Population 485 (9 page)

The proximity of the funeral home had its pros and cons. We were always being recruited to shuttle caskets and move bodies. When we washed and polished the ambulances, we were expected to do the same for the hearse. When it snowed, the funeral-home owner would summon us to his house on the hill and make us shovel the drive. I always figured that looked pretty good—an ambulance pulls up, and two uniformed medics jump out with snow shovels.

On the other hand, the presence of caskets and dead bodies kept us well stocked for pranks. Whenever new medics hired on, we took them on a tour of the funeral home and made sure to point out that the bunk room and the embalming room shared a wall. That night, we’d assign them the bunk against that wall. After lights out, the dispatcher would sneak into the embalming room and scratch on the tiles. Sometimes you’d cook up an errand that would send a rookie through the casket room. We’d plant a veteran in one of the caskets, and when the rookie got close, the veteran would moan and pound on the lid.

I used to say I would trust the Silver Star crew with my life, but not my sister. The city fire department, with its union wages and tough admission standards, tended to attract experienced career-minded individuals. Silver Star, with its low wages and cursory background checks, tended to attract part-timers, novices, and talented rogues. When I signed on, I found myself part of a merry band whose personalities were as fractured as their rescue talents were solid: Jacques, the French-Canadian Sioux who cheerfully referred to himself as a “blanket-assed wagon burner.” Before turning in at night, he stripped down to his leopard-print bikini briefs and cut muscle-man poses. He and I spent a lot of time in the brush behind the ambulance garage, rigging figure-four rabbit traps and taking archery practice, city ordinances notwithstanding. Leif, who shagged anything that would stand still. Donnie, the sawed-off veteran with the most seniority who wore cowboy boots and refused to do anything other than drive. We used to wind him up just to watch his bald head turn red. Todd, vein-skinny, sardonic, and utterly unflappable. Baz, who lived on coffee and cigarettes and spent half the shift in the bathroom with the newspaper. Phil, the gentleman among us, with a sweet wife and little boy. And Porter, who got lit at the bar one night, tried to ride home on his bike, and ran smack into a two-story brick medical clinic.

Silver Star was managed by Arnold, the owner’s son. Arnold had high blood pressure. Under stress, he tended to spring nosebleeds. He’d be in his office chair, chewing you out, and all of a sudden he’d tip back and pinch his nose, and you knew you were getting to him. The day I applied for a position at Silver Star, we were five minutes into the interview when the pager went off. Arnold tossed my résumé on the desk and jumped up. “C’mon!” We picked up a sick little old lady. She was on the floor in her nightgown, hands clenched over her belly. We carried her out on a backboard and put her on the cot. Halfway to the hospital, she relaxed a little, and a basketball-sized mass of flesh rolled out from under her nightgown and thumped to the floor. It remained attached to her abdomen by a thin, fleshy umbilicus. Arnold and I exchanged a glance across the cot. Then Arnold picked the thing up and popped it back under the nightgown like it was the most natural thing in the world. Never said a word. The lesson was twofold. Number one, failure to detect a free-floating tumorous mass the heft and circumference of a supermarket watermelon reflects a certain inattention to basic patient-assessment protocols. Number two, be cool. And if you can’t be cool, act cool. The patient will draw comfort from your demeanor.
Another day
, your countenance should say,
another little old lady sprouting giant flesh balls
.

The human body is subject to an infinite number of maladies and injuries in an infinite number of combinations. This can put a little whoops in your gut if the pager on your belt designates you to sort them out on the fly. The what-ifs are daunting. The good news? It’s likely you learned the most fundamental element of EMS clear back in kindergarten. In EMS, no matter what happens, no matter how tragic or banal the call, all patient treatment is predicated on an algorithm, and that algorithm begins with a three-letter mnemonic:
ABC
. A = airway, B = breathing, C = circulation. Whether grandma stubbed her toe, had a heart attack, or got hit by a Mack truck, your primary responsibility, as one of my instructors used to put it, is to make sure air goes in and out and blood goes ’round and ’round. No matter your level of practice—first responder, basic EMT, paramedic—you begin at ABC and ride the algorithm home.

