Policy

Another double-transfer week.
Tuesday night, we went south to Williamsport. Wednesday was another visit to the fine folks at Robert Packer Hospital. Our patient was stable, the trip was uneventful, we got her tucked into bed, met up with another crew to grab some equipment to take back to our hospital, and we were on our way.

We only had one problem. Sayre, apparently, has a curfew. And we were past it.


Need a cup of coffee after 9pm ANYWHERE in a five mile radius? Tough. Because everything is closed. Everything. Our driver just wanted coffee. The rest of us were a mite peckish, but the driver having coffee is kind of important. We drive around and no luck. We finally find a Wendy's, which is open, but only the drive through. Surely, we reason, we'll be able to get coffee here.

Now. An ambulance is higher than a pickup, has a noisy diesel engine, and enormous side-vew mirrors so we can see past the patient compartment. Which means if we pulled up to the ordering thing, we couldn't get close enough and they would never be able to hear us. Never mind that we could never successfully complete the transaction on the other side of the building, between the height difference and the mirrors, without getting out. So we park the ambulance ON THE LEFT SIDE OF THE BUILDING WHERE THEY CAN SEE IT and walk up to the window. This is the retardation that ensues.

Our driver: Are you open?

Window Idiot: The drive through is open, but the dining room is closed.

Driver: Can we just order here?

WI: No, you have to be in a vehicle. I can't take your order at the window.

The driver and I part and gesture to the AMBULANCE which is parked IN FRONT OF HER STUPID HEAD.

Me: We can't drive around the building in that, you'd never be able to hear the order over the engine.


Driver: I can't even just get a cup of coffee and pay cash?

WI: No. That's the rule.

Me: But we're in an ambulance.

WI: Sorry, that's the policy. We can't serve people on bicycles either.

I am so close to pulling her through the window I'm experiencing involuntary muscle twitch. Because, you know, four people on an ambulance transfer from an hour and a half away who are just trying to not FALL ASLEEP AND WRECK on the way home are just exactly like some douchebag on a bicycle. We all freeze for an instant and let the pointlessness sink in, then get in the rig and go home.

Checking Out

“Suicide was against the law. Johnny had wondered why. It meant that if you
missed, or the gas ran out, or the rope broke, you could get locked up in prison
to show you that life was really very jolly and thoroughly worth living.”
--Terry Pratchett

Christmas Night.
I was just washing up the last of the dishes when my pager went off. "Stand by at your stations; call the center for details." I pulled on my coat as I dialed county dispatch. I really didn't have to call the center for details; I could have just gone down to the station, but I wanted to know what, exactly, was going to mark my first on-duty Christmas. "You've got a drug overdose, with alcohol, the patient is being a little combative so we're getting the state police over there before you go in."
Aces. Just aces.
When I got to the house, the rest of the crew plus ALS and a former member home for the holiday greeted me and we rolled, party of five. I was happy there were so many of us since I didn't know exactly what 'combative' was going to mean. The first thing I saw was a quart bottle of Yukon Jack on the counter, and most of it was gone. Nice little place, dish out for the cat, Christmas tree, and a man in a recliner flanked by two staties who are explaining to him that he needed to get his shoes on. While he was doing this, his daughter asked him if he was planning to leave any kind of a note. "Nope!" he said cheerfully. He pulled on his shoes, tossed an afghan at the cat, and came smiling into the kitchen, where he scooped up his coat and stared in wonder at the number of people in the house. The crew chief made introductions and he greeted us all with a broad smile. "Jeez! All these people!" as if he just walked into a surprise birthday party. We walked him to the ambulance and in the course of questioning I learned that he took two whole bottles--pain medication and sleeping pills. He kept explaining how he just wanted the world to leave him alone and he just wanted to die, and this news is delivered with the same magnanimity as everything else he said. The paramedic drew blood, we monitored his vitals, and he asked each one of us in turn if we are having a good evening.
After assessing the relative happiness of each of our Christmases he demanded of one of the crew "Do you know the true meaning of Christmas?" The crewmember gave him a quick answer of neutral, professional benevolence, something that conveyed "We'll be at the hospital soon, just hang in there."
Our very medicated patient declared "Its when God sent his Son Jesus Christ into the world to save sinners," in a way that made me expect him to recite Luke 2 in its entirety. We got him into the ER, and when I stopped back with paperwork a good while later, the entire group of family, frends, and neighbors who followed us to the hospital were still clustered together, waiting. I looked at the varying expressions on their faces, while they came to terms with what brought them there on a night that is not supposed to be spent in a hard plastic chair in a brightly-lit hallway, and all I could think of was "And Mary kept all these things, and pondered them in her heart". She had an initially fearful but eventually hopeful Christmas to ponder in dark times. I sincerely hope these people will too.

