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Standby for Tones

Standby for Tones

Featured Writings by

Crystal Wallin, NREMT-P, CCEMT-P, FTO

La Crosse, Wisconsin

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  • Monday, June 29, 2020 8:02 AM | Amanda Riordan (Administrator)

    By Crystal Wallin, NREMT-P, CCEMT-P

    As a child, we knew it. Maybe we forgot it. The eyes of those we trusted and loved radiated kindness and safety. Whether it was a sweet faced teacher or the kind eyes with wrinkles around them of a grandparent, we saw with a glance where we stood.

    Growing older, we saw eyes that were all colors. Learning patient care, you and I both learned to tell a lot with a glance. Walking in the door of a scene, I was trained early in paramedic lessons – “sick or not sick”? Instinctive reading of a situation was often the first step of an assessment I began the moment my first boot crossed the threshold. A patient’s eyes can be cold, dead – as I type that, a face flashes across my memory. A face of a man that often wore a long black coat which only accented his presentation as he struggled with mental health challenges. He was articulate and soft spoken. But from my first encounter with him, something within me was afraid. Afraid in a way I’ve not encountered more than three or four times when in the presence of another human. It was his eyes. Something in their flat depths made me very careful not to turn my back on him or be left alone with him.

    There were other patients whose eyes I can still recall. Mothers holding their children in anguish, wives staring blankly at their husbands lying still. Eyes fogged with fever – or cataracts. Eyes with nystagmus, telling in a glance that the patient in front of me who was wracked with nausea needed a vestibular suppressant, and wasn’t going to find much relief from my IV Zofran. Eyes that were excessively glassy, or red – even the eyes with pupils contracted down to pinpoints or dilated into wide discs that nearly obscured the color of the iris; all these told the tale to us and to law enforcement on scene.

    The sad eyes with one pupil helpfully reacting and the other pupil sadly checked out, telling the story of trauma on the inside that matched the trauma we could see on the outside of our patient. Knowing from that assessment that the intracranial pressure was/had built and herniation was/would soon occur.

    So now in the tempestuous year of 2020, we are all being brought back to the eyes. Over and over in daily life, we judge the eyes of another. Are they happy, are they smiling, how are they feeling? As masks do their necessary job and help us to do our necessary jobs—we’re drawn back to the eyes. Shakespeare said that the eyes are the windows to the soul, and I believe that poetically phrased assertion is the truth. Tyra Banks popularized the term “smize”, meaning to smile with your eyes – and we all can picture in our head now what that means.

    Thank you to all who are reporting to work, putting on the garb and facing the heat, the moisture in all areas it shouldn’t be, the heat and condensation on the face masks. Thank you to the ladies who have nearly forgotten what lipstick and gloss smell like, the men who’ve sacrificed their beards or goatees to ensure proper N95 fit. Thank you for dealing with the breakouts and the freak-outs. Times when you step out to lower the mask and shield take a moment to breathe sweet cool air and when it’s time to go back in must face the unusual sensation of extreme reluctance to go back in and do the job we have always just…done.

    Thank you for being the ones who still come when help is needed, when there’s no one else to call, when someone is afraid, or hurting, or scared, or just – alone.

    Thank you for being the eyes that send out kindness and caring into this ever changing world that is 2020.

    You are all my heroes.


  • Monday, March 16, 2020 7:11 AM | Amanda Riordan (Administrator)

    By Crystal Wallin, NREMT-P, CCEMT-P

    We’ve all had them. They are the ones you see on the schedule and your heart is gladdened. If you aren’t lucky enough to be scheduled with them for a while but you see them at shift change, you linger – assuming the tones leave you undisturbed for a bit.

    Sometimes they are the intimidating ones, in your early days. They were most likely the tougher preceptors, if you were a student at that service. If you had the self-awareness to grasp, fleetingly for some or in a bold glare of spotlight for others – your own lack of knowledge and utter vulnerability in the face of a truly pressing medical emergency. They worked with precision and efficiency of movement no matter the utter urgency of a patient in true distress. Worked, while you tried to help and likely succeeded mostly in getting in the way. You with all your book knowledge that felt so good in class when the instructor needed an answer but now you are on the truck, in the street, in the neighborhood perhaps you’d be uneasy to be in alone. But when you are with these experienced providers you don’t think of the environment, as you find yourself drinking in the way they move and work together. Wondering if you will ever be like that – sure you will not because you realize in those moments that the line about the real learning beginning on the street, well, it was oh so true.

