated. They signed a form and everything…”

“Oh,” I stammer. “I didn’t know that. Well, I mean I wasn’t told…the nurses were…uh, I don’t know what to say…well, the doctor will see you in a moment,” I finish lamely and beat a hasty retreat back into the ER.

“FM,” I hiss as I walk back inside, “this woman has a DNR! Her family is outside, and they want to know why we did anything!”

“Green Acres,” she groans, hanging her head, “codes everybody, no exceptions.” “Even the DNR patients?” I ask disbelievingly.

“Even the DNR patients,” she confirms. “Apparently, their lawyers found something wrong with the way their Do Not Resuscitate orders were w
ritten. They said none of them were valid, so Green Acres resuscitates everybody until they get it straightened out.”

Good Lord! Well, I suppose if she codes again, we can just let her go this time.

I say as much to Future Missus. “Relax,” she says, “you got a save. I’ll explain things to the family.”

“Well, it doesn’t feel like one right now. It actually feels kind of disappointing,” I confess. “You’re going to talk to the family, instead of Dr. Idris?”

“He’s probably already gone home,” she snorts, then grins wickedly. “And you’re not the only one who is in for disappointment today. Idris will not be happy when I send this lady to the floor.”

“Why should he be disappointed?”

“Because the only vein I could find was in her foot. I’ve got a 22-gauge in it, with your fluids hooked up,” she explains with a twinkle in her eye, “but I’ll be damned if I’m going to discontinue a 14-gauge IV for a 22-gauge in the foot. So I heparin-locked yours, and if Dr. Idris doesn’t like it, he can kiss my ass.”

Man, I like this girl!

It’s the second day of our 72-hour weekend shift in East Lake Podunk. Yesterday morning, we resuscitated a DNR patient from Green Acres Nursing Home, and then transferred her to Big City Memorial a couple of hours later. After a fitful sleep on the first night of my 72-hour shift, I get a call from the ED. The word is that our patient will not only live, but will be back in the nursing home within a couple of days, none the worse for wear. It’s some consolation at least, knowing that even though she had a DNR, she will be going back to her husband.

Future Missus has invited us to East Lake Podunk Community Hospital’s annual crawfish boil to commemorate National Nurse Week. The three of us are sitting on a blanket on the hospital’s south lawn, devouring a huge mound of crawfish piled between us, taking painstaking care to keep from staining our uniform shirts.

Dr. Idris wandered by a few minutes ago, looking very relaxed. He sat his drink down next to mine, and I mistakenly picked it up and drank from it. Whatever it was, it burned like fire all the way down. It was definitely not tea, and I strongly suspect it was something that a nice Muslim fellow like Mohammed Idris should not be drinking.

Nevertheless, he seemed to be enjoying himself, and his wife could have driven him home if need be. He even sampled quite a few of the crawfish with us infidels, and then wandered off mumbling something about the men’s room.

“We should have warned him to wash his hands,” EP muses.

“Oh, I’m sure Dr. Idris knows to wash his hands after using the bathroom,” Future Missus admonishes.

“It’s not after he takes a piss that he needs to worry about,” EP explains tolerantly. “These crawfish are spicy, and he’s got cayenne all over his hands.” FM and I chuckle at the mental image.

She is leafing through a copy of Brides magazine, looking at wedding dresses. Since we’ve become engaged, EP has been dropping serious hints about being our wedding planner. Problem is, he has expensive tastes while I have an EMT pocketbook. He and FM are constantly whispering conspiratorially over flower arrangements, photographers, bridesmaid dresses and the like. I’ve washed my hands of it, requesting only that my groomsmen and I wear black tuxedos. I hate white tuxes.

“Medic 306, Dispatch. 1158 Highway 27 North, on a cardiac arrest,” the radio rudely interrupts EP extolling the virtues of a particular wedding dress. We both groan and reach for our shirts.

“We’re en-route,” I respond as FM sighs. I give her a quick peck on the cheek and sprint for the truck. Just north of the East Lake Podunk city limits, an old man flags us down. We back into his driveway as he impatiently shouts, “Hurry up!”

As soon as I get out of the rig, he confronts me angrily. “What take you so damned long?” he demands in a thick Cajun accent. “I call fifteen minute ago!”

“Calm down sir,” I reply, trying to placate him. “We just got the call no more than two minutes ago.” I step around him and help EP unload our gear. Inside the house we find two identical burly young men wearing identical overalls and white tee shirts, kneeling beside a frail body on the floor. They have the large, calloused hands of pulpwood haulers, and are delicately yet efficiently doing picture-perfect CPR on an elderly woman. The one doing compressions looks up as we enter the room.

“My grande mama,” he tells us breathlessly in an accent every bit as thick as his father’s. “She fall out mebbe two, t’ree minutes gone.”

“Mais non, she got a bad heart,” the man’s brother confirms.

“Okay gentlemen, step back please,” I order as I check for breathing and a pulse. There is neither, and I gesture for them to resume CPR. The cardiac monitor shows coarse ventricular fibrillation, so I charge the paddles and shock her. Her back arches violently, drawing a muttered oath from the twins. The monitor rhythm changes to sinus bradycardia and I feel for a carotid pulse, slowly breaking into a grin as I feel a strong, steady beat. She is still not breathing, however.

“Is she back?” EP asks hopefully.

“I think so,” I nod, to the relieved sighs of everyone present. “Get some vital signs, okay?” I ask EP as I begin to prepare my intubation equipment. I ask one of the twins, “Keep breathing for her for a minute, would you?”

I’ve just inserted the tube and inflated the cuff when a commotion at the door attracts my attention. Dr. Idris is standing there brushing off the mud he got on his pants from falling on the porch steps. His wife is standing just behind him, looking concerned.

“I saw the ambulance outside,” he explains. “What happened to Mrs. Pitre?”

“Ah, the doctor, he done come!” the old man exults, throwing his hands into the air. “Everyt’ing be all right now, you watch and see,” he assures his grandsons.

I am still trying to frame my reply to Dr. Idris when Mrs. Pitre arc
hes her back again, gags and pulls out the endotracheal tube before I can stop her.

Ouch! That’s not going to help her singing voice.

“Cardiac arrest, as best we can tell,” I tell him. “We shocked her once and converted her, and as you can see, she just extubated herself.”

Please don’t come any closer, Dr. Idris. They’ll be able to smell the liquor on your breath.

