When you’re suddenly hit by a powerful craving for a PB&J sammich, and you discover, much to your chagrin, that you are out of jelly…

… a snack pack of your daughter’s strawberry Jello does not make an effective substitute.

Consider that another helpful hint from your Uncle Ambulance Driver.

… you sorely need a technical advisor. And if you already have one, fire him and hire someone with a decent background in medicine. Someone who knows in which hand one holds a laryngoscope would be nice.

In an era where many medical students admit that they pick up much of their medical technique from watching ER (and I only wish that was a joke), it would be nice if your hotshot concierge physician main character weren’t such a flaming dumbass when he picks up the tools of his trade.

Less MacGyver and more accurate medicine, mmkay?

Setting: The living room of Deputy Dawg, de facto headquarters of the Pine Street Mafia.

The Players: Ambulance Driver, Ex Wife, Husband-In-Law, Deputy Dawg and his Long Suffering Wife, and by way of DVD, Tony Horton.

Extras: Assorted spawn of the aforementioned Players, plus a few curious neighbors who wandered in to watch the show.

The Plot: The members of the Pine Street Mafia, in an effort to fend off obesity, have entered into a pact. Together, they will support each other in their efforts to eat healthy, exercise, and generally avoid impending fat-assitude. To that end, Husband-In-Law has procured a copy of the P90X Home Fitness System, in which we will become lean, ripped and sexxay by confusing our muscles with a variety of high-intensity, low impact… whatever. Just reading that shit makes me tired. Tonight’s scene is the preliminary stretching video which, as best I can tell, is a combination of yoga poses and exercises intended to convince Gitmo detainees into giving up the location of Bin Laden’s hideout. Hilarity ensues.

**********

Ambulance Driver (dubiously): “I’m not sure about this. I’m already dealing with a pulled muscle in my back…”

Ex Wife: “A little gentle stretching would do your back good. Just do the exercises you’re comfortable with.”

AD: “Just the exercises I’m comfortable with? Okay then, I’ll work the remote.”

Husband In Law (scornfully): “Pussy.”

Deputy Dawg: “Come on guys, it’s just stretching. How hard could it be?”

*ten minutes later*

AD: “Pant, wheeze, groan. So what do they call this pose again?”

DD: “At the jail, we called it ‘I’m Ready For My Body Cavity Search, Officer’.”

HIL (whimpering): “Okay I take it back. You’re not a pussy. Or maybe I am, too.”

Tony Horton: “Okay now, extend your arms in front of you, fingers spread… now draaaag your hands back to your chest as if you’re pulling them through concrete…”

KatyBeth: “Hey cool, spirit fingers!”

AD (snappishly): “I got yer spirit fingers. In fact, I’ve got two spirit fingers right – “

LSW (mortified): “Aydee!”

EW (calmly): “KatyBeth, leave the room. Go play with the other kids.”

KatyBeth: “But why is Daddy crying?”

DD: “Because Daddy’s a pus- … er, wimp.”

AD: “Daddy’s not crying, sweetie. But if Daddy were crying, it would probably be for the same reasons you cried when I stretched you this way. It hurts.”

EW (snapping): “Would y’all shut up? We’re supposed to be changing positions.”

Tony Horton: “Okay, so now we’re kneeling, knees hip-width apart… hells of your hands on your pelvis, fingers on your buttocks… now aaaarch your back…”

AD: “So what do they call this one?”

LSW: “I think he said it was The Camel.”

AD: “Bactrian camel or dromedary? Because I’m so freakin’ knotted up I’ve got two humps.”

LSW: “Speaking of Camels…”

DD (sternly): “If I can’t have ice cream, you can’t have a smoke break!”

HIL (who can’t even reach his buttocks): “Okay, time for a break. Somebody said something about ice cream?”

*ten more minutes*

DD (purple-faced, with vein throbbing prominently in center of forehead): “Dear sweet merciful Jesus. How much more of this?”

EW (encouragingly): “Only forty more minutes!”

HIL: “Mommy, make the bad man stop.”

LSW: “So what do they call this pose?”

DD: “Damned if I know. I haven’t been able to see the television for the last five minutes.”

Tony Horton (disgustingly perspiration-free): “Okay, and relaaaaaax. Now shake it out, everybody get loose… “

AD (groaning): “The only thing loose is my stools. And my back is worse, not better.”

HIL (to Ex Wife): “How the hell are you managing to do these?”

AD (grinning evilly): “She’s always been flexible. Ask me how I know.”

EW (warningly): “All right now…”

AD (innocently): “What? I was just gonna tell him about the time you bet me you could kick your foot over my shoulder!”

EW (snapping): “Nobody needs to hear that story, either!”

AD: “Took her three tries, HIL, but she did it. Then she lost her balance, fell back and wiped out our glider rocker… “

EW (doing her best to ignore me): “Um, can anyone else not hear the television?”

AD: “… spent three hours in the ER afterwards, then two days at home on a heating pad, gobbling ibuprofen. Couldn’t even wipe her own – “

EW (loudly, and just a lit
tle desperately): “Hey look, everybody! Position change!”

DD: “Thank. God. Somebody help me up.”

AD (smacking DD on the ass): “Who’s your daddy? Whooooo’s yo daaaaaaday? Say my name, bitch!”

Tony Horton: “Okay now, fingers spread, both arms over your head and reeeeach for the sky! Now bend to your left and reeeaaaaach with your right arm…”

AD: “Finally, an exercise I can do!”

KatyBeth (singsong): “Wave your haaaands in the air like you just don’t caaaaare…”

HIL: “Glide by the people as they start to look and stare…”

DD: “Do your dance, do your dance, quick! Mama, come on baby tell me what’s the word…”

LSW (speaking to EW): “I think the guys are starting to lose focus.”

AD: “Nonsense! We’re in this till the end, baby! What pose are we doing now?”

HIL: “Prison Bitch In Repose.”

EW (rolling her eyes): “Actually, it’s called The Frog.”

AD: “Whatever. Hey look, new position!”

Tony Horton: “Okay everyone, now we switch to Child’s Pose. Kneel on the floor, and sit on your feet, heels pointing outward… now lean forward and place your forehead on the ground… “

DD: “I know why they call it Child’s Pose. Only a child is that flexible.”

HIL: “What do we do if our gut won’t let us get our forehead within a foot of the floor?”

AD: “We look like penitents when we’re doing this. Shouldn’t we be facing toward Ogden?”

DD: “Good idea. Let’s all face northwest.”

EW (red-faced): “Could we just focus on the damned video for a few minutes? Please?”

*click*

LSW (boiling over): “If I see one more kid with a camera phone in his hand, you’re all grounded!”

Noggin (giggling, from the doorway): “Too late. I’ve been recording y’all for the past ten minutes. Can anybody say YouTube?”

**********

Noggin fled back across the street to his house before we could take his Blackberry, probably because we were all too sore to move faster than garden slugs. Deputy Dawg threatened him with summary expulsion from the Pine Street Mafia if he reported what he had seen to anyone. So far, no YouTube video.

We’re keeping our fingers crossed.

… the drivers in front of us usually look something like this.

Remember, EMS chirrens: Everyone driving faster than you is a maniac, and everyone driving slower than you is an idiot.

I’ve been a paramedic for fifteen years. I’ve been an instructor for six months longer than that.

Once upon a time, the Little Ambulance Service That Could sent me, a brand new EMT-B, to EMS Instructor School. We were competing with a much larger service in the area, and they were shutting us out of most of the available slots in the EMT courses. So when an opportunity arose for them to have their very own in-house instructor, I was drafted for the job. I assisted with my first EMT course six months before I earned my paramedic patch. With time and teaching experience, I became one of the cadre of senior instructors tasked with training and mentoring new EMS instructors in Louisiana. I did that for close to ten years.

I still get e-mails and phone calls from instructors I trained or mentored back then, seeking advice on one classroom issue or another. Through my blog, I get e-mails from instructors and students alike, seeking my opinion on a variety of subjects. Instructors ask how to deal with clueless administrators or problem students, students seek advice on dealing with problem instructors, and some who haven’t even begun their education seek counsel on how to prepare for the rigors of paramedic school. Sometimes I have good advice to offer, and for others I have no answers, able only to commiserate and say, “I feel your pain, brother.”

I have been a student forced to sit through a boring lecture, and I have been the instructor struggling to make esoteric medical trivia relevant to a classroom of disinterested people who would likely never use the information. I have worked for companies –as a medic and an instructor – who didn’t give a rat’s ass about education, and I’ve worked for others who considered it a cornerstone of good patient care. Some of the poorest companies, like the Little Ambulance Service That Could, invested far more time, money and effort in education than other companies with a hundred times their resources.

I have juggled school, work and family commitments. I have felt the frustration when the company that is paying for your education refuses to give you the time and support to actually learn something from it. I have paid money from my own pocket to hire a subject matter expert to lecture my class, and I have sat through a class when one of those subject matter experts – a PharmD – put everyone to sleep with a lecture that would have made a research biochemist slit his wrists to put an end to the boredom. To this day, I remember nothing of the chemical structures of the drugs he was supposed to cover, but I’m reasonably sure that if you could synthesize his voice, it would be a chemical analogue to Diprivan.

All this is to say that I have been there, done that, and currently own a closet full of EMS tee shirts emblazoned with witty sayings like “Just tube it!” or “EMS: Our day begins when yours is about to end.” I consider myself well qualified to speak to the issues faced by paramedic instructors and students alike.

Therefore, let there be no pretense between us when I offer a few observations about you, the paramedic student:

**********

You don’t know shit.

I’m not calling you stupid, just ignorant. Ignorance, if not curable, is at least treatable with education. Stupid, however, is utterly incurable and untreatable, as you will soon discover from many of your patients. Unfortunately, stupidity is not uniformly fatal. Instead of killing off its host rapidly, thus chlorinating the gene pool a bit, the stupidity virus often becomes latent, lying in wait for a moment of weakness. Then, like an attack of shingles, it blooms forth in an epic display of “Hey y’all, watch this!” splendor. This outbreak is what transforms the latently stupid into EMS patients.