    So you look forward to these preceptors more than the ones who were known for giving you an “easy day” and requiring very little as they announced that having a student was a way for them to not have to do much. You came to crave the tough preceptors because they were hard on you but you learned quickly that they were hard on themselves too, and settled for not one iota less than their very best. Quizzed until your palms sweat, driving home after a shift with these preceptors you felt alive and as if you wanted to put mental hands into the knowledge they had shared all day – and grasp it tight.

    I had preceptors like that. Multiple. I was alive, energized and drinking from what I knew even then was a cup of wisdom nothing in a book could bestow upon my mind.

    Eventually I had the honor of wearing the same uniform, and working alongside of them. The days were long but just like you hear, it really is true – the years were short. Many of them continued their educational journey and left or worked their way up in the organization until they served as supervisors. Some followed a path that diverged from that shared uniform. But somewhere along the way, I began to pass on the tidbits they had taught me to the students and new employees that now I was precepting or for whom I was the FTO for that particular shift. I referenced these medics like people reference cited research. Taught about evidence based practice, looked up new research and discussed that the only thing constant is change – that to be up to date we must let go of old ways and seek to learn so that we can deliver the very best for each of our patients.

    A few years ago one of those tall in stature as well as knowledge medics retired. Well, I guess it was more than just a few years ago now. Watching the cake cutting and the heartfelt sendoff, it struck me – the medics who shaped me, who were my work heroes and honestly my family, they were shaping all of us who came along in order that we would be able to take their place. The workplace without each of them seemed a little more foreign, and soon stories that involved them began to be met with, “who?” from the new faces in stiff new uniforms. But that’s how it was always going to be, like it or not.

    The thing with workplace heroes is, you don’t know that’s what they are until you are looking backward through the lens of experience and time. When you are busy walking with the greats, whether running calls or texting them to share some new research, whether they drive or fly or nurse now or are leaders – when you are walking among them you just know they are what you want to be.

    If you are very lucky, someday one of the new shiny faces will tell you that you have shaped them. You will hear the echo of “see one, do one, teach one” and smile with a little bit of pride and a whole lot of wistfulness. For the good days that you didn’t realize were golden.

    And I hope, you pick up the phone and call or text them – and thank them.

    And then, you go back out there and learn, pass on the feeling of being alive in a way that transcends any uniform.

    My heroes will always know the difference they made. So should yours.

    Tell them, thank them. You are their legacy.

    ~*~*~*~*~*~*~

    For Lucy, Nick, and all the rest – you know who you are.

  • Thursday, December 19, 2019 12:16 PM | Meghan Winesett (Administrator)

    By Crystal Wallin, NREMT-P, CCEMT-P

    It takes a little more in some houses to find the magic. It takes a little vision, to see what used to be instead of what is now.

    I was driving near a little cul de sac recently in the bigger city where I was a full time paramedic – long before I got the idea to go to nursing school. I hadn’t thought of her in years, but it was the lights that did it. Something about that neighborhood, in this time of year, and suddenly it all came back.

    We were called in the dead of night for a female, unknown medical. Updated dispatch information en route didn’t do much to clear the ambiguous initial dispatch, “35 year old female, sore shoulder area”. The house was small, tidy and neat. Its bricks were sedately earth toned in the dark and unlike the houses around it, dark. It was nestled neatly in one of those post-World War II neighborhoods where the houses look like they are all from the same family, close in age. The roof line near the front door resembled an upside V, with the left arm of the V in a sloping sort of what a roofline might be if it were cursive.

    My partner and I were working the nighttime power truck then, and we hadn’t had to come from far. We were posting in those days, at the Y parking lot and the trip wasn’t far. We gathered our monitor, the bag and took the cot as far as the front door. Locking the brakes, we left it there and as my partner raised his hand to knock, the door opened. A man stood there. A weary man with a sad face. He smiled the most small of polite smiles and, putting one finger to his lips, gestured us inside with a short sideways move of his head.

    Two small humans were sleeping on the L-shaped sofa in the living room, with a Christmas tree nearby. There were lights on the tree, and no other lights we could see on that level of the home. He indicated we should follow him, whispering as we went up the stairs to the left of the front door, “it’s my sister. She lost her husband about six months ago and we didn’t know this whole time, well, who knows how long she’d been dealing with , well. You’ll see” and his eyes grew moist. We were at the top of the stairs then, and turned left. The first door on the left stood open, and since I was up for patient care, I went in behind him. My partner brought up the rear.

    I can see her still, sitting there, pretty and gaunt and holding a towel to her right breast. She looked at me calmly, greeted us. Thanked us for coming. My assessment was ready in my mind and I sat down the monitor, beginning the usual words which formed most introductions. She responded to my questions; she had been dealing with this for a while, how long well, months. She’d had a lot going on…her voice trailed away and I followed her gaze to a framed photo of a happy couple. I could see the lady was her, and the man was handsome.