Breakdown

Wednesday night. Second duty section of the week.
I'd hoped to get to the ambulance building, execute my little side job cleaning it, and whip out some tripsheets before any tones dropped. That is, after I had a leisurely supper that I'd pick up on the way in.
What is the saying, man schemes, and God laughs?
As I was making my final approach to town from work at about 17:25, tones. Patient to be transported directly from a Dr.'s office to a hospital 65 miles away. I step on it and get my phone out to call our crew chief, to tell him to wait, that I'm 5 minutes out.
He answers. "Hey! Howya doing!"
I say, "I'm almost there, so wait for me."
He says, "I'm in (town an hour away), and I'm just leaving. And (our other crew member) is just leaving work in (town an hour in the other direction)."
I say. "Okay then, I'll just go and see who comes."
Well, five different departments get paged out. No one is available. I should mention that the roads are borderline crap, its cold, and its snowing. We were supposed to have flurries all day. Its been flurrying with a lot of determination for hours. Finally one of the paramedics from the hospital pops in and offers to drive. We grab the second-line ambulance (the first line ambulance is OOS because of some problem with the air-system-dealie-thing ) and go.
The patient is alright, he isn't super excited about the transfer and he is so reluctant to admit he feels like crap that it takes about 30 minutes of good cop/gooder cop interrogation to get him to say he hasn't been 'quite right' for about a month. (He has some not-good things going on with his heart, he shouldn't feel good.) But he's stable. Away we go, bouncing into the night.
This ambulance isn't exactly a smooth ride. Heck, any ambulance makes you question the structural integrity of your bras, but this one seems especially swingy.
I'm chatting with the patient, and two things happen at the same time. Neither of them are good.
One, the patient starts doing this funny thing with his lips. That funny thing means "Gee, I feel an awful lot like I might throw up. I wonder if I should say something." Or in this man's case, "I feel like I'm going to throw up but damn if I'm going to admit it." I ask him, are you all right? We elevate his head. He is offered the good drugs to make it stop. He refuses them. We scramble for the Magic Barf Cones. We can't find any. I put a towel across his chest and offer him the only thing I could find; a scroungy looking red plastic bag. He looks at it, and looks at me. I smile, apologize, and wait for the wave.
Two, the ambulance starts to smell. Its subtle at first, like maybe we drove by someone's trash burning. Then it gets a little worse. Then it smells like the stretcher is parked on top of a smoldering tire fire. I mouth to the paramedic "What's burning?" He does a quick check, and shrugs, but I can see 'slightly worried' battling 'professional and calm' for real estate on his face. We check on the patient. He's still doing the lip wiggle but still doesn't want drugs. We find a Magic Barf Cone and swap him the red plastic bag.
About 20 minutes from our destination, there is a terrific bang, the ambulance lays down a blanket of smoke about 18 feet wide, and it feels like we're driving over half a cord of firewood.
We stop, the driver and paramedic grab flashlights, and look underneath. All tires are intact, and we haven't hit a rock, a deer, or a toolshed. There is talk of us 'losing our rear end'. Not being a gearhead I have no idea what that means. The patient gives me a slightly exasperated half-smile that clearly conveys the degree to which he believes we are idiots. We ask him if he feels better and he says he's "A damn sight better now that we ain't movin' no more." The Magic Barf Cone stands down.
The paramedic calmly conveys to county that we are dead in the water and another ambulance is called (and comes almost immedately, bless them) to take the patient to his destination. We limp the ambulance, which now creaks and sways like a wagon pulled by a drunken horse, to a well-lit parking lot to await a tow. Our chief comes to collect us and I finally get the dinner I never had and a much-coveted chance to pee. And bonus; no more calls for the rest of the night.