“Okay, then give her 100 milligrams of lidocaine and set up a drip at…” he trails off, noting my amused expression. “Well, you know what to do,” he finishes. “I’ll meet you at the hospital.” I say nothing as he steps into the room and helps us package and load Mrs. Pitre on the stretcher. Thankfully, her family stays several steps away, out of sniffing distance.

“Look, we’ve got this under control,” I lean close and say softly to him, putting one hand on his shoulder. “Why don’t you let your wife drive you home, and then call Dr. Saleh with any orders you have?” I suggest gently. He meets my eyes for a long minute, then nods and backs out the door. The Pitre family waves at him gratefully as his wife drives him away.

“Merci beaucoup, Doc!” they bellow as his taillights fade into the night. “T’ank you so much!”

Hey folks, what about our thanks? What are we, chopped liver?

In the truck, Mrs. Pitre is quickly regaining consciousness. She has no memory of what happened. “I felt kind of swimmy-headed, that’s all,” she says hoarsely. “That’s all I remember.”

“Well, your grandsons were doing CPR on you when we got there,” I tell her as I gently slip a twenty-gauge catheter into the back of her left hand. She flinches slightly, then smiles at me as I mutter “Sorry,” apologetically. I bolus her with lidocaine as soon as I have the IV secured.

I have just enough time to set up the lidocaine infusion before we pull up to the hospital. I toss the spiked bag on her lap as we roll her inside. Melba Guidry and Sadie Dawson meet us in the ER.

“Dr. Idris already called,” Melba tells us. “Take her to Room one-sixteen.” “

Here,” I reply, handing her the lidocaine bag, “I mixed this, but didn’t have the time to hook it up. Dr. Idris gave me verbal orders for-”

“He called in all the orders,” Melba interrupts me as we walk down the hall, “but Dr. Saleh is coming in to evaluate her. What’s up with that?” she wants to know.

“Did you see him at the crawfish boil?” I ask her pointedly. Her eyes narrow slightly, and she nods in understanding. She enters the room ahead of us, then shoos us away as soon as we transfer Mrs. Pitre over to the hospital bed.

“Get out of here, you two,” she tells us mock-sternly. “I’ve got to get this lady undressed and get a gown on her.” We don’t argue as Melba ushers us firmly from the room.

I’ve already seen her tits, Melba. I’m the one that defibrillated her.

EP ducks into the men’s room down the hall to relieve his bladder. I’m sitting at the nurse’s desk completing my report as Melba emerges from the room.

“Did they know?” she asks me quietly, meaning the Pitres.

“No, they never got close enough to smell his breath,” I shake my head.

“Lucky for him,” she sniffs.

“He wasn’t on duty, Melba. He was just at a party. He saw an ambulance at a patient’s house on the way home, and he stopped to help. He had enough sense to stay out of the way, and he had enough sense to let Dr. Saleh handle things up here,” I remind her.

“I guess so,” she admits grudgingly, and then turns her head at the sound of a painful yelp coming from the men’s room. EP emerges a minute later, wincing a bit and grinning ruefully.

“Damned crawfish,” he explains sheepishly. “I forgot to wash my hands first.”

Hoo boy, did I evoke some comments on my last post!

So much so, that I’ll debate here rather than in comments.

LawDog asked:

So, a 5% chance — one in twenty will survive — isn’t worth trying?

When does the survival chance become worth working on?

10%? 25%? 50%?

The 5% figure refers to medical cardiac arrest. As I stated in the post, there are some places in the country that have ROSC (return of spontaneous circulation) rates that are upwards of 20%. The majority of those “saves” will never leave the hospital alive. Please understand I’m not advocating that we don’t attempt resuscitation on these people, even considering the dismal outcomes. In fact, for the vast majority of medical prehospital cardiac arrests, the patient regains a pulse in the field or not at all.

But to borrow a phrase from LawDog, trauma arrests are another kettle of fish entirely. These people arrested from physical damage to vital organs. Repairing such damage requires rapid surgical intervention – something medics cannot do. A great many of the trauma codes I see brought in by EMS would not have been salvageable even if the accident had occurred in the ER parking lot. The survival rate is substantially less than 1% of all prehospital traumatic arrests. Not to wax hyperbolic, but for some of these attempts, the medic’s chance of dying during the transport comes close to exceeding the patient’s chance of surviving.

Jules said:

I know this because I’ve been there and 3 years later watched him walk down the isle as the Best man to my daughters Maid of honor…humbling to say the least.

So yeah…there is a season and a time…who makes that call?

We make that call. Or at least, we should be. Not to discount what I’m sure was a very happy outcome, but your story equals anecdote, Jules, not evidence. EMS practice cannot be driven by what might happen with that one-in-a-million patient.

I’d like to ask you a couple of questions about the kid saved. Was he multi-systems trauma? Blunt or penetrating? What was his presenting cardiac rhythm?

The data is pretty compelling. Blunt trauma cardiac arrest patients with severe damage to more than one body system do not survive.

Asystolic trauma patients do not survive.

Penetrating trauma arrests with PEA (pulseless electrical activity) rates of less than 40 do not survive.

P.J. Geraghty pointed out:

Keep in mind the >96,000 people waiting for organ transplants. It’s often hard to diagnose internal injuries rapidly upon arrival at a chaotic scene, and if you can restore a pulse in a reasonable time, that patient might be able to donate organs. This has the potential to save several other lives, as well as help console his family in their grief.

It won’t happen in every case, but quite a few of my cases start as out-of-hospital traumatic cardiac arrests that were resuscitated by EMS.

Excellent point PJ, and one I failed to address. But I’ll disagree with you slightly on diagnosing the internal injuries. Yeah, the exact cause of death may only be apparent after an autopsy, but I’d posit that a competent EMT should be able to at least determine the gross extent of injuries. You may not know that it was a dissected aorta that did the job, but you can note that rib fractures, a distended belly, lower extremity long bone fractures and blood/CSF leaking from the ears equals more problems than can be fixed.

I’ll ask you the same question I asked Jules: In your experience, of those organ harvests that started out as prehospital traumatic cardiac arrest “saves,” what percentage of them were multi-systems trauma with asystole or slow PEA as the presenting rhythm? Perhaps you’ll prove me wrong, but I’d bet damned few. I’d bet on most of them being VF, VT or fast PEA rhythms initially, or isolated trauma.