    She looked up again, and said, well, here, and took away the towel. I was speechless at the oozing open dark skin that was what remained of her breast. My eyes came up from the cancer to her face, and she nodded with lips pressed together and replaced the towel. She said, “I can’t walk and I’m weak and I think I need something for the pain, now”. I nodded, my partner who had witnessed the exchange helped and we got her down the stairs to the cot, past those sleeping two small humans next to the Christmas tree and into our truck. The brother followed, stopped at the front door, looked at the two toddlers, said hoarsely, “I guess, I guess I’ll stay with them”. She nodded, her head fell back and she just kept holding that foul, wet towel over the horror underneath.

    I started a line, I think. I gave pain medication, radio report, took her inside the hospital upon arrival. Gave bedside report. She didn’t offer any clarification, didn’t indicate any desire to speak of the backstory or even the now story.

    My partner and I cleaned that truck in silence. Radioed back in service. Drove to the red light at the corner. Waited. I concentrated very hard on holding my eyes wide open, looking at the sticker on the dash on my side that warned of the height clearance for overhangs. Held our Toughbook, trying to imagine writing a heartache like that one, like the one coming to those toddlers on the cough – writing it down in orderly black and white words.

    We didn’t speak for a long time. I don’t remember what we said when we spoke again, or who spoke first. I can tell you that neither of us spoke of it at all.

    Some things are too terrible to put into words and you push them down and go on to the next patient and try not to think about What Happened After the Call.

    Until years later and Christmas lights in a cul de sac with one dark house. With a sloping cursive kind of upside down V roof.

    Hug your loved ones. Enjoy your time with them. Extend kindness to everyone you meet. Everyone.

    Because it takes a lot more in some houses to find the magic. To see what used to be, instead of what is now.

    And some dark houses with a Christmas tree hold more grief than any holiday should hold.


  • Thursday, October 24, 2019 7:40 AM | Amanda Riordan (Administrator)

    By Crystal Wallin, NREMT-P, CCEMT-P

    I wonder if they know, patients and families, how we carry them with us?

    Oh, we like to think we don’t, or at least pretend we don’t. We are professionals who do this for a living and so we all have a wall of sorts. Behind that wall are all the ugly things, the things we don’t want to admit we saw/were impacted by/were changed by. The wall may be temporary and one we clamber over occasionally as we work through the things placed back there, in a safe time and space, dealing with in a healthy way. The wall may be tall and bitter and the things we throw up high over the edge may lurk there, rotting and undealt with until one day they demand our attention. We employ all sorts of things with which we choose to manage the effects of the job. I will tell you that the loudest scoffers and the dramatic eye rollers are among those who have sobbed in quiet quarters, describing the call that nearly broke them. Why the determination to act as if we are all untouched? Culture, I guess. Bravado. Grappling with the way to couple our human response to repeated front row seats to the tragedy of others – combined with the backbone and ego necessary to get on the truck and handle anything the tones throw in our lap, long hours at a stretch.

    Maybe once the mask slips, it’s harder to put back in place? I hope we get to a place as a profession where the mask is unnecessary at all. Where we do the job and we take the time to get to a healthy space and we allow our personnel to do this before throwing them back, immediately, into the churning call volume. Human minds don’t speak response times when they’ve been exposed to trauma. Human minds need a minute. I think we will get there.

    But aside from all of that very real conversation, there’s another way we carry the calls. Let me explain.

    Any given time I drive down streets or roads in our response area, there they are. The calls, the patients. The other night we were going out for a family birthday in the city where I was a full time paramedic and as we entered the city limits, I looked over reflexively at the stately farmhouse. As I always do, I remembered a particularly vulnerable family who opened their doors to myself and my long-term nighttime partner one evening. The family patriarch was dying, and the house was carefully readied. Family was present, the energy was calm and loving. He was in the restroom and they were unsure of how to get him from where he was on the toilet, using the lift provided for them. They were gracious and apologetic for calling and in need of guidance. They got a couple of young, new paramedics who hadn’t used a lift before but together we all worked it out. You know, I remember that farmhouse every time I drive by for one reason. The father/grandfather of that family, despite being wrecked by cancer and frail, in pain, slightly embarrassed at the assembly in the large bathroom on his behalf- kept up a steady stream of encouragement, calm patience and then dignified appreciation for everyone’s cooperation and teamwork. I look at that farmhouse every time I drive into the city because I remember the way he led the group, even in his vulnerability. What a family to be shaped from a soul such as his. That stately farmhouse will always evoke that memory to me.