Back in my freshman year of college, I had a professor who called this little truism “man’s capsule of knowledge.” Simply put, there is what man knows, and what man does not know. And the more man learns, the more he realizes how truly ignorant he really is. It is humanly impossible to ever make our knowledge outpace our ignorance, and there is no shame in admitting that. Unwillingness to recognize and acknowledge your ignorance, however, is just stupid.

And make no mistake, most of your more experienced or educated peers are operating from a position of ignorance, too. Lucy Hornstein, MD, explores this unfortunate fact in Declarations of A Dinosaur: Ten Laws I’ve Learned As a Family Doctor. In her book, Law #8 states, “Half of what is taught in medical school is wrong, but no one knows which half.”

Change “medical” to “paramedic,” and there you have the state of current EMS education. The only constant in this profession is the certainty that things will change. In five or ten years, you’re going to discover that half of what you learned in class is wrong… but you won’t know which half until then.

So, got that? You’re ignorant, your partners are ignorant, and your instructors are ignorant. For that matter, so am I.

After all, I taught all sorts of wrong information over the years, just like your paramedic instructors and the professors at Dr. Hornstein’s medical school. We taught students that spinal immobilization was beneficial and rarely harmful, that volume resuscitation in trauma patients saved lives, that the Golden Hour was based on scientific research, and PASG could auto-transfuse blood from the lower extremities to the trunk.

Now we know better. We know that spinal immobilization benefits very few, if any, patients, and may indeed harm some. Aggressive volume replacement, at least among trauma patients with uncontrolled internal bleeding, does harm. The Golden hour was a PR tool, not scientific fact, and as it turns out, the length of time spent outside the hospital makes very little difference in mortality most trauma patients; some die immediately despite our best efforts, some die weeks later from infection or organ failure, and the ones who make it out of the operating room alive don’t seem to notice the difference between twenty minutes or three hours in getting there. Lately, it even seems that supplemental oxygen administration – the most sacred of EMS cows – doesn’t make much difference for many of our patients, and may even harm some.

So yeah, we’re ignorant. But the difference between you and your instructors is, at least they have some inkling of how ignorant they are. So until you learn a little more, listen to what they have to say. Pay attention in class. Don’t ever let the words, “Why do we have to learn all this shit we’re never gonna use?” escape your lips, because right now, you’re too ignorant to know what information you will or won’t find useful. Much of the knowledge I’ve found useful over the years wasn’t even covered in my initial paramedic training, while much of what we spent the most time learning us has proven utterly irrelevant to patient care.

You’re going to be performing procedures on real, live people. You’re going to be administering chemicals that alter the function of the human body. It behooves you to know how that body works, and that requires a helluva lot more than being able to accurately label a diagram of the abdominal organs or the bones in the human body. When your car breaks down, are you going to take it to a mechanic, or to the pimply-faced kid behind the parts counter at Autozone? Because if your knowledge of the medications you give, and their effect on the body, extends no further than, “That’s the next drug in the algorithm,” all of your expensive paramedic education has done little more than make you the EMS equiva
lent of that pimply-faced kid manning the parts counter at Autozone. And would you really want to be that guy’s patient?

Whether it’s the intricacies of the Krebs Cycle and electron transport or membrane thresholds and action potentials, or a million other pieces of medical minutiae you may not appreciate now, a functional understanding of human anatomy and physiology is imperative to your success as a paramedic. You may not need to know the inner workings of the human body as deeply as, say, a physician, but you almost certainly need a greater depth of understanding than paramedics educated not even ten years ago. EMS as it is practiced today is a different creature than it was ten short years ago, and ten years from now if will be a different profession than you’re practicing today.

Your understanding of the human body will help you adapt to ever advancing changes in medical theory. That understanding will serve you in good stead when faced with the surprising revelation that something you’ve done for years doesn’t really help patients at all, or may even do them harm. Like aggressive volume resuscitation, for example. Or spinal immobilization. Or PASG application. Learn how the human body works, and you’ll be more likely to face those revelations with a bemused smile and a, “Well, that makes sense, when you look at it that way,” equanimity. What you don’t want to be is that dinosaur who looks around and no longer recognizes his profession, forever grousing, “That’s not the way we learned it in school.”

**********

Experience ain’t all it’s cracked up to be.

Hardly a week goes by where I’m not asked a variation on the question, “So, I’m trying to figure out where I go from here. Do I work as an EMT for a while, or do I go straight into paramedic school? How much experience do I need before I’m ready for paramedic school?”

You see, “experience” is such a nebulous word. Speaking as an educator, I find that for every EMT whose street time has honed his assessment skills and taught him the clinical presentation of various disease pathologies, there is another who has learned little more than the location of all the fast food joints that offer EMT discounts.

If I’m lucky, that’s all he’s learned. All too often, that street experience has taught him how to be lazy, cynical and rude, and I have to devote precious classroom time to helping him unlearn all that experience. Give me the green EMT every time; they’re easier to teach.

Many of my colleagues would advise green EMTs to gain several years of street experience before enrolling in paramedic school. They fail to consider the great variable in the equation: the partner.

Every new EMT envisions being paired with a grizzled veteran who can take a green individual under his wing, mentor and teach him the tricks and wisdom that can’t be taught in the classroom. Frequently, they get the other type of partner — the one who despises rookie EMTs and couldn’t teach an armadillo to dig a hole in the ground.

As the saying goes, “There are a few paramedics with 20 years of experience, and there are many more with one year of experience, twenty times.”

That’s the value of education, folks. It gives us the framework to learn from our experiences. It gives us the context to interpret that unusual presentation correctly, and realize that a clinical zebra is simply a horse with a custom paint job.

I’ve learned that every student views a new learning opportunity through a prism of their past experiences. If they have the right attitude and a strong educational background, that prism can refract a muddied clinical presentation into something much clearer. With the wrong attitude, however, or a weak education, that prism can distort the clearest of pictures into something unrecognizable.

From this ambulance driver’s perspective, that experience is best gained in an educational program with a strong clinical component – not on the job. Many prospective students shy away from such paramedic programs because they often take longer or are more expensive. Don’t make that mistake.

A “boot camp”-style paramedic program may graduate you quicker, but you likely won’t get the clinical experience under a trained preceptor that you’d get in a longer program. On the flip side, the college-based, “zero-to-hero” programs designed to take a raw student all the way from layperson to paramedic won’t teach you much relevant EMS knowledge unless that program includes an extensive clinical component. Not every program is created equally, and there is more to consider in choosing a paramedic program than the tuition cost.

There are loads of paramedics out there who will sagely advise, “The real learning begins once you hit the street,” and they’re right.

But what is equally true, and often not said, is that much of EMS continuing education is simply a rehash of information you should already know, and many of your more experienced colleagues have been unknowingly repeating the same mistakes for twenty years. My advice is, learn as much as you can in class. Mistakes there are far less costly than the ones you make in the field.

**********

You aren’t here to save lives.

I know that flies in the face of every recruiting pitch we use to draw students into paramedic classes in the first place. It contradicts every piece of PR propaganda we use to educate the public about EMS. It may even contradict your very motives for choosing EMS as a profession.

Doesn’t make it any less true, though.

Bottom line is, we don’t save many lives. On the rare occasions we do, it’s largely the result of luck and good timing, and pretty much any yahoo with a CPR card could have performed the lifesaving intervention. Ask any experienced EMTs how many lives they’ve saved, through their actions and their actions alone, and if they’re honest the number will be damned few.

And frankly, if saving lives is the only thing you’re about, you might as well stay an EMT-B. Of the existing research on the efficacy of EMS, the only things that are proven to reduce mortality are BLS interventions: early CPR and defibrillation. But before you go patting yourselves on the back about how wonderful EMTs are, keep in mind that those two things are also considered layperson interventions as well.

But if your motivation goes beyond the adrenaline rush of lights and sirens and the occasional code save, paramedicine has much to offer. Much of what we do, if administered appropriately and in a timely fashion, makes the patient’s injury or illness less stressful, and makes the job of the Emergency Department staff much easier.

A few years ago at an EMS conference, after our respective sessions were done, a colleague and I set forth down Sixth Street in downtown Austin in search of beer and hot wings. Over a platter of spicy wings and not a few pitchers of beer, we proceeded to solve all the problems of EMS. Of course, most of those solutions were lost in the fog of the next day’s hangover, but one thing my buddy said to me that night stuck with me ever since.

“Kelly,” he had said, “it’s not our job to score touchdowns.”

“More hot wings, less beer,” I advised. “You’re starting to babble.”

“No, seriously,” he insisted, punctuated with a gentle belch of Fat Tire Ale. “We’re the special teams of emergency care. It’s not our job to score touchdowns. That’s the job of the offense.”

“I see where you’re going,” I mused, eyeing him speculatively. “So who, exactl
y, is the offense in your little analogy?”

“The Emergency Department,” he answered. “The offense is the doctors and nurses in the Emergency Department, and occasionally the surgeons or the cath lab.”

“And EMS is special teams… how, exactly?”

“We receive the patients and advance them as close to the goal as we can. We provide the ED staff with good field position. It’s hard to score touchdowns if you’re consistently stuck with bad field position. On the other hand, if your special teams are very good, it makes it that much easier for the offense to score. We don’t save many lives ourselves, but we can make it much easier or much harder for the ED staff to save a life, depending upon our performance.”

“We score touchdowns… er, I mean save lives,” I protested.

“Yeah, but only a tiny fraction of the time,” he explained, “and only if we’re very good or very lucky. Our job is important, dude. We can’t win the game by ourselves, but we can damned sure lose it for everyone else. You can’t win consistently without good special teams. But it’s not our job to score a touchdown on every play.”

“Screw you, Brosius,” I retorted. “I’m a game breaker, baby. I’m a threat to score every time I touch the ball.”

My bravado aside, you’d do well in your careers to heed my buddy’s analogy and consider yourselves the special teams of emergency care. The plain truth is, you’re not going to save many lives in your career, and you’re setting yourself up for a world of disappointment and disillusionment if that’s what you expect.