If you have some data that suggests otherwise, I’ll be happy to post it here in an update, and we can all learn something.

Divemedic wrote:

I also practice in an area where our save percentage of WORKED medical arrest patients exceeds 20% for return of pulses. Less than half of those ever survive to hospital discharge. The majority of those that do, present in VF, VT, or a PEA with a rate greater than 40.

Patients presenting with asystole as the initial rhythm rarely survive. Patients who arrest as a result of trauma rarely survive.

I have never seen a trauma patient who presents in asystole survive. Not one. In 18 years, not one.

Your experience mirrors my own, and pretty much falls right in line with NAEMSP’s position paper on the subject.

Mr Fixit wrote:

We do not do what we do based on outcomes. We do what we do because those are the things we can do, and hope for the best outcome.

You are dead wrong there, Blog Brother. We do base our practice on outcomes. This is what drives medical care forward. Why ain’t we giving high dose epinephrine any more? What about pneumatic shock trousers? Rotating tourniquets? Prophylactic lidocaine in myocardial infarction? Bleeding people with leeches? Chanting and incense?

Because those things did not improve outcomes.

You’ve been a medic at least ten years. Think back on all the medical “facts” you learned in medical school that have been proven wrong since then. Paying attention to outcomes in what leads us to abandon old practices that do not work in favor of new ones that do.

Another issue to be considered is finite resources. There comes a time when you stop certain practices because they are simply a waste of time and money. I’ll put it to you this way: If, while you’re feverishly working
a futile traumatic arrest, you get another another call in your district for a 14 year old with severe asthma and respiratory arrest. The covering truck is five minutes further away, and the resultant delay proves fatal for the kid.

Is that your fault? No. But was it preventable? I’d say yes. You had finite resources tied up on a patient that 999 times out of 1000, will die anyway. The 1/1000 that lives will most likely be a vegetable.

You went on to say:

Every transport should be the same. We wouldn’t decide that it’s OK to stop by and get a coke while we are transporting a heart attack.

Every patient deserves a prompt and professional response. Not all of those will warrant the same treatment, or even transport at all. You’re confusing my argument for intelligent use of resources with cherrypicking who deserves proper care.

The days of “you call, we haul” will soon be over, if they aren’t already. A more intelligent philosophy would be “you call, we respond.”

While we’re on that subject, how does it make sense that we design EMS systems to best serve less than 1% of our patients (cardiac arrests)? If your fire department served an area that was 99% high rise buildings, what sense would it make to focus your training, deployment and equipment purchases on the 1% that are single story wood frame homes?

Folks, I welcome debate. I consider this your blog, too. I write it to amuse myself, but I’d be lying if I said your opinions don’t matter to me. If or when more people weigh in, I’ll update this post. If this subject bores you to tears, feel free to skip this one and browse the archives or check out the next post.

My opinion is that we shouldn’t attempt to resuscitate multiple systems traumatic arrests, particularly those that present with no cardiac electrical activity. It’s a position based on my experience and good scientific evidence. It’s not playing God. It is intelligent use of resources, including the lives of the rescuers, who are at increased risk every time we turn on those lights and sirens.

I got into this profession to help people. I’ve stayed in it for the same reason. Beneath this hard, cynical exterior is a warm, gooey center. But I’ve come to believe that I need to focus my physical, mental and emotional energy on the patients that can be helped. Doing a resuscitation for the benefit of family or bystanders ultimately only builds false hope that we can’t fulfill, and unreasonable expectations that we as a profession are unprepared to meet.

Y’all take care – of your patients and yourselves.

Update: 5-06-07

Janean wrote:

I hope you won’t think me a chicken if I choose to work a 6 year old neighbor with marked lividity because his mother is standing right beside me begging me to do something when I want to smack her for not taking him to the ER last night when he was coughing so hard and running a fever.

Of course I won’t think you’re a chicken. I’ve done the same thing myself, and I’ve also withheld resuscitation attempts on an obvious SIDS baby while the father took the house apart in his grief and rage. It’s hard.

On the other hand, back in the day I was the Emergency Medical Services for Children program coordinator for Louisiana, for a brief while. One of the projects we were doing was assisting in the formation of infant and child death review panels for each parish – they reviewed the circumstances of out-of-hospital pediatric deaths, and recommended autopsies and further investigation where warranted.

At the formation of one review panel, a coroner (also a pathologist, which isn’t as common as you might think) asked me pointedly, “Why are EMTs required to attempt resuscitation on every baby, even the ones who are obviously dead?”

“They aren’t,” I answered, “most likely they were doing it in a misguided attempt to treat the family’s grief.”

“Well, we’ve had a number of cases of potential child abuse go unprosecuted because the scene and the body were so contaminated by EMS resuscitation attempts,” the coroner and the sheriff told me.

That floored me, I’m here to tell you. Not only does the “courtesy code” cruelly build false help where there is none, but it may also keep a child murderer from being prosecuted. I’d imagine that is a rare occurrence, but it’s food for thought.

And Matt G. asked in a post on his blog:

While you’re passing on such pearls of wisdom, you think that you could circulate the concept to rural fire personnel that they don’t have to run lights and sirens when, say… they’re going to lunch? That it’s possible to run the lights without the siren? That, when they run Code 3 to a Citizen Requests Assistance (Fell down; can’t get back up) call in which the dispatcher specifically said during the page-out that the caller had begged for no lights and sirens in her cul de sac neighborhood, that she’ll likely decide NOT to call, next time she could use the assistance of a burly firefighter or two?

Sad but true, brother. In defense of the fire department, a number of rather large, urban departments have a policy of using lights and siren on every response and every patient transport, no matter how trivial the call or how stable the patient. So it ain’t necessarily limited to rural volunteers.

Lights and siren use is coming under increased scrutiny around the country. More and more insurers and risk managers are asking pointed questions about whether a particular call or condition actually warrants the increased risk of lights and sirens. Many forward-thinking EMS agencies are changing policies to limit the use of lights and sirens. I seem to recall as study that showed, in urban settings, lights and siren use only decreased response time by 30 seconds or so, while exponentially increasing the chances of an accident.

You’ve seen how motorists act when you turn on the woo woo box – most of them lose their freaking minds. Contrary to popular belief, lights and sirens usually increase the likelihood of an accident.

Update, part deux: 5-06-07

Gary makes an excellent point on the percentages in the comments section.