Au Revoir, Les Enfants

My experience is limited. I was licensed in the Spring so its been not quite a year, I'm still having 'first experiences'. Saturday was my first psychiatric emergency. A few months ago I had my first infant arrest. Someday there'll be so many different things that I'll have to give the experiences different names, but for now, that infant arrest is referred to in my house as 'that baby'.
'That baby' presented with severe difficulty breathing. His mother, suspecting something was wrong, didn't put him in his crib that night. She was sitting in a chair holding him, and put her head back, but when she heard him make a little squeaking sound, she looked down to see frightened, staring eyes and purple skin. She did rescue breathing. He settled into a startling purple-yellow and she got going calling EMS.
He was only a few days old, and premature. When she got onto the ambulance with him he looked like a doll the color of an old bruise. They fought for hours to stabilize him, flew him to another hospital, where it was discovered that he was septic. He ended up elsewhere and a liver transplant was considered, but ultimately his little body wore out and he died.
I wanted to write about that baby before. Lots of things came to mind but most of it sounded hollow. Its a hard old world sometimes and not everyone gets a happy ending. There is hope, for sure, but sometimes invoking hope in the face of wordless grief cheapens both.
I'm thinking about him today because the other day I saw his mother. The last time I saw her, she was exhausted. She hugged me before she left the ER and I was hit with a wave of heat from the raging fever that would hospitalize her as well, later that day.
This time, I saw her smile. She didn't recognize me, and I was glad. I was hoping she was having one nice day and a break from the memory. He's just 'that baby' to me and there is an empty place in my heart that I am okay to carry. I hope that what she carries is a burden she can shoulder though I do not pretend to understand how.

Wreck

Crash last night in town.
Driver was passing in a no passing zone and found themselves in a losing game of chicken with a tractor trailer.
Tractor trailer vs. car with a short front end = nearly six feet of intrusion into the passenger compartment. After the truck was pulled off it took a very long time to remove a very broken (and decidedly deceased) person from the vehicle.
We sat around back at the station speculating about what could have been so pressing that a person was passing multiple cars on a stretch of double yellow. Bad phone call? Fight with a significant other? Just late/tired/preoccupied? We'll never know.
I went home last night thinking about the consequences of our actions. It doesn't get much more lasting than 'permanent'. It doesn't get much more real than 'dead'. For some reason a line from one of those old 12 Step 'handouts' popped into my head:

Just for today I will save myself from two pests: Hurry and indecision.

Turns out, hurry and indecision are real bastards.

Transfer

The hospital we normally transport patients to is a great little hospital. Clean, pleasant, smaller than the high school I went to, it only took a few months to acquaint myself with many people who work there, not only because many people I know do work there, but darn, the place is small. You see the same faces over and over. It doesn’t take long to learn where everything is. A nice place to become accustomed to this EMT stuff.

The downside of that is that we don’t have a lot of specialties covered. Orthopedic surgery, neurology, cath labs, all that sort of thing usually buys you one of two things; a ride on a helicopter if the weather is good and your condition is poor, or a transfer.

Transfers are not everyone’s favorite thing. The facilities we travel to most often are between 65-85 miles away. An hour or two in the back of an ambulance is not for the potentially carsick. Spending those 1-2 hours with a patient who might be 1) also potentially carsick, 2) combative or deep in the throes of a really interesting neurological deficit, or 3) radiating funk for one reason or another is the gamble you take when you agree to go. You have one of those moments where you kneel down beside your inner child, take them by the shoulder, and remind them that 1) this is what you signed on for, 2) that person probably doesn’t want to be transferred either, 3) make sure you go potty before you leave, and 4) stop your whining.

Last night the call came from the transfer coordinator and I was asked a question. "Hey, do you want to go to (insert town within spitting distance of Canada)?" I did a rough calculation, decided I could probably function on the number of hours of sleep I’d get once we returned, and agreed.
We arrived at the hospital and gathered up the paperwork that included medical records, our ‘permission slip’ to blow town with the patient, and the usual name/address/SSN stuff. I glance at the form and see the words RECTAL BLEEDING as reason for admission. Uh oh.

Fortunately this is a ‘was happening’ thing and not an ‘is happening as we speak’ thing. The patient is ambulatory and we get him all snugged up on the stretcher. He tells me matter of factly that his colon is ‘about to blow up’ so they are just going to go ahead and ‘take it out’. Suddenly, lost sleep and a couple of bone-jarring hours on the bus don’t seem to be much of an inconvenience.

The trip was uneventful, we even managed to make the patient laugh a few times on the way. (I would venture to say that the soon-to-be-colonless is a tough crowd. So we did okay.) He told us he should be home by Thanksgiving. I hope he is right.

Special Places in Hell

I don't use that phrase often; I hear people say it, "There's a special place in hell for people like that"...

Its very tempting in this case.

But what disturbs me more is that this didn't happen in a vacuum. This house was not situated on 10 acres in the middle of the mountains. It was in a neighborhood. Mail got delivered. Meters got read. People saw, smelled, and suspected, but nothing happened until things were irrevocably bad. This lady died on 25 October and the assault on her dignity doesn't rest solely with her grandson.

If you see things, suspect things, say something.