So. Is your patient getting air? No? What must you do to change this? Change the position of her head? Put a tube in his throat? Blow air into her lungs? Got that taken care of? Now let’s check circulation. Does your patient have a pulse? No? Has someone started chest compressions? Is it time to fire up the defibrillator? Perhaps you walked into the little old man’s apartment and he said hello. You have just completed your most primary assessment. The fact that he is upright and talking tells you his ABCs are up and running. You will need to assess the
quality
of his ABCs, but at the very least they are
present
.

From ABC, the algorithm bifurcates. The bifurcations fill entire textbooks. If the patient is unconscious, you go left. If the patient is conscious, you go right. Are you dealing with a medical problem (turn left) or trauma (turn right)? You just keep working your way through the maze. At every intersection, you read the sign and turn accordingly. In general, you work from head to toe, a quick once-over the first time, to find and treat life-threatening injuries. If you find bad things of magnitude—a sucking chest wound, massive external hemorrhage—you stick your finger in the dike (cover the chest wound, control the bleeding) and get rolling. “Load and go” it’s called, or “scoop ’n’ scoot.” If the patient is stable, or if transport time allows, you perform a secondary assessment, running head to toe again, with more attention to detail. You’ll be checking for more subtle signs of trouble: the little bruises tucked behind the ears that indicate a basilar skull fracture, clear drainage from the ears that may be spinal fluid, swollen ankles indicative of congestive heart failure. Throughout the algorithm, priorities rule. See the motorcyclist with a leg like a pretzel? Ignore the leg—find out if he is breathing. Check to see that his trachea is in line, not squashed to one side by a leaking lung. The most garish problem is not always the most deadly. And through it all, remember: If at any point along the algorithm your patient crashes, you don’t panic. You just move your little game piece back to square one, to ABC, and begin again. Air goes in and out, blood goes ’round and ’round.

I pulled mostly weekend shifts at Silver Star. Weekdays were covered by full-timers working in teams of two. When the full-timers rotated through weekend coverage, they split and paired up with a part-timer. One pair worked “first out” on Saturday, and the other pair worked “first out” on Sunday. Being “first out” meant you had to be at headquarters. Working “second out” meant you could go about your business in town, but you had to carry a pager and be able to make it to headquarters in under ten minutes to cover any call that might come in while the first-out team was in the field. This arrangement meant that even as a part-timer working weekends only, you were putting in a forty-eight-hour week. The calls and experience accumulated quickly.

I pulled most of my shifts with Jacques. You learned to stay on your toes with Jacques. He had a brilliant mind but was plainly bent. He used to sit around the little apartment starting intravenous lines on himself. For the practice, he said. He favored the veins in his feet. He read voraciously and was a martial arts maven. One minute he would be ruminating aloud on the restorative powers of meditation, and the next he would be doing the splits, or he’d have you facedown on the floor, rubbing carpet burns into your nose as he demonstrated some new submission hold. You learned to step through doors cautiously, because you never knew when he would have his throwing knives out. He set mousetraps in the coffee filters and rousted Baz by rolling firecrackers under the bathroom door. Returning from a call at three
A.M
., he wound down by hitting golf balls across the highway. Looking for a quick and easy way to gather worms for fishing, he wrapped copper rods around the defibrillator pads, then stuck the rods in the dirt. He’d charge the defibrillator to 360 joules, hit the double triggers, and shortly, nightcrawlers emerged from the earth. He rarely settled, due in no small part to the fact that he frequently worked a cigarette, a wad of chew, and a can of Mountain Dew simultaneously. He was bent, but he was fearless, and one of the best medics I’ve ever run with. We made call after call that first couple of years. He became my gonzo sensei.