I’d like to ask my fellow EMS professionals a question:

What is it with working the useless trauma codes, folks?

And by “useless trauma codes,” I’m talking about 99% of the ones we transport.

I’ll admit to a certain fascination with resuscitation, particularly early in my career. I think every medic has, to a certain extent. Resuscitations are hard work, but they also represent the opportunity for us to utilize all our skills, and what medic wouldn’t be jazzed by that?

Raise your hands if you’ve ever thought or voiced the following sentiment:

“Damn, I’m bored. I could use a really good cardiac arrest call right now.”

Yeah, that’s what I thought. Just about every EMT has – hey, wait a minute. You there, in the back. You don’t have your hand raised. Yes you, the one with the moist eyes and perpetually wringing hands. You mean to tell me you’ve never wished death on your fellow man to relieve your boredom, even in the abstract?

Please pick yourself off the floor, Empathy Boy. I didn’t mean wishing death on specific people. I’m talking hypothetically, that if Billy Bob was destined to arrest anyway, that you fervently hope it happens in your district, on your shift.

Oh, so you have voiced that sentiment? Yeah, thought so. You may sit down now, Empathy Boy. Perhaps you aren’t too namby pamby to be in EMS after all.

So since we’re pretty much unanimous in that sentiment, let’s talk about what we expect to accomplish.

Do we really expect to save a life? Nationwide, the survival rate from out-of-hospital cardiac arrest hovers around 5%. If you happen to live in one of those large urban centers with progressive EMS systems, perhaps your chances are substantially higher, but still, most places have survival rates not much higher than they were in the days of Johnny and Roy, and that presupposes a medical arrest. Traumatic arrest survival rates are less than one percent, and that number includes a very high percentage of people who “survive” in a neurologically devastated state.

Were it me, I’d just as soon not be a turnip, thankyouverymuch.

Are we practicing on the dead, in the hopes that we keep our skills and minds sharp to help the next salvageable patient? Perhaps some merit to that, I suppose.

But the simple truth is, the vast majority of traumatic cardiac arrests are dead when we get there. Dead, as in Assuming Room Temperature. Gone on the Celestial Transfer. Admitted to the Eternal Care Unit. Soon to be eating their salads from the roots up. D-E-A-D.

I won’t bore you with the science, but NAEMSP has a position paper on the subject that outlines some common sense guidelines pretty well.

I’ll boil it down for you:

Victims of blunt, multiple-systems trauma who are absent of vital signs on arrival of EMS are dead, no matter what rhythm you get on the monitor.

Victims of isolated blunt trauma to one body system who are absent of vital signs on arrival of EMS and present with asystole are dead.

Victims of penetrating trauma who are absent of vital signs on arrival of EMS and present with asystole are dead. You can add pretty much anybody with a rhythm of less than 40 beats a minute to that list.

Any traumatic arrest victim that requires fifteen minutes or more in transport time is dead.

Those people are no longer viable. They have been reduced to a tragic statistic. Every time you load ‘em in the rig, turn on the woo woo box and go tear-assing through the streets in a futile effort to save that life, your chances of becoming a tragic statistic increase exponentially.

We are gathered here today to mourn the passing of John EMT and Jerry Medic, selfless caregivers who gave their lives in the service of their fellow man. John and Jerry died trying to save a wreck victim with a fractured skull, cardiac tamponade, bilateral pneumothoraces, and a stellate liver fracture, but who also happened to have an agonal rhythm on the monitor. Funeral services for the mother and two children they hit will be here in the chapel at 2:00 pm Tuesday.

Unless you want a similar eulogy, practice a little common sense, please.

Jeff B poses the question on his blog:

Since Sheryl Crow only wants us to use one sheet of paper per visit (apparently trees are such a scarce commodity these days,) and since the Spotted Owl is making a comeback and isn’t endangered anymore, can I wipe with owl feathers?

Heh. Good question. Personally, I think Cheryl needs to be wiping with this:

“Where do you want to park?”

“Doesn’t matter. As long as it has some shade.”

“We could park outside of McAlister’s…”

“Fine with me.”

“Or we could pull around behind the medical mall. Would that be okay?”

“Sounds good.”

“Do you need a Coke or something first? Want me to run by the Jiffy Stop?”

“Nah, I’m good.”

“Well, we could park on the back side of the Jiffy Stop, and that way you could just run inside if you wanted a Coke or a snack or something…”

“Fine.”

“…but I’ll park wherever you want me to.”

“WILL YOU SHUT THE FUCK UP AND PARK, ALREADY? For Pete’s sake, what is it with you and all the questions? Do you find it that difficult to make a decision?”

“I’m sorry. You just…intimidate…me. I don’t want to fuck up.”

Intimidate? Moi? I am Mister Warm and Fuzzy. I am nice to old ladies. Children love me.

“Have I ever, even once, jumped your ass for anything?” I ask tiredly. “What has you so afraid of me?”

“Nothing you’ve done, AD,” she concedes. “You just have this… reputation.”

Reputation? REPUTATION? Jeez, don’t tell me this whole Doctor Ambulance Driver thing is going around again…

“People call you Doctor AD,” she explains. “They say you know more than most of the doctors around here. I just want you to think I’m a good paramedic.”

I roll my eyes knowingly. “They say I’m better than the doctors, or do they say I think I’m better than the doctors?”

“Well, some of them say you think you’re better than the doctors,” she clarifies, “but most of them actually say you are better than the doctors. And frankly, that intimidates the shit out of me when I work with you.”

“Allison, I can’t control what people say or think about me,” I sigh tiredly. “I have my head up my ass just as often as anyone else. I screw up. I make mistakes. And contrary to popular belief, I am not an egomaniac who thinks he is more qualified than any of the ER docs around here. I’m a college dropout. Even the worst of them has three times the education I have.”

She says nothing, just raises an eyebrow.

“Okay, maybe I’m more qualified than Dr. Kirk, but he doesn’t count. Even the other doctors think he’s an incompetent ass.”

“I’m really not like this all the time,” Allison explains earnestly. “I only get this performance anxiety when I work with you.”