On the other hand, if you’re not all about the glory of scoring touchdowns, you can find a great deal of career satisfaction by making your patient’s time in your rig a little less stressful, no matter how trivial their chief complaint, and delivering them to the hospital in a little better condition than when they started.

And occasionally, when you do score a touchdown, no one will begrudge you celebrating with a funky end zone dance.

**********

Learn how to evaluate medical research.

It may surprise you to know this, but it shouldn’t: most of the information in your textbooks is outdated, by as much as five years, by the time you read it. Moreover, the material in that textbook is written at a 10^th grade reading level. If your education comes exclusively from that textbook, you’re only getting half the picture, and a frightfully blurry and superficial picture at that.

But those textbooks are based upon research, however outdated it may be. At the end of each chapter, you will find a bibliography of that research. Take the time to read those studies, and any related ones that you may find. Subscribe to a few peer-reviewed emergency medical journals, or at the very least read what you can find in your college library. Learn how to use Medline and Pubmed. Keep abreast of the most current research as it pertains to emergency medical care.

That college statistics class isn’t to prepare you to do dosage calculations, folks. Any fourth grader has the math tools to do dosage calculations. No, the statistics class is intended to make you a more discerning evaluator of the numbers liberally sprinkled throughout scientific research. Hopefully, you’ll retain enough of it to be able to tell which study authors do or do not know their confidence interval from a hole in the ground.

The future of your profession is going to be shaped by two factors: knee-jerk reactions from politicians and regulators, and by medical research. The better you understand and use the latter, the more you’ll be able to prevent the former.

**********

You are what you write.

An EMT-B receives little, if any, training on proper patient documentation. In many EMS systems, medical documentation is not the EMT-B’s responsibility. Thus, there are some of you who, when you write the report on your first patient as a paramedic, will be writing your very first patient report, ever.

I hope that prospect frightens you as much as it does me.

If your EMT instructor made you practice writing mock reports, be thankful. If your employer allows you to act as the lead EMT on BLS calls, including the documentation, be grateful for the experience. If your paramedic program requires an English composition or technical writing course, thank your lucky stars.

Because when it comes right down to it, every essay and research paper you type, every mock run narrative you scribble, is useful practice for the day you will need to document a complex patient presentation, and the treatment you provided, in such a way as to make it easily understandable by twelve people who were too stupid to know how to avoid jury duty.

And trust me, that day will come. It’s not a matter of if, but when.

Clinical competence and a friendly disposition are usually enough to keep you out of court. Good documentation will be the thing that saves your ass when they aren’t. The attorneys in a negligence case have fairly straightforward jobs. The job of the plaintiff’s attorney is to make you look like the dumbest, laziest, sloppiest medic who ever lived. Your attorney’s job is to make you look like a combination of Johnny Gage and Marcus Welby, MD. He wants the jury to see you as competent, intelligent and conscientious.

And the weapon each attorney will use is your run report.

Which side finds your run report more useful is entirely up to you. If you can’t apply basic concepts of grammar, punctuation and spelling to organize your thoughts into a coherent written report, it doesn’t matter if you provided stellar patient care. You are what you write.

If you gradiate hi skul not noing how too rite reel gud, it’s time you learned.

Keep a list of commonly misspelled medical terms in your clipboard. There is no excuse for being unable to spell the language of your profession.

Use a report template if necessary. Doesn’t matter if it’s SOAP or CHART or whatever mnemonic you choose, just use some sort of organized format.

Buy and read The Missing Protocol: A Legally Defensible Report. It is an essential part of every paramedic’s library. If you don’t have a personal library, start acquiring one. The more you read, the better you’ll write.

Put some effort into your assigned essays and research papers. The quality of your writing in class has a direct bearing on the quality of your writing in the field. And at least in class, your work will be graded in terms of percentage points in a GPA, and not zeros in a settlement offer.

**********

Don’t just do something, stand there.

It is a curious habit of the EMS profession that we insist on defining ourselves by a skill set and not a body of knowledge. You see medics do this sort of thing all the time. They make ludicrous assertions like, “We can intubate! We can do more procedures than the nurses! They ought to let us work in the ER, too!” All too often, medics are judged by how much treatment they are willing to provide. We call these folks aggressive medics, as if the willingness to intubate first and ask questions later was a quality others would wish to emulate.

You don’t see other professions doing such things. Nurses don’t proclaim, “I am RN, wielder of the sacred Foley catheter!” Respiratory therapists don’t say, “I nebulize, therefore I am.”

EMS attracts action-oriented people. I know of very few EMTs, myself included, who weren’t adrenaline jun
kies at least at some point early in their career. The thrill of lights and siren has, at one time or another, entranced us all. But at some point though, you will mature beyond viewing your patients as interesting puzzles to solve, or the ultimate high fidelity skills manikin. Hopefully you will reach that maturity level sooner rather than later, and will unwittingly harm relatively few patients before you get there.

Bottom line is, the skills are easy, and that’s why we focus on them so often. It is relatively easy to learn a psychomotor skill through constant repetition and apply it according to a narrowly defined set of protocols. It is far more difficult and expensive to educate someone on why, and most importantly, why not to apply that skill. And more and more, research indicates that many of those skills are not beneficial, or so rarely needed that maintaining proficiency in them is impossible.

Much of your EMS education thus far has focused on lots of doing, and relatively little thinking, and it’s fair to say that timely application of BLS will always be the cornerstone of good patient care. There will always be instances in which we must act, and act quickly, and the more we practice those skills, the more reflexive they will become.

But as paramedics, we have at our disposal an array of assessment techniques, diagnostic equipment and treatment options that are fairly sophisticated, and our thought process in applying all those things needs to be equally sophisticated. Quite often, our patients derive the greatest benefit from the treatments we don’t provide.

In other words, don’t just do something, stand there. More thinking, and less doing.

As new medics, you’ll need to practice your newly acquired ALS skills until you gain proficiency. It will take time. But what will mark your arrival as a real medic is the realization that you render your best patient care by being what my friend TOTWTYTR calls a “stand back, big picture, non-interventional, direct-the-work-of-others paramedic.”

More thinking, and less doing. Don’t just do something, stand there.

Good luck in paramedic school.

Update: TOTWTYTR weighs in.

… I give you the Bakonikov.

Lots more bacon stuff on The Huffington Post (hope I didn’t get any liberal cooties while I was over there). I particularly like the bacon landscape.

h/t Jaycee One.

… and the shameless lengths to which we go to support them. Case in point:

Epijunky, one of my favorite people on the web, suffered a recent setback in her efforts to become a paramedic – namely, the financial kind.

I’m not one to bleg often, so I’ll simply point you to the post detailing where and how to donate, if you’re so inclined.

And for my part, all proceeds from the Ambulance Driver store will be going to the Epijunky Paramedic Scholarship Fund, until further notice.

Buy yourself a shirt or coffee mug, folks, or donate directly if you’d like. EMS needs more paramedics like Epijunky can be.

… there’s a new column up at EMS1.

Enjoy!

… than an uncomplicated field delivery.

Baby and mama are fine, I got to look dashing and heroic, and Rookie Partner is still so amped that you couldn’t drive a knitting needle up his ass with a sledge hammer.

I tried my best, but I was still unable to persuade Mama that “Aydee” was an appropriate middle name for a little girl. Dammit.

When I asked her what name she did have picked out, she couldn’t even spell it. I imagine that Mostly Cajun will have a field day with it in this Sunday’s edition of The Name Game. It’s a real humdinger.

Patient: “So, my feet have been swolled up for like five whole days, and I think they’re infected and they hurt real bad, and this cut’s all angry looking and I just can’t hardly get around and I’ve been running a fever and I vomited once yesterday, and sometimes the pain shoots all the way up my leg and I just got out of Providence House and I’m out of my meds but I don’t think I really need them my moods are just fine without them but ohmygawd I’m worried about this cut on my foot and look, both of them are turning BLACK on the bottom!”

[AD examines foot and finds no swelling or signs of inflammation, no heat, negative Homan's Sign, no signs of cellulitis, no history of gout, strong distal pulses, one 2 cm superficial cut to the top of the foot, scabbed over and healing well, no tenderness to palpation, able to flex and rotate her foot through all planes without visible signs of pain, but liberally coated with dirt and toe jam.]

AD: “Well um, it’s kind of hard to quantify pain, Ma’am. Might be something going on there that we can’t see. So tell me, how did you get here? Did you walk?”

Patient: “Yeah, I live down at XXXX Fydallo Ho Expressway. I ain’t got no cell phone, so I had to walk all the way up here to use the pay phone!”

AD (mentally counting to ten): “But, but, but, that’s like… five blocks from the hospital. You walked fifteen blocks to call an ambulance, just so we could take you to a hospital five blocks from where you started from?”

Patient: “Yeah, but I figured there might be something bad wrong! Did I do the right thing, calling the ammalance?”

AD: “Certainly, Ma’am. That’s why we’re here.”

Patient (sympathetically): “Bug fly up your nose?”

AD (confused): “Huh?”

Patient: “Well you got this really bad facial tic all of a sudden…”

* Hand to God, this conversation actually happened.

#1 Dinosaur takes an uncharacteristic step over into moonbat territory.

Hey Dino, how does it feel to be the liberal equivalent of a birther?

Update: Gosh, you mean Democrats are planting people in these Town Hall meetings, too? I thought that was a Republican trick!?!

I am shocked. Shocked, I tell you.

If you must mow your steep ditch banks, use an electric or gasoline-powered string trimmer.

If you absolutely must use a push mower on those steep banks, take care not to mow at night, when the dew is heavy on the grass.

And whatever you do, don’t mow drunk.

Failure to follow this advice may cause you to slip on the wet grass and stick your foot under the mower, resulting in the traumatic separation of three of the five little piggies attached thereto.

And that grass clumps up when wet, causing the poor Ambulance Driver to search through your ditch by flashlight, carefully breaking up every clump of wet grass clippings in a hasty search for your missing piggies.

This Lawn Care Protip has been brought to you by the fine folks at Snapper mowers, Johnson & Johnson bandages, and your friendly neighborhood toe fetcher Ambulance Driver.

… but I’d be satisfied if you’d simply genuflect when you find yourself in my presence.