    We drive down a bluffside street to our eldest son’s house and I remember the older German man who fell frequently, who that same partner and I knew well by first name. We’d pick him up and discuss the need for evaluation and he would set that stern German jaw and with his accent unchanged by time, firmly avow his need for lifts but not for any doctors or hospitals. I wonder what happened to him, in the end. Did family talk him into acquiescing? Did he go to an assisted living? Or did he finally fall asleep for good in that study full of beautiful old books, where we often assisted him off the floor? I remember the winter night my partner shoveled his walk. I remember his name yet.

    Or the duplex where we transported a young mother of two small children in for evaluation, the way we had to move small bicycles, one pink and with streamers on the handlebars, one with training wheels, out of the way of our stretcher. The way a healthier and pink cheeked version of her grinned down on us from the living room walls, a sharp contrast to the sharp cheeked and medicated, in pain version of her on the couch. The way I shut the back doors of the ambulance and turned, unfortunately in time to see her husband close his eyes and lean his head against the door frame of the entrance from the laundry room to the garage, where we’d just exited. In that gesture, a lifetime’s worth of “if only’s” and “how will I….” all but screamed wordlessly, as those bikes sat just to the side. I wish I hadn’t seen that. I wonder when we pass that duplex, how he’s doing. How the kids are. If she had to say goodbye or if she rallied somehow.

    And the playground at the corner where we turn to make our way to the ambulance garage. The playground with equipment that allows children in wheelchairs to play. The playground that was the idea of a soul I will probably never be able to talk about with dry eyes, but a soul that shaped my view of life forever.

    It is an honor, and a privilege. I need the wall less and less, as I age. I realize its all part of the human experience, and the job, and time blurs the edges just enough that they are easier to release. Still…

    I wonder if they know, patients and families, how we carry them with us?


  • Thursday, October 03, 2019 12:35 PM | Amanda Riordan (Administrator)

    By Crystal Wallin, NREMT-P, CCEMT-P, Gundersen Tri-State Ambulance

    He’s clearly still a man of military background. That much is clear from the moment my boots top the last step and enter the doorway to the living room. Knocking with my free hand, I call out “paramedics” and an answering voice I do not recognize calls from the depths of the rear of the residence, “back here!”

    Making my way down the hall with the footsteps of my partner behind me, I round the last corner to the restroom. And there they all are. The gentleman of the home is seated in a wheelchair, one foot on the floor. His sole leg leads up to the seat of the wheelchair, where the other leg ends just above the knee. The sparkle in his eyes is in no way diminished or dimmed, and he regards me with quiet composure as I take in the situation. There are people in turnout gear and boots, there is a clipboard held by a young woman who begins to give me report, unbidden and concise.

    “Patient was transferring himself from the commode to his chair when the chair rolled out of reach and he slid to the floor. He was able to use his good leg and hands to assist himself to the floor without falling but was unable to maneuver himself back up and called for help after a short time. Patient denies injuries, is refusing transport. Here are his vitals” and she reads off a very normal sounding set of numbers with corresponding categories.

    Throughout this, we regard each other. I’m watching for chest rise and fall, symmetry, pupillary size and evaluating skin color and condition. He is continuing to watch me with those measuring eyes. I thank the clipboard holder and reach out my hand. Introducing myself and gesturing back towards my partner, I receive a warm, firm shake in return. It is close and warm in this neat restroom at the rear of the residence and I tell the responders they can go, most likely clear but to give me a few minutes if they don’t mind. A hearty “sure, Crystal” and the two responders who still know me grin and say they’ll wait outside to catch up. I’m not often on the trucks now, and the lady with the clipboard looks at me again. But she leaves without further comment and they all go down the hall with my partner.

    A safe but polite distance from the patient, I ask him if there’s anything else going on that the report didn’t catch. He smiles with one corner of his mouth and assures me that the only other thing going on is his chagrin at hosting so many strangers in his bathroom. He tells me he always locks the wheelchair but forgot this time. He does not have a pole in the bathroom as he does in the living room and bedroom, which are assistive to him in times such as this. He will be looking into getting one. We make our way back down the hall to the living room, past the military plaques and awards and neat photographs I saw on the way in.

    He allows me to get a couple sets of vitals and we talk about the items on his walls. He is not very forthcoming beyond a few sentences of explanation and so I do not pry.  He signs my computer signifying his refusal of transport after we discuss his right to transport as well as his right to refusal of such. I reiterate that this refusal does not mean he can’t call back later, and to please do so if anything changes. He grins a full grin then, tells me he appreciates all of us but he can take care of himself.

    I nod in genuine agreement, in the middle of this pin neat and spotless home of a man who bears the remainder of a life of service greater than any I will achieve in this lifetime. I remind him that should anything change, we are happy to come again, and I thank him for his service. He nods at me and says, “we all do a part, you know that, I am sure”. I will think of those words often in the months to come, as his quiet example and message stay with me.