“What does that have to do with finding a fucking place to park the ambulance?” I whimper plaintively. “It’s a hundred degrees out there, the air conditioner ain’t working worth a damn, and all I want is to find a shady spot and go to sleep until Satan calls our unit on the radio. You don’t have to kiss my ass or cater to my every whim. You’re my partner. I’m not going to bite your head off, Allison. “

“Do you think I’m a good medic, AD?” she asks, almost tearfully. I groan and lean forward, banging my head repeatedly against the dash.

“Yes – bang, bang – I think you’re a good medic – bang, bang – you’re the best darned medic I’ve ever worked with - bang, bang – plus you’re smokin’ hot and every guy that works here envies me for working with you – bang, bang – and I’ll pledge my undying love and respect if you will just find a shady place to park this fucking diesel-powered sauna - bang, bang - so I can do my fucking Sunday crossword and catch a nap - bang, bang – PLEASE. I’m begging you.”

Allison sighs and pulls the rig around to the back side of the medical mall, parking under the awning in the shade. The radio stays mercifully quiet as I finish my crossword, and I roll my rain gear up to serve as a pillow, prop my head against the window and try to find a comfortable position. It isn’t easy. The air conditioning has barely begun to cool the rig, and the temperature outside is already approaching ninety – at 9:30 am.

I am six-feet-two and, shall we say, big boned. A less charitable definition might define me as fat and hopelessly out of shape. Even our biggest units lack the legroom for me to be comfortable, and I can’t go lie down on the stretcher to catch a nap. I can’t rely on Allison to hear the radio if we should both doze off, not to mention the fact that she is incapable of navigating the parish without my help, so I stay up front and try to wedge my bulk into a semi-comfortable position.

The air conditioner blows gently on my face as I slowly drift off to sleep…

“Control to 307,” says a disembodied voice, then repeats it again, with an edge. “Control to three.Oh. Seven.”

I awaken with a start and look over at Allison, head back and snoring with a cardiology book propped on the steering wheel.

“307,” I respond. “Did you have traffic?”

“Ten-four, 307!” comes the snippy reply. “Traumatic injury, 2354 Johnson Ferry Road. Parish Fire is responding.”

“What kind of traumatic injury, Control?”

Penis caught in a zipper? Chainsaw massacre? Thermonuclear detonation? Another ostrich attack? Would it trouble you to provide a little more information, Satan?

“Unknown at this time, 307,” comes the unhelpful reply. “Bad cellular phone connection, and we’re not sure on the location.”

“307 en route,” I yawn as Allison puts the rig in gear and engages the lights and siren.

“I hate that bitch,” she mutters as we pull into traffic. A green Chevy Lumina panic stops in front of us, forcing Allison to swerve to the right.

“Hate is such a strong word,” I tease. “Besides, she can’t help the way she is. The head injury left her with nothing but a sour attitude and the ability to tie her shoelaces. And dispatch, of course. We should be happy she can still control her bowels.”

“She hates my guts,” Allison says adamantly. “She always gives me the shit details.”

“I’ve noticed that. Since I’m your partner, I tend to get splattered with it, too. She hates you because you’re young and attractive, while she looks like six pounds of soft shit in a four pound sack. Plus, she hasn’t been laid since the Reagan administration. She’s entitled to be a little cranky.”

“She is evil, and she must be destroyed,” Allison intones solemnly, then brakes hard at the Interstate on-ramp. “Which way?”

“Westbound,” I say, pointing. “I’ll agree she is an agent of Satan, but her duties are large
ly ceremonial.”

Allison floors the accelerator as we merge onto the Interstate, and the old rig lumbers up past eighty-five and tops out there. Eighty-five doesn’t sound fast, unless you’re in a vehicle with a braking distance and turn radius slightly smaller than the average ocean liner. I whimper silently and suck a little bit of velour up my ass as Allison crowds a slow-moving Ford pickup. She curses and honks the air horn repeatedly.

Our Father, who art in Heaven…I wish she wouldn’t pick emergency driving as the avenue to demonstrate her assertiveness and confidence. She drives like a fucking NASCAR driv – JESUS CHRIST! She’s going to kill us both.

Allison becomes aware of my feet stomping the imaginary brake pedal as she weaves back into the other lane, with scant feet between our rear bumper and the car behind us.

“Idiots!” she says disgustedly, but with an insanely happy grin on her face. I reply with a sickly grimace of my own.

“Remember the First Axiom of Emergency Driving,” I say through gritted teeth as I grip the Jesus Handle on the windshield pillar. “Anyone driving slower than you is an idiot. Anyone driving faster than you is…a maniac.”

“Are you okay?” she asks with a concerned glance.

“Just fine!” I lie. “You know, it does us no good to get exactly halfway to the scene really, really fast.”

“Sorry,” she blushes, easing her foot off the accelerator.

“Take Exit 37 North,” I direct, “about three miles up. Johnson Ferry Road is way the hell up Highway 22. It runs back toward the river.”

“Gotcha,” she nods. As we exit off the Interstate onto less congested parish roads, I lay my head back on the seat and try to think Happy Thoughts.

“Just go north until you get to the fork in the road,” I yawn sleepily. “Johnson Ferry goes to the left. Wake me up when we get there.”

Ten minutes later, I feel the truck brake hard and yaw to the left. I open my eyes just in time to see the Johnson Ferry Road sign flash by my window.

“Have a nice nap?” Allison inquires sarcastically. “Thanks so much for all the help navigating.”

“Don’t mention it,” I say graciously. “Take it as proof of my utter confidence in your stellar paramedical skills.”

“So where are we going?” she asks, scanning the side roads.

Damifino. And neither does dispatch.

“Slow down and look for a water trail,” I advise, only to get a blank look in reply. I smile tolerantly. “Metropolitan Parish Fire Department has a station not five miles from here. If I were a betting man, I’d say one of their small tankers is already on scene.”

As if on cue, the radio crackles, “Parish Fire to Corporate Greed EMS Unit responding to the incident on Johnson Ferry Road.”

“CGEMS 307, go ahead.”

“ETA, 307?”

“No idea, Parish Fire. Where are y’all?”

“Come all the way to the dead end. The patient is in the woods about three hundred yards down a logging road. Man had a tree fall on him.”

I’ll bet that smarted.

“We see your truck, Parish Fire. Control, you can mark our unit on scene.”

Allison pulls the rig to the logging road and pauses there hesitantly. “Whaddaya think?” she asks.

I roll down the window and look at the rough trail. It looks firm enough. God knows, there is no mud. Everything is parched, covered with six inches of powdery dust.