Or you could pull to the right and slow down. That’d be swell, too.

1. Competent Borg dispatchers have a lot in common with Bigfoot, the Loch Ness Monster and the G Spot. Everyone has heard of them, and many believe they exist, but very few have ever actually found one.

2. When you respond to the riot at the after hours club, it helps to keep your windows rolled up when you exit the rig. That way, the fumes from all the pepper balls fired to disperse the crowd won’t make it into your rig.

3. Rookie Partner is apparently immune to OC spray. I should have known, since the boy can take a bite out of the devil’s ass and think it needs Tabasco.

4. People who called an ambulance because they were too afraid to help Mama off the floor by themselves, will then stand directly behind you and critique your lifting technique.

5. Any patient who starts off by saying, “I ain’t gonna lie to you”… is.

6. When someone delivers an Oscar-worthy performance of faked breathing difficulty, and decides to follow it with an encore of feigned unconsciousness and breath-holding, the insertion of a big, fat nasopharyngeal airway will cause even the most dedicated of method actors to break character. And unlike an ammonia cap, it’s clinically justified!

… but at least have the courtesy to make it a good story.

Demented old folks
chasing Phenergan faeries.

It’s like herding cats.

Blogging two years and eight months. 817 posts, counting this one. God knows how many comments. Countless new friends, including one good friend with a raging case of Sitemeter Envy.

And today, at 2:57 PM CST, one million unique visits.

I don’t know what to say, other than to thank each and every one of you who reads my disjointed little scribbling on the web. You guys rock.

Unfortunately, Mystery Visitor didn’t stay long, so the prize will have to go to the next visitor, this guy from Eros, LA who clicked over from TOTWTYTR’s blog:

Drop me a line if this is you, Eros. I’ll send you a book or something.

… for all you EMTs in Louisiana and surrounding states: Registration for the Louisiana EMS Memorial bike ride is now open.

This year’s ride is September 26th, and runs from New Orleans to the State Fairgrounds in Baton Rouge. If you’d like to honor a fallen comrade either by participating in this year’s ride or sponsoring another rider, click on the registration link, won’t you?

It’s for a good cause.

… and he was a good friend of mine.

Once upon a time, close to forty years ago, a certain little boy who would grow up to be an Ambulance Driver was terribly afraid of the dark. The only thing that kept the closet monster and the troll that lived under my bed from eating my face while I slept, was this stuffed frog.

Lately, he has taken up sentry duty for a little girl who isn’t so afraid of the dark as I was, but still likes the comfort of a good friend nearby. I figured since she’s fast outgrowing sleeping with Daddy, and Daddy long since outgrew sleeping with his stuffed frog, I might as well introduce ‘em to each other.

Still, I’m tempted to creep in there and carry them both back to bed with me.

… when you’re likely to be called out:

1. Thirty seconds after you’ve perched on the toilet.

2. Right after you’ve paid for your takeout order, but five minutes before it’s ready.

3. Thirty seconds after your engine crew has sat down for a meal at the firehouse.

4. Thirty seconds before Shannon Tweed gets nekkid in one of those late night Skinemax movies.

From Blog d’Ellison.

… just for Eric Augustus.

“So anyway,” Rookie Partner is saying, “chick was old, like my Mom’s age. That’d just be too weird.”

“That’s nice, RP,” I mutter distractedly. The ‘net connection at Borg Hive North is unbearably slow, and I’ve tried, without success, to upload the same page on my electronic PCR three times now. If the system times out again, I’m considering the “hit any key to continue” solution. With a very large hammer.

“You ever been with an older woman, AD?”

“Define ‘older’, RP,” I sigh in resignation as the connection times out a fourth time. “When I was 25, I got drunk at a Christmas party and went home with the assistant DON at the hospital. She was 40, or close to it.”

Fuckit. I’ve got 24 hours before The Borg considers me a bad drone for turning in late tickets.

“I dunno,” he shrugs. “Like, older. Forty-five or something.”

“Dude, I’m forty,” I retort. “Forty-five ain’t old at all.”

“It is when your mother is forty-five,” RP counters.

“Your mother is forty-five?” I tease. “Is she single? More importantly, is she hot?”

By way of reply, RP shows me a picture on his IPhone.

“Dude, she is hot! Can you hook a brutha up?”

RP’s only response is to glower darkly.

“Seriously,” I grin, sinking the needle even further, “If we hit it off, you’ll only have to call me Daddy when we’re working on the ambulance, just like we do now. Whaddaya say?”

RP scowls and gives me the finger.

“If I wind up being your stepfather, we’re gonna have to work on your social skills,” I chide. “You can’t just –”

“Headquarters to CCT Four,” the radio interrupts.

“Why are they calling us on the radio?” RP wonders. “Don’t they know we’re at the station?”

“Goldfish dispatchers,” I remind him as I reach for the radio. “Their memory resets every three seconds.” I wait for RP to stop laughing, and then key the mike.

“CCT Four,” I reply. “Gourd head.”

“CCT Four, you have an emergency at 1512 Fydalla Ho Expressway. 22-year-old female having a seizure.”

“Tin foil,” I sigh. “We’re en route.”

I close my EPCR window and gather my gear, and follow RP to the rig. Seven minutes into my shift, and it’s already starting.

“Which way?” RP grunts as he starts the truck and engages the emergency lights.

“Uuhhh… left,” I point, rolling my eyes. “Same place Fydallo Ho Expressway has been since, well, forever.” RP has the makings of a good partner, but his navigational skills need some work.

Actually, it’s more than just navigation. He still seeks my direction on many things, and I think he should be past that by now. So when he asks for directions, or asks where he should park the rig, or asks what equipment I want to bring to the scene, I’ve taken to replying with a raised eyebrow and a pointed look. Or, as in this case, sarcasm.

Sheepishly, RP hits the siren and turns left out of the driveway. As we approach the on-ramp of Fydalla Ho Expressway, RP clears his throat. “Reason I asked,” he ventures, “is I don’t know whether we need to go north or south. And if it’s south, we’d probably get there quicker if we turned right and took the surface streets to the Sadler Street on-ramp.”

Good point.

“Well, 1512 is gonna be Methamphetamine Acres Trailer Park,” I remind him. “And that’s north of here.”

“Why didn’t they just say it was at Meth Acres?” RP asks in exasperation.

“Apparently, you weren’t listening before,” I chide. “They’re goldfish, and you can’t expect them to – “

” – remember anything more than five minutes ago, or predict anything more than five minutes from now, or use common sense,” RP finishes with a rueful grin. “I get it now.”

“Still, that was good thinking before,” I admit. “When you hook me up with your Mom, we can double date with you and the cougar from the bar. I’ll even let you drive.”

RP, in direct contravention of Borg emergency driving policy, removes one hand from the wheel and renders a middle-finger salute as the entrance to Meth Acres flashes by on the right. RP flashes a chagrined look, and starts to open his mouth. I raise one eyebrow and say nothing.

“I’ll just, uh, make the block,” he says apologetically.

Good idea.

By the time we loop back around to the entrance, our siren has drawn several members of the International Bystander Society outside, flashing their characteristic gang sign: one hand waving frantically in the air, the other pointing to the trailer in question.

“Where do you want me to…” RP starts to ask, trailing off as I fold my arms across my chest and give him The Look. Again. “Uh, yeah. Guess I’ll just park down there by all the frantic people,” he decides.

Works for me.

One of the bystanders, a woman so large she has her own gravitational pull, takes a break from her tachylawdia episode long enough to accuse, “Y’all drove right past us!”

Did I mention that IBS members are also prone to stating the obvious?

I ignore her as RP and I haul the gear up the stairs to the sweltering trailer. She lumbers up the steps behind us, still bitching mightily in between praising Jesus for our arrival. “Ain’t you heard what I said?” she demands. “Y’all drove right past us da first time!”

“It’s a NASCAR ambulance, Ma’am,” I explain. “It only turns left.”

That shuts her up for a minute as she stares at me blankly, still jiggling from her jaunt up the steps like a big, sweaty perpetual motion machine.

“Why don’t you point out the patient we were called for, Ma’am,” I suggest gently. “Someone having a seizure?”

“Thass her outside,” the woman grunts, jerking her thumb toward the door. “She done had three of ‘em.”

Outside, one of the moons orbiting our lead bystander identifies herself as our patient. Rather than ask her why she allowed us to walk right past her, I decide to focus on questions less likely to make my head explode.

“What’s your name, Ma’am?” I ask politely as she holds out her left arm for the BP cuff Rookie Partner is holding in his hands. Apparently, this ain’t her first rodeo. “Do you have a history of seizures?”

“Taketha,” she answers, “I been havin’ seizures three or four years.” Helpfully, Taketha holds out her left index finger for RP to check her blood sugar.

Damn, she’s good. If she anticipates the pulse oximeter, I’m offering her a job.

“What kind of seizures do you have, Ma’am? Grand mal? Absence seizures, maybe?”

“Dunno,” she shrugs. “I takes medicine for ‘em, though.” She thrusts a small change purse into my hands, and I sort through the medication bottles stuffed in it.

Antidepressants… anxiety meds… not a damned anticonvulsant in the bunch. Lurvely.

“Did you witness the seizure?” I ask the other woman, who nods eagerly and launches into a windy narrative beginning somewhere around the patient’s mother’s car accident in 1977 when she was pregnant with our patient’s older brother and how she got a bad womb from all that and that’s how Taketha got cursed with the seizures in the first place and ain’t no doctor been able to fix her and -Lawdy! – we just gots to put all our faith in Jaysus! and…

… hopefully her story will catch up to present day pretty soon and will include some relevant information about the current episode. Then again, I’ve always been a starry-eyed optimist.

I let her ramble for perhaps twenty seconds and then interject. “Did she convulse?” I ask. “Muscle twitches and such? And how long did it last?”

“Lawd, she was shakin’ all over!” r />

“For how long?” I press.

She pauses a moment, thinking. “I called 911 right off! So… maybe twenty minutes? She stopped right befoah y’all got here!”