    We all do our part of service, many of us. It is a privilege and an honor to have the opportunity to care for those who have served in a greater capacity. Success is often measured by today’s standards in quantitative units – big house, sleek car, size of paycheck.

    Maybe it’s as simple as quiet self-possession in the twilight of a career of service to something greater than oneself. A crossword puzzle book on the end table and a crockpot bubbling goodness in a small kitchen. A sleeping cat in the corner chair and a spotless bathroom at the end of a hallway that is filled with reminders of an earlier life.

    I went out into the bright sunshine and heat, caught up with the responders and laughed about the way I’m straddling the fence between ER nurse and working paramedic. Heard about kids and sports and met the new responder, complimented her on the report and exchanged pleasantries. Soon both agencies wheeled our respective apparatus/trucks out of the quiet retirement mobile home park towards the next call for service.

    A former supervisor of mine said it best.

    People helping people, that’s what it’s all about.


  • Wednesday, May 22, 2019 5:58 PM | PAAW Administrator (Administrator)

    By Crystal Wallin, NREMT-P, CCEMT-P, Gundersen Tri-State Ambulance

    I wanted to help my community – we all did. We didn’t think of money, we weren’t drawn by camera lights or crowds. There isn’t a well-defined ladder to hefty retirement, generally speaking. We come from all walks of life, all ages and gender definitions, multifaceted backgrounds and regions of the state and country. But we will all tell you, we are one family. And it goes exactly as this year’s EMS theme says so well – “beyond the call”.

    The tones drop, the garage bay comes alive, the doors roll up. The truck or rig or apparatus rolls out onto the apron, dispatch information is acknowledged, the doors roll down, lights and siren activate and we are en route once more. The initial response is shaped by geography, call area, and nature of the call. Who needs us, what exactly are they needing from us? We use the ride there to navigate through maps or GPS units, paper or technology leading us to the door of the person who’s suddenly having a bad day. I will go over roles sometimes with my partner, and sometimes our crew includes a student or new employee. We lay the plan based on the dispatch information and loose ideas of who will do what, when we arrive.

    The call is always different, the environment never the same, the protocols lending guidance and shape to the beautiful fluidity that is street medicine. All these years later, the responsibility is no less weighty to me than back in the volunteer years when I would notice my hands shaking a little en route to a call. The honor, the trust, the responsibility that comes with the autonomy is not to be diminished. We give our everything to the patient, the love of someone’s life, their child, their parent – their person, while they stand helplessly by. Assessment, treatment, packaging, loading, secondary assessment, transport begins, repeat assessment, recheck interventions, re-dose, give report, unload, hand off with further report at bedside. Restock, put the truck back into order for the next person who is having a very bad day. Return to crew quarters, return home if a volunteer service. Lay back down on the crew quarters single bed, stare at the ceiling. Maybe take up where you left off doing a training, reheat supper that you were making. Take that long ignored bathroom break. If a volunteer, sit in your familiar car at the station and make that return to home.

    Beyond the call – what is that? What does it mean?

    It means the way the call doesn’t fade, the way we carry the memories with us. Medicine is governed best when it is shaped by evidence based practice, with data and statistics to keep us competent, qualified, up to date with best practice and vigilant in our delivery of what all patients deserve – quality healthcare. Beyond the call, though, that’s what defines us, unites us and how we all become loyal to the point of a melding of all that is us as individuals – as well as a pride of our calling. We meld, most of us, until we can’t quite tell you where we as a person and we as a provider are separate. EMS becomes part of us as much as our eye color, or our preference in caffeine delivery.

    I have been at a social event with a few other paramedics when a band member was injured by a falling piece of equipment. Without a word at one another, or a glance, myself and one of the other paramedics were up and working together in that age old tandem of assessment. Another medic who is also with our company was there and when we returned to the table, he smiled and said, “always on the job”. 

    That’s it. Beyond the call – we don’t stop caring, stop assessing, or stop in our willingness to help our community, our fellow humans. When bad things happen, people instinctively go to find help. EMS people know without hesitation that they are the help, and they walk towards the bad thing without a thought.

    We will come when you call. We will give strangers our nights, weekends, holidays and more without a thought for self. Sometimes to the point we need to remind ourselves to have balance between work and off time.

    Happy EMS week to all my family. Rural or urban, in uniform or not, fire based/hospital based/private duty, we are here. Whether we are on duty or off, we are coming whenever help is needed, ready to open those garage doors, roll out onto the apron, activate those lights and sirens and head once more toward a stranger in need. And it won’t stop when the doors go back down, the lights and sirens are off. We are always here, walking through the grocery store or gassing up at the corner station. If you need us, we are always waiting. Proud.