“Should be okay,” I judge. “Plus, I’m not all that jazzed about walking three hundred yards through this shit. Let’s see how close we can get to this guy.”

She eases the rig down the logging trail, and my judgement is soon proven correct. The trail is indeed firm enough to hold the rig.

Unfortunately, it’s also only slightly less rough than an oxcart ride across the Himalayas, with the oxen going at full gallop. Not that it matters, though. This is going to turn out to be a body recovery.

Perhaps a couple of hundred yards down the logging road, we find a clearing with a small Caterpillar dozer parked in it. Beyond it is a cluster of people kneeling behind a log, several of them wearing the blue tee shirts of the Metropolitan Parish Fire Department.

“Well look who it is,” grins one of the fire department EMTs, “Beauty and the Beast!”

“Don’t call my partner a beast,” I admonish. “She’s sensitive. What have we got?”

“Guy was cutting out some dead falls, and he cut the wrong one,” he straightens up, gesturing at the man laying on the ground. “The one he cut was holding another one up, and it fell on him.”

Oh shit, that guy ain’t good. In clinical terms, he is Circling the Drain.

“I told him to leave that damned snag alone,” another logger says, anguished. “There was a bunch of vines between the two trees, and when the tree he was cutting fell, it jerked the rotten snag down on him.”

“How ya doing, partner?” I say gently, kneeling next to the man. He’s lying on his right side, and his skin is an unhealthy gray. I place my hand on his shoulder and am struck by how cool he feels.

“Can’t breathe,” he gasps painfully. “And my back hurts, too.”

No shit. You’ve got a knot the size of both my fists right at the base of your thoracic spine, and from the looks of things, a crushed chest as well. Plus, you’re probably paralyzed.

“My partner’s gonna put some oxygen on you to help with that breathing, partner,” I reassure him, “so just take it slow and easy, and we’ll get you outta here pretty soon. What’s your name, anyway?”

“Larry,” he gasps, sucking in shallow breaths of 100% oxygen. Around his neck is a No Neck cervical collar, pitifully small for a man of his height. Larry is tall and rangy, with a farmer’s tan – brown neck, arms and hands, fish belly white torso under the filthy tee shirt the firemen had cut away

Well, now we know that the No Neck Fits Everyone Society still has plenty of members. At least they had started assessing him, though.

I slowly run my hands down Larry’s torso, noting the coolness of his skin and the Rice Krispies sensation of subcutaneous air under his armpits. Broken ribs on both sides of his chest click as I palpate, accompanied by an agonized groan from Larry. I gingerly probe the massive swelling on his back, expecting to feel pulp. I am not disappointed.

“Larry, can you feel me touching your hands?” I ask, thankful for the affirmative answer. “Okay, now how about your feet? Wiggle your feet for me, please.” Larry complies, moving both feet.

Okay, I am officially fucking amazed.

I look up to see Allison hovering nearby, holding the portable oxygen tank.

Okay, so we’re back to you acting like the subordinate and letting me run the calls, is that it? At some point, you’re gonna have to fly on your own.

“Want an IV?” she asks.

“Nope,” I shake my head. “We’ll get that in the rig. We gotta go now, and we’ve done all we can do here. I want a rapid diesel bolus to West Big City Regional as soon as we can get him loaded, so bring me the spine board.”

“Already got the board right here,” calls one fireman, attaching straps to the board as he talks. “Want me to get the stretcher?”

I look around at the minefield of stumps, small saplings and sawdust, and the powdery fine dust that permeates everything in the area.

“No, I think we’re better off just carrying him to the rig on the spine board. But I will need just about every sheet and towel you can find.” He nods, hands the spine board to his partner, and sprints for the ambulance. I motion Allison and the other two firefighters into place beside Larry.

“Hey, Larry?” I warn. “We have to put you on a board in just a few moments for the trip out of here. It’s probably gonna hurt, man.”

“Can’t you give me something for the p-p-pain?” he gasps.

I wish I could, brother. Even though I don’t have a blood pressure on you, but I’d bet money it’s pretty damned low.

“I’m sorry I can’t, Larry,” I apologize. “Maybe once we get you to the truck, I can d
o something about that.”

After I’ve done all sorts of other painful things to you, of course.

The firefighter I sent to get blankets is back, waiting expectantly.

“Lay them out on the board,” I direct. “Pad as much as you can all along the board, but leave a hole for his back.”

The firefighter nods his understanding, hurriedly taping blankets to the board. He kneels next to the patient and wedges the board behind him, and with a lot of grunting and some semi-coordinated pushing and pulling, we get Larry secured to the board. He’s even still able to move his legs afterward. No small victory, that.

Larry’s color has me worried. I’m pretty sure he has bilateral pneumos, and no doubt some intra-abdominal bleeding. His radial pulses are rapid, weak and thready and his breathing is shallow. I’d like to listen to his breath sounds, but I left my stethoscope in the rig.

Improvising, I place my hands on either side of Larry’s chest, mentally wincing at the rib crepitus I feel there. “Larry, I need you to do me a favor,” I tell him. “Repeat a phrase for me. I want you to say the words ‘ninety-nine’, okay?”

“Ninety-nine,” he heaves. “Dude, I’m thirsty.”

Add that to the growing list of Bad Fucking Signs. At least you have tactile fremitus on both sides of your chest, so your lungs haven’t totally collapsed. We need to get you to the truck without paralyzing you, though.

I catch Allison looking at me worriedly. “That ride back to the blacktop is going to be rough,” she says quietly. “Do you think he can take it?”

She’s reading my mind. No, he can’t take it. We drove in at a crawl, and still I was banging my head off the bulkheads. It’ll be ten times worse in the patient compartment, and rolling the stretcher down this pig trail ain’t an option either.

“It would probably be a good idea to turn the rig around and drive back to the road,” I answer. “The firefighters and I will carry him out to the road. We’ll meet you there.”

Allison nods and sprints to the rig as we each grab a corner of the spine board and heft Larry off the ground as gently as we can. None of them seems particularly enthused at the prospect of toting his 180-odd pounds the three hundred yards back to the asphalt. We draft the other logger into Sherpa duty, carrying the rescue bags and oxygen cylinder.

“Okay guys,” I sigh. “Let’s do it, as smoothly as we can.”