Okay, so seizing maybe five minutes, using the standard 1:4 panicky bystander time conversion ratio… wait a minute. Stopped right before we drove up!? And walking around and talking almost immediately?

“She stopped seizing right before we drove up?” I ask suspiciously.

“Befoah ya’ll drove past da first time,” she clarifies spitefully.

Actively seizing for five minutes, no bladder incontinence, and completely alert and walking around less than sixty seconds after the seizure stopped? I think I detect the unmistakable aroma of bullshit.

“Okay,” I sigh resignedly. “To what hospital would you like to go, Taketha?”

“I ain’t goin’ to no hospital,” Taketha demurs. “I be all right now.”

Well, that’s a new one.

“You sure?” I ask skeptically? “Seizures are nothing to mess around with. You should at least have your medication levels checked.”

“I be all right,” she insists. “My Momma gonna be here any minute. They done called her.”

As if on cue, a cell phone rings. The woman masquerading as a small planet startles, then fishes between her breasts, retrieving her cell phone from somewhere deep within the recesses of her muumuu. “Oh heeeeeeyyyy girl!” she brays. “No, the ammalance here now… girl, now she say she ain’t goin’… naw, she ackin’ aight now…”

I listen to her side of the conversation for a few moments, then motion impatiently for her to hand me the phone. “Hello, this is AD of Borg,” I say politely once Mrs. Jupiter forks over her Razr. “To whom am I speaking?”

“Is she really having a seizure?” a tired voice says without preamble.

“Um, the neighbors witnessed what they described as a seizure,” I hedge. “Is this Taketha’s mother?”

“Yeah, dis her Mama,” the voice says. “So how she ackin now?”

“Well, she seems to be okay now,” I allow, “but she doesn’t want to go to the hospital. Given her history of seizures, I think it’s a good idea that she – “

“She had one seizure when she was sixteen, and a whole buncha bullshit ever since,” the voice cuts me off. “She don’t need no hospital.”

Music to my ears. I knew this smelled like bullshit.

I motion for RP to pack it up. “Grab my clipboard from the rig, would you?” I ask. “Looks like we’ll be getting a refusal.”

While RP is lugging the gear back to the rig, I start jotting Taketha’s particulars on the back of my gloved hand. “Taketha,” I begin, “we’re just gonna have you sign a form stating that we offered you medical treatment and you – “

“Uuuunnnhhhh.”

I watch as Taketha puts her hands to her temples and begins moaning, louder and louder, and finally begins shaking violently all over, provoking another fit of tachylawdia from her neighbor.

“Lawdy lawdy lawdy –Jesus! –lawdy lawdy lawdy – Jesus, she done caught another seizure! – lawdy lawdy lawdy…”

I watch dispassionately for a few moments more, observing her faux myoclonus. It’s the closed eyes that finally do it for me.

“Taketha,” I call out, “I know you’re busy seizing, but it’s time to go to the hospital. Get up and let’s walk over to the stretcher.”

And to the amazement of her planetary neighbor, Taketha obediently gets up and walks to the stretcher, moaning and shaking like a dog shitting tacks the whole time.

“Try not to convulse too hard until we get you in the truck, dear,” I instruct. “The stretcher’s kinda top heavy, and you could tip it over and hurt yourself.” Obediently, Taketha tones down her convulsions to a mild, whole-body shiver.

By the time RP returns with my clipboard, I have Taketha secured on the stretcher. “Change of plans,” I tell him. “She had another seizure, so we’re taking her to Charity.”

“Not Charity,” Taketha corrects, taking a break from her convulsion. “I don’t wanna sit in the waiting room. Take me to Big City Regional instead.” And with that, she resumes her twitching.

RP stares at me in consternation, and I reply with a shrug. As we wheel Taketha to the rig, I watch in amusement as realization dawns on Rookie Partner’s face, and indignation threatens to boil out of his ears like steam from a kettle. He slams the stretcher in the rig with none of his characteristic gentleness, and climbs in behind me.

“You want a line?” he asks eagerly. “How about a fourteen?”

“Nah, just a smooth ride,” I demur. Much as I’d like to practice a little punitive ALS, it never makes the faker hurt as much as it should, and it never makes me feel as good as I’d want. RP looks crestfallen, but climbs out of the rig and closes the doors behind him. As we pull out of the trailer park, the partition window slides open and RP snaps his fingers.

“Does it have to be a smooth ride?” he asks plaintively.

“Hit all the potholes you want,” I chuckle. “Just get us there in one piece.”

**********

“So how did you know she was faking it?” RP asks, an hour later. We’re on our way to stand by at one of our outlying stations while the truck normally posted there finishes up a run at the local hospital. Never mind the fact that by the time we get there, the other truck will have cleared from the call, and we’ll only turn back around and go home. It does us no good to point out that the dispatch emperor is wearing no clothes.

“Closed eyes,” I answer. “That was the big giveaway. Plus, the fact that she could actively control the degree of her myoclonus tends to peg the bullshit-o-meter, too.”

“And she didn’t even pee her pants,” RP points out.

“That doesn’t always happen, RP. Sometimes the seizure is brief. Sometimes it’s only a partial seizure, and they have no alteration in level of consciousness. Sometimes, it’s a generalized tonic-clonic seizure, but they already have an empty bladder.”

“I thought something was up when they said she woke right up after her seizure. That never happens.”

“Almost never happens,” I correct. “Seizures are a lot more complicated than what you were taught in EMT school. Not every seizure is followed by a postictal period. But yeah, most of the time when they actually convulse, you’d expect to see at least a brief postictal state. Certainly more than sixty seconds, anyway.”

“So is there any difference in how they’re treated?” RP wants to know.

“Why are we wasting time talking about seizures?” I wonder. “Let’s get back to the original topic of me dating your hot-assed Mom. You were just about to give me her digits before we got that call.”

“Was not,” RP retorts.

“Are you worried that I might wind up being your new stepfather?” I tease. “I already told you that I won’t make you call me Daddy.”

“Dude, you’re not dating my Mom,” RP vows.

“Because if that’s what you’re worried about, don’t be,” I reassure him. “I assure you my interest in your Mom is purely physical.”

“Look, can we just change the subject?”

“I understand,” I needle. “The prospect of me spanking your Mom’s ass weirds you out a little bit. I’ll give you some time to get used to the idea, and then you can hook me up with her. Tell me something, though. Are her boobs really as big as they look in that picture?”

RP’s face reddens, and he turns in his seat, livid. I can’t hold a straight face any longer.

“Keep your eyes on the road, hero,” I chortle. “I’m just yanking your chain.”

RP glares at me suspiciously for a moment, but dispatch interrupts before he can reply. “Headquarters to CCT 4,” the radio crackles.

“Re
turn to Borg Hive North,” RP predicts.

“CCT 4, gourd head,” I reply.

“We have an emergency call for you at the intersection of Highway 317 and Parish Line Road,” dispatch orders.

“En route,” I sigh in acknowledgment as the call information comes up on our mobile data terminal. Another seizure.

“Looks like seizure night,” RP groans as he cranks the wheel to turn us around.

“They always come in threes,” I tell him as I hit the lights and sirens.

“Really?”

“No, not really,” I wink. “But if you’re gonna get the complete EMS education, I might as well pass on the myths as well as the street lessons. You may want to torture a rookie partner of your own one day.”

When we arrive at the Quickie Mart at the intersection of 317 and Parish Line Road, another gaggle of IBS members beckons frantically, pointing to a man lying in the ditch. As we approach, I take a closer look and groan, banging my head against the window.

“What?” RP asks, concerned. “You want me to call for backup?”

“No,” I sigh, “I don’t even want you to stop the truck. Can we just drive off and pretend we never saw him?”

RP’s only reply is to stare at me in open-mouthed consternation.

“Okay, okay,” I relent. “But this one is yours, not mine. Pull up alongside the guy in the ditch.” As RP puts the rig into park, I roll down the window and bellow, “JUNIOR! Get your worthless ass outta that ditch!”

Junior stops seizing and cracks one eye open. “Oh it’s you, Mista AD.”

“Get in the truck, Junior,” I order.

“I cain’t move, Mista AD. I just had me a seizure.”

“I don’t have time for this, Junior,” I warn. “If you make me get out of this truck, I’m calling the cops on you for another false 911 call. Get your bag, and get in the rig, and you’d better not give my partner any shit.”

“Ummmm… frequent flier?” RP surmises.

“Yep, and he’s all yours,” I grin evilly. “Alcoholism, Hep C, paranoid schizophrenic. And try not to get too close. He’s probably got lice, too.”

“I’m not supposed to take any seizure calls,” RP protests.

“That’s only if it actually turns out to be a seizure call,” I correct, “which in this case is simply the ruse Junior used to get someone else to call 911. Get a history and vitals, and don’t take any shit from him. If he thinks he can play you, he will.”

“So how do we write it up?” RP wants to know, eyeing Junior distastefully in the rear-view mirror.

“That’s up to Junior,” I shrug. “Demonic possession, hearing voices, thinks he’s Liberace… he’ll come up with something that will get him committed for seventy-two hours. And by the time his stay in the booby hatch is complete, the shelter will take him again.”

“Thanks so much,” RP says acidly.

“You’re welcome,” I say graciously, blowing him a kiss. “I’ll be sure to drive slowly, so you have plenty of time to get to know each other.”

**********

“I think that dude did have lice,” RP observes sourly an hour later, idly scratching the back of his neck. “I can’t stop itching.”

“You didn’t have enough close contact to pick up lice,” I reassure him. “Now scabies, on the other hand…”

“Scabies?” he asks, shuddering in revulsion. “What are scabies?”

“Tiny little mites,” I say offhandedly. “Damned sight harder to get rid of than lice.”

“That’s just fucking great,” RP mutters acidly, finding yet another itchy spot on his left forearm.

“Yeah, tiny little mites…burrowing under your skin… laying eggs right below the surface… spreading wherever you scratch… making themselves at home on your body, setting up house… depositing eggs and little mite droppings…”

RP squirms uncomfortably in his seat, trying unsuccessfully to reach a particularly itchy spot between his shoulders.