    One family – one calling – one honor.

    Thank you for allowing all of us to be of service. It is our privilege, and our joy.

    Be safe out there.


  • Monday, April 22, 2019 9:16 AM | PAAW Administrator (Administrator)

    By Crystal Wallin, NREMT-P, CCEMT-P, Gundersen Tri-State Ambulance

    The reunion happened on a sunny spring day but I can’t say anyone would’ve seen it coming. Especially me.

    It was the first shift in awhile; I’m not out on the street as much as before now that I am a part-time medic and a full-time ER nurse. But oh how I missed it, and I’m positively jovial—probably obnoxiously so but I can’t help it. Doing what you love means sometimes you just bubble over with joy in the oddest of places. And this reunion, I am sure, is literally the oddest of places. But I digress.

    First call of the shift, it begins innocuously enough. I’m on a power truck with a medic I haven’t worked with in months, maybe over a year. We are catching up, we’ve done truck check and entered the narc count and the familiar routine is in play. The tones go off and our unit’s number is dispatched overhead in the garage bay where we are finishing up beginning of shift duties.

    “303, report to <motel name> in town of <name>. You’re needed for a detox patient who has been vomiting and requires transport to the hospital. Law enforcement is on scene.”

    I bound up on the running board and into the passenger seat, announcing “I can take this” and my partner grins, “have at it!” and we’re off. First responders are paged and en route. We take it nice and easy up the four lane through to the north side and into the adjacent community. Pull up alongside the motel, joining the squad car and first responder vehicle parked outside the room number given in the dispatch information.

    An officer is rounding the back of the truck almost as soon as my boots hit the running board, and then the ground. He says without much eye contact, “gentleman inside has been detoxing, wants to go in for help with that. Watch out – there’s <another word for stool> everywhere in there”

    And he’s gone.

    My partner and I put the monitor and kit on the cot and wheel it to the door. Two fireman are inside, EMTs, taking demographic information and obtaining baseline vitals. Greetings are made and a short report received – in short, this patient has been drinking for days and has run out. He feels shaky, his heart is pounding, he is weak and he has been incontinent of stool. Repeatedly.  Vitals are within normal limits, exact numbers are given by the veteran fireman who is holding the clipboard but the gist of it is that they aren’t worrisome.

    My patient is seated on the edge of the formerly clean, modern motel room without much personal effects to be seen. He is wearing a button up shirt and nothing else. First things first, towel on the floor to walk safely through any landmines of stool. That taken care of, I reach my patient with the sad eyes, and I attach the four lead. Normal sinus on the monitor, no ectopy but the rate is a little rapid – in keeping with the dehydration his skin and dry mucous membranes are showing evidence of collaboration. He’s polite, almost submissive in his excessive manners and downcast eyes. Haircut is recent – ish. He’s a few days away from a razor’s touch to his face but all in all, not long. On the floor near the restroom are his jeans but they are not salvageable at this point without a heavy duty washer. An empty pint bottle of cheap vodka is beneath the empty luggage rack against the wall. Small amounts of unformed stool are gently deposited on the way to the restroom  from the area of the bed, resting in smooshy looking piles. They look almost as apologetic as the patient on the bed, still very unctuous as he self-deprecates his way through paragraphs of regrets.

    He was staying with a friend. No, he doesn’t live here. No ma’am, he doesn’t live elsewhere. He just stays wherever he can, ma’am. Been sober for about five months ma’am, partied a few days ago with some old friends until he ran out of money and he is feeling purely awful and he’d rather just die, ma’am, than go through this again, yes he would. No way to fix this but some vodka, any chance…?

    No, I tell him. Help is here but help won’t include vodka. We put a bath blanket on the cot, folded in half the long way so that the blanket is perpendicular to the cot in a sort of plus sign. Another towel on the appropriate spot on the cot, then my patient is directed to sit on the towel. The bath blanket is folded snugly across his middle - a paramedic burrito - and a second bath blanket is used in the conventional way to cover him up. He is cleanly packaged; after being secured with straps and the monitor placed behind him on the head of the cot, we walk to the truck.

    The air outside is fresh and the patient continues his dialog in the same vein as he did inside. We load him, I climb in the side door and have a seat. Secondary assessment reveals no additional findings, repeat vitals obtained (my second set, third set counting the first responders’ initial set). Transport begins.

    During transport, I verify the demographics, get them entered. It is then that I see the name. The patient’s paragraphs of self-loathing, self-deprecation and obvious depression have been continuing to pour out and he refers to himself at this point in the third person. I am reading his name in the fireman’s handwriting, and I exclaim, calling him by name. He stops, looks up at me thru his eyebrows and bangs, chin down in that excessively submissive way. Says, “Yes?”