At my direction, we start carrying Larry out of the woods. We haven’t made it the fifty yards through the clearing before I can hear my body talking to me:

Brainstem: “Uh oh. I sense some physical exertion here. The Fat Boy ain’t exerted himself this much since the stampede at the All You Can Eat Crawfish Buffet. Okay, let’s get moving folks! Sympathetic nervous system, we need some adrenaline! Lungs, deeper and faster! Heart, you know what to do!”

Adrenal glands: “One huge dose of epinephrine and norepinephrine, coming up!”

Heart: “Holy shit! Who stomped on the gas?”

Lungs: “Faster and deeper, check! Stretch receptors, kwitcher bitchin!”

Muscles: “We need a nap. Y’all keep the noise down up there!”

Brainstem: (sending a jolt of nerve impulses and increased blood flow to my skeletal muscles) “Wake up, you sluggards! Get with the program here!”

Muscles: (whining) But we don’t wanna! It’s too haaaaaard!”

Forebrain: “This ain’t so bad. I can do this. Maybe I’m not in such bad shape after all…”

Brainstem: “Uh oh, the sensors are detecting False Sense of Security and elevated levels of Self Delusion in the anterior cingulate gyrus. Release the Harsh Dose of Reality neurotransmitters!”

Heart: “I canna go much faster, Cap’n. I can maybe squeeze another thairty beats or so a minute, if you give me a wee bit o’ time…”

Lungs: “Okay, activate the Wheeze Mechanism!”

Muscles: “Okay, evidently Brainstem didn’t believe us when we said we’re sitting this one out. Send the bossy fucker a Cramp Message.”

Firefighter: “AD, you okay? You look a little…winded.”

Forebrain: “Did he just say what I thought he said? Pride, tell him to fuck off!”

Brainstem: “Okay, I’m detecting dangerous Hostility levels toward young, physically fit firefighters. Activate the Good Teamwork Internal Censor. Battle Stations, everybody! Heart, dammit man I need more power!!”

Heart: “I’m givin’ her all I’ve got Cap’n, and she’s barely holdin’ tageth’r!”

(Yes, my heart sounds just like James Doohan from Star Trek. Yours doesn’t?)

Hypothalamus: “Hey, I’m getting elevated temperature readings on all sensors! Activate Emergency Cooling Measures! Surface blood vessels, dilate! Sweat glands, activate!”

Sweat Glands: “Gimme a fucking break! He’s a fat guy! We’re ALWAYS running at 110% rated capacity!”

Firefighter:
“AD, you okay? You need us to stop and rest? Hey guys, I think AD is gonna pass out.”

Forebrain: “Fuck you, you disgustingly fit little simpleton. Take your young ass back to the station and polish your fire truck or something. Go lift a weight or something. Okay Legs, you can do this. Right. Left. Right. Left. Deep breaths. Can’t help Larry if you die from a heart attack first.”

Heart: “Dinna tempt me, ya’ fat bastarrd. Twas you got me inna such poor condition inna fairst place.”

Brainstem: “Uh oh, was that a Pep Talk? Okay everybody, you know what to do. REVOLT!”

Muscles: “Way ahead of you, Brainstem. Okay, Cramp Actuator wide open…NOW.”

Lungs: “Cough. Wheeze. Hack. Choke.”

Anal Sphincter: “Someone call my name?”

Stomach: “Send up a belch. Stand by for full reverse on the Peristalsis!”

We stagger the the back of the truck with my body in full revolt. What muscles that aren’t rubbery are cramping painfully. I’ve sweat so much that my uniform is entirely soaked, as if I had put it on directly from the washer. The powdery dust has adhered to my wet uniform, making me look like a big, fat, wheezing sugar cookie. My heart is hammering, my ears are roaring, and I can’t summon the breath to even speak. Luckily, Allison doesn’t need verbal directions to position the stretcher behind the truck with the rear doors open.

We strap Larry to the stretcher and load him into the rig, and I clamber in behind him. Allison already has two bags of fluid hanging.

Thank God. I think I’m going to need one of them for myself.

“IV access,” I croak to Allison as I stagger to the front of the truck, ripping my shirt open and standing directly in front of the air conditioner vents. I grab a blanket for Larry and toss it to one of the firefighters, motioning for him to drape it across my patient.

There’s no room to move – too many people in the truck. Firefighters are cutting the rest of Larry’s clothing off, Allison is starting an IV, and the fire captain is standing at the foot of the stretcher.

Fucker looks almost as bad as I feel. At least I’m not the only one here who is outta shape.

“So thirsty,” Larry whispers. “Can’t breathe.”

I motion for one of the firefighters to open a cabinet. “Water,” I gasp. One-word sentences are about all I can manage right now. I can see the incredulous looks on everyone’s faces even as I say it.

He’s not actually going to let this guy drink water, is he?

I motion impatiently for the water, but the firefighter finds nothing in the cabinet but bottles of sterile saline for irrigation. Suppressing the urge to whimper, I dig frantically through the oxygen cabinet and find two sealed humidifier chambers. I cut the tops off with my trauma shears and chug them down, right in front of Larry and the incredulous firefighters.

“Dude, what about me?” begs Larry plaintively. “You’re fucking cruel.“

I scoot Allison off to one side as I collapse on the bench seat. She finishes taping down her IV and looks at me expectantly. “Go,” I gasp, making a whirling motion in the air with my finger, praying that she interprets it correctly to mean lights and sirens.

She cocks one eyebrow as if to say, “You got this?” I nod reassuringly and give her a sickly smile. Allison scoots out the side door, slams the doors, and presently we are heading back the way we came, lights flashing and siren wailing.

I can’t hear Larry’s lung sounds in the back of the rig, but there is more subcutaneous emphysema in his axillae and the pulse oximeter won’t get a reading. I open
the IV wide open, wrap the automatic BP cuff around his arm, and fetch two long 14 gauge catheters from the IV cabinet.

Larry looks at me accusingly as I drain the last drop of water from the humidifier chamber with one hand while I swab his chest with the other. “So thirsty, and you’re drinking water right in front of me,” he says faintly. “Cruel bastard.”

You have no idea, Larry. The difference is, if you puke, you choke on it. If I puke, I just get the floor messy.

“I can’t give you any water,” I tell him as I unsheathe the needle. “And this may hurt you, but right now I’m trying to save your life.”