Jacques took me to my first full-blown trauma. A woman and a man on a motorcycle lost it on a curve. The woman got flung ahead of the cycle, wound up wrapped belly-first around a pine tree. The bike followed her into the tree, crashing into her back. Her kidneys and liver were lacerated. She was in imminent danger of bleeding out. She had severe head injuries and was unconscious, but her gag reflex was still intact, and she wouldn’t tolerate an oral airway. The last thing you want to do is jam an airway down someone’s throat and make them puke. If they aspirate the vomit—breathe it in, literally—you suddenly have a patient with a compromised airway. The first responders already had her in a neck collar and strapped to a backboard, so we didn’t linger. As Jacques hit the siren and struck out for the hospital twenty minutes away, I looked at the woman under the bright cot lights and realized I was in it for real. I taped sandbags around her head to increase the stability of her neck. Then I got busy with the secondary survey, and began accumulating follow-up vital signs, taking her pulse and blood pressure every few minutes, rechecking her breathing, looking for signs of shock. It is critical to recognize shock early, and our instructors drilled us on the signs: rapid pulse, rapid respirations, falling blood pressure. Then they added a grim little coda: by the time these signs begin to show, your patient may be past retrieving. So you do what you can. Keep the patient warm, deliver oxygen, drive fast. Start an intravenous line if your license allows—ours did not at the time. We did have the woman in a pair of military anti-shock trousers. These are essentially inflatable pants. Like much of the EMS repertoire, they were developed during the Vietnam War. Theoretically, inflation of the pants forces blood out of the legs and lower abdomen to the more vital areas of the chest and head. MAST trousers have fallen from favor in recent years. We still carry them, but we rarely receive permission to inflate them when we radio the emergency room doc for orders. I no longer recall if we received permission to inflate that evening. I just remember that about five minutes out, the woman began to seize and puke, and for the rest of the ride, I was consumed with the maintenance of our old friends, A and B.

The seizure came first. The woman’s entire body stiffened, even as her eyes stared blankly at the ceiling. As soon as the seizure passed, the puking began. And for a second or two there, I was terrified. I thought surely the woman would choke and die, a pathetic irony in the face of all her other life-threatening injuries. Strapped down on her back, she was in the worst possible position. I grabbed the suction unit, but her teeth were clenched. The puke (a burgundy syrup—we later placed it as red wine and crackers) burbled up through her teeth and lips and spilled over into her open eyes. Realizing I had to act immediately, I flipped the entire backboard up on its left side. The straps and sandbags held the woman in place, and I kept one hand on the underside of her head to further support her neck. The puke rolled out of her mouth and down my arm. I got the backboard propped and swept the suction across her mouth. Using a technique we learned in class, I crossed my fingers and tried to pry her jaws apart, but it was futile. I still remember looking up through the little communicating passageway and out the windshield, dipping my head, desperate to get a glimpse of the hospital as we hammered into town and down the boulevard. I kept suctioning and trying the finger technique, and finally got the woman’s teeth open just enough to admit the suction tip. When we pulled into the ambulance bay, I remember hands reaching in to help us debark, I remember being a little breathless giving report, and six months later, when I heard the woman was finally walking out of the hospital, I remember thinking that in all the madness, with all the critical things going on, the greatest lifesaving action I made on her behalf involved the diversion of throw-up using the principles of gravity. “You did well out there,” said Jacques, in a rare serious moment. It was all that mattered.

From ABC on, the rescue trade is big on mnemonics. The idea, I suppose, is to help you recall assessments and procedures under pressure. Textbook authors and instructors bury you in the things: OPQRST =
O
nset,
P
rovokes,
Q
uality,
R
adiates,
S
everity,
T
ime.
DCAP =
D
eformities,
C
ontusions,
A
brasions,
P
enetrations
. SAMPLE =
S
igns
/S
ymptoms,
A
llergies,
M
edications,
P
ast
P
ertinent history,
L
ast oral intake,
E
vents preceding.
CUPS =
C
ritical
C
PR,
U
nstable,
P
otentially unstable,
S
table.
Notice how the last two mnemonics sometimes assign the bold letter to two words simultaneously, while in other cases, the letter matches only the first word. Excusable to a point, but turn the mnemonics crowd loose, and things quickly get out of hand. ABC becomes ABCDEFGHI:
A
irway;
B
reathing;
C
irculation;
D
eformity;
E
xpose;
F
ahrenheit (temperature); EK
G
, pulse oximetry, vital signs;
H
ead-to-toe exam;
I
nterventions,
I
nspect back
. Okay through
E,
I guess, but the Fahrenheit thing is a little sketchy. Then, to squeeze in EKG, we completely ignore
E
and
K,
highlighting
G.
And since
P
and
V
are too far down the alphabetical line, pulse oximetry and vital signs are tacked on to EKG like a cheap porch.
H
is for head, you’re on your own recalling “to toe exam.” And finally, “I,” presented in classic double-assignation form.