    All the pieces fall into place here in this sunny day in the back of an ambulance in 2019 and I tell him I remember him very well. In 2010 as a new medic, we went to his mother’s home often for him. Acutely intoxicated, he would be semi clothed or not at all. He would have the issue of the piles or puddles of stool – all over the home, even sprayed up on the walls maybe as high as my waist. His father was deceased, his best friend, and he was drinking his pain away in the home of his elderly mother. He’d always sob, addressing himself in the third person and saying he “really did it again”. We always had to lay out blankets folded lengthwise to walk on, as there would be hardly a square foot free of stool.

    In 2016 as a nursing student still also full time on the truck, I responded one rainy Saturday to a complex of midscale apartment buildings, to a basement apartment. The apartment manager had arrived in a response to neighbors saying they hadn’t seen a resident in days. The manager was pacing in the hall upon our arrival, running his fingers thru his hair wordlessly. A firefighter met me at the door and told me to watch where I stepped – there was stool everywhere, even up onto the walls. A man inside had been down for days, was detoxing. I asked if his first name was so-and-so, the firefighter answering, yes – how do you know? I asked if he spoke of himself in the third person, again yes. My patient inside was in very bad shape, worse than I’d ever seen him. That day I learned he had lost his mother, as well. His depression was intense. After a very complicated, careful extrication – walking again on blankets folded lengthwise - from an apartment that surely would need subflooring and some drywall replaced, he was in my truck and the doors shut behind my partner. During transport, I put the computer aside and met his eyes. That day they were looking up thru hanks of encrusted hair, full of what my best guess would identify as dried emesis. I felt as if I was able to make connection with him, just a little. We spoke of AA, of sponsors, of a community of sobriety that could rally around in the absence of his family. I told him I remembered him and his mother very well. I told him I believed in him and the path of sobriety, although privately I thought to myself, I wasn’t so sure he could beat this. On that day, his gaunt appearance and grown out hair and beard were stark and disturbing. He sobbed as I gave report to the nurse at the ER that day.

    So now it’s 2019 and he has never looked this clean cut before, but it’s him, I can see it now that I know it. I prove I know him, really remember him, by listing his mom’s street name, tell him of the day I came to transport him out of that dark basement apartment – remind him I believe in him and that AA works if you work it. His eyes fill with tears and from the pocket of the button up comes a sobriety chip. He says, “Your dad was the recovered AA guy who went on to be a counselor?” I nod, he says with more tears, “I remember that day you took me. Nobody told me they believed in me since my mom died until that day.”

    He breaks down. He tells me he was doing it, then he screwed up. I ask more questions and find out that he quit going to meetings, lost contact with his sponsor, connected with old drinking buddies. Again we go over “it works if you work it” and “one day at a time”.  

    When I leave him in the ER, he’s sobbing again. I give report to the nurse, warn her of the burrito’s contents and then make a point to shake the patient’s hand - although with my still gloved one. I tell him I don’t want to see him anymore, and I know he can do it. I strip the gloves off, leaving them in the wastebasket in the room. I’m walking out with my own head down, thinking that in my two days a month on a truck, what were the odds – when I hear him say my name. I turn, and that hand with the stool under the fingernails is holding that chip aloft.

    “I can do it. You won’t see me again.”

    I hope so. I really, really hope so.

  • Friday, January 25, 2019 7:55 AM | Amanda Riordan (Administrator)

    By Crystal Wallin, NREMT-P, CCEMT-P, Gundersen Tri-State Ambulance

    It’s mid-morning and when the call comes in. Our crew today is made up of three of us; the usual dual medic crew of myself and my partner is increased by the presence of a flight nurse. The local flight service owned by our parent company has its flight team members do ride time with our ground service once a year in addition to time spent in ICU, NICU, OR etc.

    It is my first shift back after a diagnosis of multiple sclerosis back in late summer and I am giddy driving to work that morning. I worked for years as a night time dispatcher before paramedic school, and for much of my early career as a street medic, I worked a straight night time power truck. In the years that followed, I worked a combination of night shifts and 24 hour shifts. Now as an ER nurse, I work 3pm to 3am and love it. But this snowy cold morning of my first shift back in uniform finds me on a day shift. It is a testament to my love of the job that catapulted me out of my warm bed and into the hot shower at the first nagging of my cell phone alarm.

    Something about that uniform feels like putting on my most authentic self. I am not sure how long it will be before I identify as a nurse no matter the fact that I love my current employment in a small town ER, but that gold patch on my arm feels good after my medical leave.