Without further preamble, I pierce Larry’s chest with the needle, right above the third rib in the mid-clavicular line. Air rushes out, and Larry barely has the time to grunt before I repeat the procedure on the other side of his chest. I slump back on the seat and punch the button on the automatic BP monitor.

So far, so good. If I can keep from passing out, we both just might make it. And his blood pressure is…what, 94/60? Not as bad as I thought, but he’s had five hundred of saline. Time for another IV.

As I’m looking for a vein in the other arm, I thumb the speed dial button on the cellular phone, still docked in its cradle.

“West Big City ER, this is Jeremy speaking. Go ahead with your report.”

“Hey Jeremy, it’s AD with Corporate Greed EMS. We’re…” I pause to look through the divider window between the patient module and the cab, and Allison holds up one hand, flashing all five fingers, twice. “…ten minutes out with a severe chest trauma, logger hit by a falling tree. Bilateral pneumos, probable thoracolumbar fractures, too. GCS 15 right now, though, and he’s moving everything. I’ve decompressed his chest, got him packaged, working on a second line. We’re gonna need a Trauma Room.”

“Vitals?” he wants to know.

“94/60, heart rate 136, respirations 30, saturation unobtainable.”

“Good enough,” he replies. “Room One on arrival. We’ll be waiting.”

I brace my forehead against the cabinetry and make the stick on Larry’s right arm, sinking a second 16 gauge catheter just inside the bend of his elbow. He winces and cries out.

“Goddamn!” he curses me. “Dude, I’m hurting here, and I’m sooooo thirsty. Don’t be cruel, man.”

Yeah, but you’re obviously breathing better. And your sat is starting to come up, too.

“Actually Larry,” I tell him, “I am fucking dripping with the milk of human compassion. It’s just that I can’t give you either of those things in your condition.”

Before Larry can reply, the truck slows and yaws right as Allison takes the Interstate exit to West Big City Memorial. We’re less than thirty seconds from the Emergency Department. I spend the little time I have left doing a quick secondary survey, looking for minor injuries. In addition to what I’ve already found, I suspect his left scapula is broken as well. His vitals have improved markedly, though.

“A ten foot section of tree trunk maybe two feet in diameter fell off the top of a dead snag,” I tell the ER doc as we wheel Larry into Room One. “Hit him square between the shoulders. Broken ribs on both sides, probably left scapula, too. Big deformity to his lower thoracic and upper lumbar spine – we padded as best we could. I decompressed both sides of his chest. He’s had a little more than 1500 of saline. Vitals as we were pulling in were BP 104/66, pulse 120, respirations 24. Saturation is up to 91% on high flow oxygen.”

“Neuro deficits and level of consciousness?” Dr. Shepherd asks, stepping back to allow a portable x-ray machine to be maneuvered to the bedside.

“Awake the whole time,” I answer, leaning unsteadily against the wall. “I never asked him if there was a loss of consciousness prior to our arrival. Motor and neuro intact in all extremities.”

“You okay?” Dr. Shepherd asks.

“Actually, I could use a couple of ice packs, a wet towel and a large glass of water,” I tell him.

“I can imagine,” he chuckles. “Hot as hell out there.”

“No Doc, you don’t understand,” I tell him, gripping the door as I try to stem the overwhelming dizziness threatening to engulf me. “Unless I get cooled off, right now, you guys are gonna be picking me up from the floor.”

“Get the stuff,” he says curtly to the unit clerk hovering outside the doorway. Shepherd scoots me down the wall a few feet until I’m out of the way of the resuscitation team, and then eases me to a sitting position on the floor. Presently, the clerk brings me the wet towel, ice packs and water.

“Thanks,” I tell him gratefully, draping the towel over my head and placing the ice packs on my neck and forehead. Dr. Shepherd turns his attention back to managing Larry’s chest trauma. I sit for a few minutes as my head gradually clears.

“I don’t know how you do it, AD,” the clerk says admiringly. “You damned near kill yourself trying to save a stranger’s life. I couldn’t do what you do.”

“Yeah,” I sigh ruefully. “I’m a real giver. Larry and I were just talking about how damned compassionate I am.”

Ummmm, okay. I’ll take a stab at this. Personally, I think Jesus was the first EMT. Case in point:

And Jesus went about all Galilee, teaching in their synagogues, and preaching the gospel of the kingdom, and healing all manner of sickness and all manner of disease among the people.

Matthew 4:23

Note that it says nothing about people bringing the sick to Jesus. Jesus went out among the people, healing the sick. Since biblical historians pretty much agree that Jesus was a carpenter, not a doctor making house calls, I’d posit that EMS was his part-time, volunteer gig. Aside from being the bartender and caterer that everyone wanted for their wedding, that is.

Plus, Jesus had the first field resuscitation. Although his response time sucked, he obviously had the medic chops to get the save, even with a 48 hour down time for the patient in question – all before the invention of CPR or defibrillators, no less.

So to quote those great 1970s philosophers, The Doobie Brothers…

Jesus is just all right with me.

I have been privileged to receive the April ROFL Award from Janean for this post.

Janean is a dear reader from Orygun who has been reading this little screed in the blogosphere since the very beginning.

Heh.

And still I haven’t managed to run her off with my profanity and feeble attempts at humor, and she even nominates me for an award suitable for hanging on my own little Ego Wall there on my sidebar!

Thanks, Janean!

To answer your question, yes.

And of course, malignant melanoma is soooo much more attractive.

And that’s all I got, folks – semi-humorous snark.

Some real bloggy goodness coming later tonight, though. I promise.

I feel like the new geeky kid at school who has suddenly been proclaimed cool by the homecoming queen and now everyone has shown up at my house for a party because my parents are out of town and even the jocks have stopped giving me wedgies and I’m really one of the popular kids and the hot senior chick totally wants to make it with me even though I’m a sophomore and holy shit I’m finally gonna get laid and…

…wait, where is everybody going? Hey guys, come back! I’m cool, I swear!

No, not you too, Senior Girl! I was just kidding about before! And I’ve got cool tunes, and we can break into my Dad’s liquor cabinet, and take his ‘Vette for a spin and…and we can play Twister, and I’m really good at Trivial Pursuit, and we have Jenga and, and…

…and gun porn! Yeah, would you stay if I posted some gun porn? Because I really really really want you to stay and keep coming back. I’ll do whatever it takes.

Really.

Guys? Uh, guys?

(crickets chirping)

Come baaaaack, Shane! Come baaaaack!