“… eating your dead skin, using some of it as nesting material, some of it as food for their clutch of eggs, burrowing deeper as they need more room… you know they say that each adult mite is capable of laying ten thousand eggs…”

RP whimpers and scratches furiously at his scalp. “Dude, would you just shut up?!?” he begs.

“Oh, I’m sorry!” I say innocently. “Does that bother you?”

Before he can reply, the MDT chirps in its clipped electronic voice, “Incident assigned.” I sigh and pivot the screen to where I can read it, and then tap the screen to log us en route to the call.

“1000 Shoreline Boulevard, Room 212,” I order. “Three guesses as to what kind of call it is.”

“Damn, another seizure?” RP asks wonderingly.

“Got it on the first try! Maybe we can get you on a game show or something.”

RP, still scratching at psychosomatic itches, just shakes his head as he merges onto the interstate and almost immediately gets off at the Shoreline Drive exit. Behind us, three Big City Police cruisers follow us down the off ramp, lights flashing.

“Reckon they’re going to the same place we are?” RP muses, and as if in answer, the cops swing around us and pull into the Shoreline Drive Motor Court.

“Look like it,” I grunt. “Must be something more than a seizure. Tell dispatch we’re staging outside until pee dee calls us in.”

RP obediently relays the message, receiving a bewildered “Unit calling?” in reply.

I lay a hand on his arm before he can repeat the traffic. “Let Mr. ‘Unit Calling’ figure it out for himself,” I order. “You gave our unit number, the transmission went through just fine, and he only has six units to keep track of. He doesn’t even have to answer 911 calls, because someone else does that for him. He wants to know bad enough, he’ll call us again, or start paying closer attention to his radio traffic.”

A flashlight blinks at us from within the courtyard, and beckons us in with big, sweeping arcs.

“Guess that’s our cue,” I sigh. “Let’s go see what we’ve got.” Before exiting the rig, I key the radio and advise dispatch that we’re on scene.

“Ten four, CCT 4,” comes the immediate reply. Looks like he finally figured out who was calling him, and why.

The cops are clustered around an open door on the second floor, and predictably, the Shoreline Drive Motor Court doesn’t have elevators. RP sighs and starts to lug the stretcher up to the second floor landing, and stops in surprise when he sees I am not helping.

“Remember the ABCs,” I remind him.

He stares at me uncomprehendingly for a moment, then brightens in understanding. “Ambulate Before Carry, right?” he grins.

“Perzackly right,” I wink. “If the patient can walk, we’ll walk him. If not, we can send a cop for the stair chair.”

“Howdy, Foster,” I greet the junior officer amiably. “You look a little out of breath. Did they call us for you?” Foster’s shift sergeant tries, unsuccessfully, to suppress a grin.

“Funny,” Foster answers in a tone that say he thinks I’m anything but. “Nah, we were called for a noise disturbance, said a bunch of drunks were fighting on the balcony. Looks like your boy was actually having a seizure.”

“Nobody was fighting,” one of the drunks says defensively. “My friend just had a seizure, and everybody was scared, yelling for help.”

“So who saw this seizure?” I ask, kneeling next to the man whose head he held cradled in his lap. The guy is somnolent, ice cold and soaking wet.

“I did!” several voices chime in at once, and all of them proceed to deliver a long, drunken narrative of the events, punctuated by rambling non-sequiturs and solemn declarations that no, they weren’t drunk at all, especially not our patient, who as far as they knew, didn’t even drink alcohol, much less abuse drugs, because you know, that would be
illegal, immoral, and maybe even fattening.

I listen for perhaps thirty seconds, bark “QUIET!” and then nod politely at the drunk holding his buddy’s head in his lap. “You first,” I suggest, “without all the embellishment.”

“Well dude, he was kinda fightin’ with his girlfriend, cuz she said he’d been drinking too much, and he’s all ‘fuck you, beeyotch, I ain’t even close to being drunk enough’ and she’s all ‘fuck this, I’m leaving’ and he’s beggin’ her not to leave and shit and she ain’t paying any attention and she goes ‘Mikey, will you take me home?’ and I’m all ‘hey don’t put me all up in the middle of this shit’ and all of a sudden he’s all laid out on the balcony, floppin’ like a fish!”

“Anyone know if he has a history of seizures?” I ask the crowd.

“Never had one before,” one reasonably sober individual answers as he pushes his way into the room, “and I’d know. I’m his little brother.”

RP busies himself getting vital signs and a blood glucose while I take the brother to the side and ask a few discreet questions. The patient’s name is Frank, and no, he’s never had a seizure, and yes, he’s as drunk as a boiled owl, and no, he doesn’t do drugs, and yes, the brother is pretty sure of that, and no, he doesn’t have any other medical conditions or take any medications that his brother is aware of, and no, he’s been with him for the past 24 hours and he can safely say that he hasn’t fallen or suffered any head trauma, and yes, he’d like us to take him to the closest hospital to be checked out.

“BP 116/72, pulse 64 and regular, respirations 14 and clear, glucose is 78,” RP informs me when I step back to the patient. “Why the hell is he soaking wet, though?”

“Because we put him in a cold shower, dude,” the drunken friend Mikey sighs. “Don’t you know anything?”

RP ignores our bystander medical expert and just looks at me quizzically.

“Sometimes junkies or drunks pass out,” I explain, “and their dumbass friends throw them into a cold shower because they saw it work on tee vee once. And it really doesn’t do anything other than make the patient wet and slippery, and potentially hypothermic, but it tends to make the dumbass friends feel like they’ve done something useful.”

Mikey glares at me as the cops break out into guffaws.

“Can one of you guys get the stair chair for us?” I ask the cops. “Lower rear driver’s side compartment of our rig.” Foster makes no move to comply, mainly because fetching my stair chair would involve the physical exertion of walking fifty feet, and Foster abhors walking any distance further than the distance from his cruiser to the counter of the donut shop. Well, and probably because he wouldn’t piss in my mouth even if my teeth were on fire. But that’s okay, because the feeling is entirely mutual.

“Coming right up,” one of his fellow officers says amiably. Two minutes later, he’s back with our stair chair, fumbling with the mechanism to unfold it.

“We’ve got it from here, thanks,” I tell the cop sincerely. I position the chair next to the patient and motion for RP to grab the guy under the knees. I’ve got under his arms, where thankfully most of the water on his torso has dried or evaporated in the warm night air. His pants, however, are still soggy, but that is RP’s end of the patient. Rank hath its privileges.

“So what hospital are you taking him to?” the shift sergeant wants to know as we buckle our patient into the chair.

At the word “hospital,” our patient sits bolt upright and says, quite clearly, “Hospital? I ain’t going to no fucking hospital. Just leave me right here.”

Well now. Aren’t we awfully damned lucid for someone who just had a grand mal seizure.

“Okay,” I say agreeably. “Mind telling us why you don’t want to go to the hospital?”

“I didn’t have no seizure,” he declares vehemently. “I just need some sleep, that’s all. You sumbitches ain’t taking me anywhere against my will.” His speech is clear, not slurred at all.

Oh, he’s speaking my language now. Preach it, Refusal Boy!

“Your friends say you did have a seizure,” I point out. “Why not go to the hospital and try to find out why?” I’m trying my best here to sound reasonable and friendly, hoping against hope that my body language isn’t screaming BULLSHIT! in big, red letters.

“I ain’t going to no hospital,” he says stubbornly. “Y’all can’t make me.”

I can’t legally take you anywhere against your will,” I assure him, “provided I can document that you understand the consequences of your decision. So demonstrate to me that you know what’s going on around you and that you understand the risk you’re taking by refusing care. Do that, and sign my little form, and we’ll be on our way. Party on, dude.”

“Bring it on, motherfucker,” he sneers. “I know my rights.”

“Watch your mouth!” the shift sergeant snaps. “The man’s here to help your ignorant ass, so shut up and do what he says.”

I sigh inwardly, and go through the steps of an abbreviated Folstein mini mental exam. It’s not the full, ten-minute questionnaire, but the questions I ask, and the answers to them, do a helluva lot better job at documenting present mental capacity than scrawling “AAOx4″ in their chart. His buddies interrupt with impatient, put-upon sighs, and the patient goes through the entire exam rolling his eyes and making jerking-off motions at every question, but in the end, I have enough documentation to demonstrate that not only is Frank Quibodeaux an obnoxious asshole, he is also in full possession of his mental faculties.

And thusly, fully capable of signing my refusal form without getting me or The Borg sued. Of course, The Borg probably won’t see it that way. Refusals of care don’t generate revenue.

Frank signs my refusal form with a flourish, and I turn to the shift sergeant for his signature as an impartial witness to the refusal of care. As I do, Frank unbuckles the stair chair straps, stands up, and promptly does a credible impression of a marionette with half his strings cut. He flops over at the waist, arms and neck limp. He flops his arms several times, as if he’s Morris Day doing The Bird.

That is, if Morris Day were a skinny, tattooed white boy with a negative tooth:tattoo ratio, and executed his dance moves with his face six inches from his shoelaces. Frank looks for all the world like one of those children’s toys of the giraffe on a pedestal that, when you press a button, the giraffe goes completely limp. All except for the legs, that is. He’s still standing upright while he’s doing this.

“Well, that has to be the poorest excuse for a fake seizure that I’ve ever seen,” I observe wryly, “but if you continue to do it, we don’t have much choice other than take you to the hospital.”

On cue, God releases Frank’s little button, and he stands erect, perfectly lucid once again. “Already told you sumbitches I ain’t goin’ to no hospital,” he vows.

The shift sergeant, rapidly tiring of our patient’s antics, plants his nose about six inches from Frank’s and growls, “I don’t know what your malfunction is, son, but if you want to go to jail tonight, you’re on the right track. Now you might be having seizures or you might not, but we can’t leave you here like this. So you either sit your ass in that chair, or you go to jail.“

At that, Frank smiles defiantly and holds out his hands for the cuffs. “Bring it on, motherfucker,” he challenges.

“Said the magic words,” the shift sergeant smiles grimly, pulling his cuffs from their belt pouch. He gets as far as locking the second cuff before Frank’s bravado runs squealing into the night like a little bitch.

“W-w-w-wait a minute,” he begs. “I’m sorry, man. I’ll be good, I promise.”

“Nope,” the cop answers without a trace of sympathy
. “You said ‘bring it on, motherfucker’. I’m bringing it. After you get checked out at the ER, you’re mine.”

“Awww man, don’t take me to jail!” Frank whines. “I won’t do it no more, I promise!”

“Take his ass to the ER,” he orders, ignoring our patient’s unseemly begging. “Consider him in custody.”

“We need someone to ride with us if he’s still in cuffs, Sarge,” I remind him apologetically. “Borg policy.”

“No problem,” he waves it off. “Foster, your rookie rides in with the ambulance crew, and you can follow them to the hospital.”

Foster doesn’t look pleased with the order, but then again, Foster isn’t usually pleased by anything other than shift change. All the way down the stairs, Frank bellows drunkenly, “Miserable cocksuckers! Fuckin’ pigs! I smelllll BACONNNNNN!”

For his part, Frank’s little brother cuffs him soundly on the back of the head and snarls, “Shaddup, dumbass! It’s bad enough I gotta ruin my night by coming along to bail your ignorant ass outta jail, but you gotta act like a little bitch with all the fake drama!”

RP and I package Frank on our stretcher, stow the stair chair and gear, and I motion to the brother and the rookie cop to climb in, pointing to where they should sit. Frank continues with the drunken braying while the rookie cop discovers how difficult it is to get a drunk to listen to reason, and I perch in the captain’s chair and entertain thoughts of very large IV catheters in very sensitive vascular spaces, like the corpus cavernosum, for example. I hit the speed dial number for Big City Heart Hospital and thumb the SEND button.

“Howdy, Jeff,” I greet the voice that answers, “AD with CCT 4, two-minute ETA with a male, late twenties, looks to have ETOH-induced supratentorial high-intensity tremors. Vitals all stable, see you in a couple minutes.”

“Whoa, wait a minute,” Jeff splutters. “Supra what? And he’s got ETOH on board?”

“Supratentorial high intensity tremors,” I repeat, grinning into the handset. “Figure it out. We’ll be there in a couple of minutes.”

“Room assignment on arrival,” Jeff sighs resignedly before I thumb the END button.

“Never heard ‘em called that before,” muses the rookie cop. “In EMT school we always called it status dramaticus.”

“That’s another name for it,” I allow. “So you’re an EMT, too? Better not let Foster know. He hates EMTs.”

“Does Foster like anybody?” the rookie wonders. “Won’t matter much anyway. I’m only riding with him for tonight. My FTO called in sick.”

“Who’s your FTO?”

“Rita Menendez,” he answers. “She’s pretty good.”

“Better than good,” I grunt. “She’s hardcore. If she’d been here tonight, our little friend here would have gotten zero latitude.”

“Fuckin’ female cop,” our drunk patient sneers. “Wished they had a dick, that’s all. Tell ya what, I’ll give ‘em some dick!” He winks lewdly, grabbing his crotch.

“I really wish she was on duty tonight,” I tell him sincerely. “You outweigh her by thirty pounds, but if you screwed with her, she’d show you what the other end of that little wanger looked like. She’d snap your little ass in half.”

“No doubt,” the rookie chuckles. “She doesn’t play around.”

“While we’re on the subject of little wangers and bad behavior,” I tell our patient, “let me caution you about showing your ass to the ER staff. Things will go much easier for you if you shut your mouth and adopt a friendly attitude. You never know when some pissed-off nurse may decide to see exactly how large a Foley catheter you can tolerate.”

“Sumbitches ain’t gonna do shit but let me outta these – hey, what’s a Foley?” Frank mumbles.

“Keep up the hollering and threats,” I warn him, “and you’ll find out.”

Jeff stops us at the triage desk as we wheel Frank into the ER. “Supratentorial High Intensity Tremors,” he grins. “SHIT, right?”

“You got it,” I wink. “Where do you want him?”

“Psych 2, AD,” he points. “Is he under arrest?”

“Yep. After you’ve determined he can safely spend a night in jail, the cops are gonna want him back.”

“Wonderful,” Jim says agreeably. “Saves me from having to be his travel agent, finding him a ride home.”

We wheel Frank into the psych room, unceremoniously deposit him in the bed, raise the rails and pull the curtains closed. Five minutes later, he is still braying drunkenly when the nurse walks into the room, carrying a chart and a urine cup. I can’t quite make out what is said, but presently the nurse stalks out of the room with a determined look on her face.

“What’d he do?” I ask.

“Called me a cunt and kicked the urine cup out of my hand,” she says matter-of-factly. “Now we’ll see how much he likes a Foley.”

I wink at the rookie cop as she walks back into the room, trailed by a burly security guard and an equally large ER tech. We stand just outside the door and giggle fiendishly as we listen to Frank squeal.

**********

“Haven’t we seen enough of you guys tonight?” I grin at the shift sergeant as I climb out of the rig. “What have we got?”

“Girlfriend called 911,” he grunts. “Said she needed help, and hung up. That’s why we’re here. Looks like this guy had a seizure, a real one for a change.”

“Jesus H. Christ!” blurts RP as he rounds the back of the rig. “Another one?”

“Did you wish for a seizure call before I got to the station tonight?” I ask RP suspiciously. “Maybe mention, out loud, that it’s been quiet or slow lately?”

“Yeah, right,” he snorts. “I thought you said all that was superstitious bullshit.”

“After the fourth seizure call in six hours, I reserve the right to change my mind. Actually, the fifth seizure call, if you count the refusal on the casino guard.”

“Guy’s lying on the couch inside,” the cop jerks his thumb toward an open apartment door. “Still kinda out of it, though.”

We enter the apartment to find the guy’s girlfriend standing watch over him, nervously smoking a cigarette. She’s not hysterical, but she wastes no time telling us that he ain’t staying in her apartment, not after no seizure. Uh uh, naw suh. She ain’t been knowin’ him all that long anyway, and she ain’t gonna deal wif him when he like dis. We can brang him back when he ackin’ right.

I gently tell her that we’ll take care of him, but brangin’ him back to the apartment after he start ackin’ right is an arrangement she’ll have to make herself. We generally only take people to the hospital.

As the girlfriend harumphs her displeasure at that news to the cop, I kneel next to the couch and feel for a radial pulse. RP maneuvers around me and wraps a blood pressure cuff around the guy’s left arm. He’s pumping up the cuff when our patient’s eyes snap open. He recoils, ripping off the blood pressure cuff and scrambling up the back of the couch, eyes darting wildly.

“Easy, buddy,” the cop says placatingly. “They’re just trying to help you.”

“Yeah,” RP smiles reassuringly, edging closer. “I just want to check your vital signs.”

“Ya’ll leave me the fuck alone!” the guy yells.

“Latrell, let the people take care of you!” the girlfriend urges.

“Just gonna take your blood pressure, okay buddy?” RP asks, warily trying to wrap the cuff around the man’s arm. He reacts by batting RP’s hand away and cocking a fist.

“All right now,” the cop interjects sternly, taking a step forward. “Just calm down and – “

“Latrell, let the people do they job!” his girlfriend screams.

“Y’all leave me the fuck alone!” Latrel
l replies, even more loudly.

“Watch your mouth and lower your voice!” the cop snaps, “These people are just here to help you!”

“Everybody shut up and back away.”

The cop looks at me incredulously. RP stares. The girlfriend favors me with an indignant glare.

“The guy’s just had a seizure,” I say reasonably. “He’s postictal. He wakes up disoriented, and suddenly there are four faces crowding in on him. We’re overstimulating him. Let’s give him some space.”

RP and the girlfriend visibly relax and take a step back, but the cop just stands there, looking speculatively, back and forth, at me and the patient. “Sure,” he shrugs dismissively. “Why the hell not?”

I lay the oxygen tank I am holding in the seat of an armchair, and take a seat on an ottoman near the couch. “Hey, Latrell,” I say with my most disarming smile. “My name’s AD. How you doin’, man?”

“You motherfuckers better leave me alone!’ Latrell yells menacingly. “I ain’t going to no hospital!”

“Nobody’s gonna take you anywhere you don’t want to go,” I say evenly. “Just let us make sure you’re okay, and we’ll be on our way. Your girlfriend’s concerned about you, man.”

Latrell stares at me for a moment, and then his gaze flickers to the armchair across the room. Without warning, he launches himself from the couch, bounds across the coffee table, and picks up my oxygen cylinder, cocking it like a baseball bat.

“Y’all better leave me the fuck alone, or I’m gonna – ooofff.”

“Go to jail, or to the hospital in handcuffs,” I finish for him grimly, knee planted firmly in his back as I force his face into the carpet.

It was his eyes that betrayed him. I saw him tense, and when he leapt I was right behind him. I’m twice Latrell’s size, and God knows I can’t move as quickly. But I was closer to his target than he was, and like I said, his eyes telegraphed his move. By the time he cocked that oxygen cylinder to swing, I was already inside its arc. I grabbed his right wrist, swept his feet from under him, and landed atop him when he fell. Knocked the wind out of him, it did.

And right now, Latrell is lying on the floor with a 285-pound man kneeling on his back, surrounded by an atmosphere made up of 21% oxygen, and wishing fervently that he could buy even one molecule of it.

“Thought you said he was just postictal,” the shift sergeant grunts as he applies the handcuffs.

“Thought he was,” I reply. “Now he’s just a belligerent asshole.”

“What’s the difference?”

“For me, it was having the presence of mind to seek out a weapon, and then trying to use it. That ain’t postictal. That’s just being a prick.”

“Motherfucker, let me up!” Latrell yells. “I ain’t did nuthin’!”

“Shaddup!” barks the shift sergeant as he hauls him to his feet. “If you’d have behaved yourself, this wouldn’t be necessary!”

“Is he under arrest?” I ask.

“Nah, I’ll follow you to the hospital. If he behaves himself in the ER, I’ll take the cuffs off.”

“Technically, Sarge, we’re supposed to – “

“I’ll be right behind your rig,” he repeats, then grins evilly. “Unless you’d like to wait here with him until I can get Foster and his rookie over here.”

“Uh, nope,” I say hastily. “I think we can deviate from protocol just this once.”

“Hey man,” Latrell yells indignantly, “when y’all gonna take the motherfuckin’ cuffs off me? I ain’t did nuthin’!”

“After you get to the ER,” the sergeant answers, “and you prove that you’re not gonna give the medics and the ER staff any trouble.”

“Y’all git these cuffs off me right now,” Latrell threatens, “or I’ll whoop all yo motherfuckin’ asses.” He swells up to his greatest height, all 140 pounds and 5’6″ of him, as if that will make the threat more credible.

“Word of advice, Latrell,” I say drily as we strap him to the cot, “if you want these cuffs off as soon as possible, ‘I’ma whoop all yo muhfuckin’ asses if you don’t’ isn’t the most convincing way to go about it.”

**********

“Incident assigned,” our data terminal chirps a couple of hours later. RP and I are sitting outside an all-night Burger King, hoping that the act of ordering food won’t induce another seizure somewhere within our coverage district. Obviously, it is not to be.

“Wonderful,” RP snarls. “And I’m frickin’ starving!”

“Go see if you can hurry things up,” I say soothingly. “I’ll mark us en route.”

Thankfully, they were bagging up our order as the call came in, so at least we have our food. I say as much to RP as he stashes the takeout bags behind our seats.

“Not like it matters,” he grouses. “It’ll be cold by the time we get to eat anyway.” For a kid so skinny you could x-ray him by holding him up to a strong light bulb, RP loves his food. He eats more than I can. I’m beginning to think the boy may have a tapeworm.

“That’s what they make microwaves for,” I say placidly. “Welcome to EMS. If we never took the time to shit or eat, no one would ever get sick.”

“Are we the only unit in the city?” he snarls, not mollified one little bit. “How many is that for us tonight, seven?”

“Nine,” I correct. “You forget the two transfers, and the refusal on the casino guard. And only five were seizures. This one’s an unknown medical emergency.”

“So what’s your point?” RP grumbles, savagely stabbing a straw into his drink with one hand and taking a sip.

“EMS is lak a box a chawklits,” I drawl in my best Forrest Gump voice, “You nevah know what yew gonna git.”

Normally, we don’t have to do much to clean the front of the rig at shift change. Dr. Pepper sprayed on the inside of the windshield, however, requires a little extra elbow grease to remove. You’d think I’d learn not to say such things while my partner’s mouth is full.

“So what do they mean by ‘unknown medical emergency’?” RP asks, tapping the MDT screen.

“That’s a secret code phrase known to all dispatchers,” I answer. “As near as I can tell, it either means ‘riot in progress’ or ‘please respond to the thermonuclear detonation’.”

“CCT 4 to headquarters,” RP radios, shaking his head. “Do we have any further info on this unknown medical emergency?”

“Stand by, CCT 4,” comes the reply. Disgusted, RP savagely slams the mike back into its holder.

“Stand By is his middle name,” I needle. “Unit Calling Stand By Arceneaux. Better get used to him, because he works our shift.”

“God, but that guy annoys me!”

“Cut him some slack,” I advise. “Dude’s only got three functioning neurons; one’s infected, one’s infarcted and the other’s inhibitory. Kinda hard to multitask when you’re like that.”

RP turns left onto Meadowbrook Circle, and slows down. “What’s the address again?”

“834,” I answer. “This is 706 over here. Should be on my side, on the next block.” The neighborhood is a new one, filled with spacious homes abutting a golf course. You’d think that the residents would be well-to-do, but that isn’t the case. Most of them bought homes they couldn’t afford with their Katrina and Rita insurance settlements, and half of them have already gone into foreclosure for non-payment. With the housing market the way it is, it’ll soon be a very affluent ghost town.

“None of ‘em have house numbers!” RP bitches, slowing to a crawl and playing our spotlight over porches and front doors. “You’d think that if they could buy a $350,000 house, they could afford to stick some reflective numbers on the curb!”

“You’d think,” I agree mildly as we pass several people standing around a black Suburban parked at the curb, its driver’s rear door ajar. I make eye contact with them and nod politely as we creep past. We’re halfway down the
block before one of them decides to wave us back.

Now, why the hell didn’t they flag us down when we were ten feet away? Some people I’ll never figure out.

“Behind us, RP,” I grunt. “That was them back there.”

Cursing, he throws the rig into park as I step behind the box and press the backup button. I spot for RP as he backs our rig the couple hundred yards back to 834 Meadowbrook Circle.

“My Mama is having a stroke!” one woman greets me, panicked.

“Okay,” I smile reassuringly. “Where is she?”

“In the back seat!” she points. “We were going to take her to the ER ourselves, but we can’t get her into the truck!”

“Forget the equipment, RP,” I call out. “Just get the stretcher.”

There is a knot of concerned children and grandchildren gathered around the rear door of the Suburban. I politely say, “Excuse me,” several times, to no avail, and finally shoulder my way through to find a pleasant-looking elderly lady, leaning against the passenger seat of the Suburban, both feet still firmly planted on the ground. She looks very bewildered.

“Howdy Ma’am,” I say gently. “I’m AD of Borg. What seems to be the problem tonight?” The woman doesn’t answer, just alternates between looking at me in bewilderment and smiling uncertainly at her family.

“Anyone see what happened?” I ask. “And what’s her name?”

“Annalise Comeaux,” answers says the woman who flagged us down. “She complained of a headache. I went to fetch her some Tylenol, and when I came back downstairs, I found her on the floor!”

“Did she complain of blurred vision, weakness, anything like that?” I ask. “Was her speech slurred?”

“Nothing like that,” the woman shakes her head. “Just a headache. She takes medicine for high blood pressure.”

“Miss Annalise,” I say, taking the woman’s hands. “I’m going to lift your hands up, and I want you to close your eyes and hold them up while I count to ten.” When I release her hands, both of them flop back down onto her lap. She doesn’t close her eyes, either.

Well, so much for doing the stroke assessment when the patient can’t follow commands. Guess we’ll have to do this another way.

“Miss Annalise, let’s get you to the hospital,” I tell her. “See if you can stand up, and we’ll walk you over to the stretcher.” Obediently, she allows us to lead her to the stretcher and sit her on it. She doesn’t limp, nor does one arm seem weaker than the other. When she flashes that uncertain smile at her family, there is no Elvis sneer. It’s even on both sides.

“Get some vitals and a blood sugar while I talk to the family,” I order as RP loads the stretcher. He nods in understanding and climbs into the back of the rig, closing the doors behind him.

I briefly question her daughter about Mrs. Comeaux’s medical history. She isn’t a diabetic, never had a seizure, hasn’t taken any new medication, hasn’t fallen or struck her head. She’s generally healthy, her daughter tells me, other than the aforementioned high blood pressure. And that’s well controlled with her daily dose of Lopressor, I’m also told.

I assure the family that we’ll take good care of their mother, and make sure someone will follow us to the hospital. “Not too closely,” I warn them. “Don’t turn on your hazard lights, and don’t try to keep up with the ambulance. We’re going to take it safe and slow, so y’all make sure to do the same.”

“Blood sugar’s 128, pupils equal and reactive,” RP tells me as I open the rear doors. “Vital signs all good, too. You need anything else?”

“Nah, I’ve got it from here,” I wink, seeing that he’s already laid out a saline lock and IV start kit, and has Mrs. Comeaux hooked to the cardiac monitor. “Just get us to Big City Memorial, non-emergent. And good job, RP.”

Rookie Partner beams proudly as he strips off his gloves and climbs out of the box. Presently, I feel the rig lurch beneath me as we get underway. I busy myself with starting an IV and drawing blood, and Mrs. Comeaux flinches when she feels the bite of the needle.

“Ouch!” she exclaims indignantly.

“Welcome back,” I grin, extending a hand. “My name’s AD. What’s yours?”

“Annalise,” she smiles sweetly, shaking my hand.

Good grip strength in that one at least.

“Do you remember what happened, Miss Annalise? Do you know where you are right now?”

And now we’re back to that uncertain smile, and no answers forthcoming.

I recheck her vital signs, check her pupillary responses again, check her cardiac rhythm. Put her on oxygen at a couple of liters, just for shits and giggles. She’s hemodynamically stable, but she definitely ain’t with it. I keep trying to communicate with her, though, and gradually I am rewarded by better and better responses. By the time we reach Big City Memorial ER, I’ve managed to complete a full stroke assessment. She’s by no means oriented, but she follows commands well, and she’s otherwise neurologically intact.

“Whatcha got, AD?” the triage nurse asks as we wheel her past the desk.

“Dunno,” I shrug. “Guess you could call it altered mental status. Blood sugar and vital signs all normal, neuro exam’s unremarkable. No facial droop, no arm drift, no dysarthria. No limb ataxia, extraocular movements and visual fields all intact. It’s almost as if she’s – “

“Seizure,” RP interjects.

“Well actually, I was gonna say she acts like she’s postictal from a seizure,” I correct. “But I suppose that’s close enough for – “

“No, seizure,” he says urgently, tugging at my arm and pointing. I turn to see Mrs. Comeaux arching her back, eyes open and staring vacantly, her mouth open and twisted in spasm, right arm stiffened and curling toward her chest.

“Well, then,” I observe lamely. “Guess that explains the altered mental status. What room, guys?”

We hustle her into a room, transfer her over, and make room for the swarm of nurses descending upon her bedside. Outside the room, I repeat the story to the ER doc. Fascinated, RP cranes his head to watch as Mrs. Comeaux bucks on the ER stretcher, and one nurse injects a dose of Ativan through the IV. Less than a minute later, the seizure wanes, and the crisis has passed.

“Fucking cool,” RP grins as we walk the stretcher back to the rig.

“First seizure you’ve ever seen?” I smile tiredly. Sometimes it’s neat, having a sparky new rookie for a partner.

“Yeah, unless you count the other ones tonight.”

“I don’t,” I reply. “Well, at least you finally got to see what a real one looks like.”

For those of you who have read En Route or the previous paperback version of the book, drop me an e-mail, please.