    So after greeting my partner, meeting our rider whose long career in nursing impresses both of us, we complete our truck check and kits, narcotics check, I am logged into all programs without incident. Radio clipped on my hip and Boston strap with the familiar weight of the mic just below my left clavicle, I am sure my ear to ear grin looked exactly like any rookie’s face.

    And the familiar tones sound a few hours later for this call, “deedle-eedle-eedle-eedle, 303, you’re needed for a call in Midsize Town for a 20-something female who fell in her shower”. We put ourselves en route, set off down the road, winding our way around cars and mindful of the wet snow. I’m driving as my partner is charting his last patient. As often happens, we go back and forth about the nature of the call, what might’ve caused the incident, who does what once on scene. Every paramedic does things a little differently and every regular crew develops a rhythm. I’ve not been part of any crew rhythm in a few months and I want to be mindful of my partner’s preferences. He’s a newer medic but an incredibly intelligent one. I am glad to be with him on this shift as I find my place on the street after being used to the pace and metronome of the ER.

    We arrive on scene in not too short order, and I back the truck into the driveway. Fire is on scene, and left us the driveway. Backing remains a muscle memory skill and I engage the emergency brake, notify dispatch while my partner updates the mileage on the tablet’s Navigator screen. These things I do as if it was only yesterday, and that too feels good. My boot hits the running board and my hand is automatically turning on the radio at my hip. We enter the house, the three of us, finding ourselves immediately inside a living room. Six eyes are gravely fixed on us; a beautiful bulldog, a toddler of perhaps two years of age, and a small human of about 4 years. The 4 year old calmly points us back to the hallway. Just outside a bathroom door, a fireman looks up.

    “Hey guys – hey, long time no see! So, this is <Jane Doe> and she was taking a shower, felt light headed, we’re just about to get some vitals here” and as I step into the doorway I see the second fireman with his monitor in front of my patient. He looks up, and the proximity causes us to decide I can relieve him in the small space.

    I hunker down, elbows on knees and heels of my dripping boots off the floor. I survey my patient. Her eyes are tightly shut, she’s gripping the towel wrapped around her with one hand and holding the other to her brows. She’s tachypnic, there are some puddles on the floor but her face is dried and no diaphoresis noted. Her color is good. Her eyelids are fluttering. It takes all of a solid minute on the clock but she finally opens her eyes and focuses on my face, my quiet questions. She slows her breathing to hear what I’m calmly asking and I’m able to get those baseline vitals. I find out she uses a cane to walk, a cane which the small human happily hands to the firemen when the request is relayed out and down the hall. She had an injury awhile back, years ago, and a nagging reminder which necessitates the usage of the cane. Today she woke up feeling nauseous and as the morning has gone on, everything she had in her GI system has left by both exits available. After about four hours of this, she thought she’d take a shower. During her shower she felt light headed, went to sit down on the side of the tub and slid onto her bottom on the floor. Her vitals now check out great. She confides that she also has problems with anxiety and some panic issues since she’s become a single mom. We go over a few other medical history things and that tachypnea is gone, now. She indicates a neat pile of folded, clean clothes by the sink, and I hand them to her. I get a second set of vitals after she is clothed, and she wants to stand. The cane is on one side and with me on the other, she easily stands. Repeat vitals show no deviation from the baseline we’ve established. We stand there a minute, chatting like two ladies do about the small humans in the living room and how it’s hard to be sick when you’re the mama in charge. She’s visibly calmer now. We walk slowly together to the living room.

    Both small people are watching through the blinds as my partner finishes shoveling her walk. Her driveway is already done, and the flight nurse is petting the pretty bulldog. I tell fire they’re ok to clear, exchange “good to see you, good to be back, thank you, be safe out there, hope you don’t have to see us again” pleasantries – and they’re gone.

    The patient and I sit on the couch. She’d called a family member prior to our arrival and we decide we will wait for him. I ask her what I can get for her while we wait, and she looks at me in surprise. “It’s been a long time since someone asked me that”. She tells me of Gatorade in the fridge and where her meds are for anxiety, etc. Vitals are unchanged. I bring her the Gatorade and give her the mom line “just sip it now, I know you know that” and she smiles easily, her shoulders are now relaxed and she puts the anxiety meds within arm’s reach. The relative comes and they work out that my patient will stay home with some of the family member’s help; he will stay and watch the small humans so she can get a little rest.

    My partner goes to the truck to get the computer for my patient to sign the release while I go over a few things with her. She needs to rest, try to keep some fluids down but if anything changes, she needs to think about being seen. She continues to say she has been feeling much better, that’s why she wanted to shower. She ruefully grins at me, saying “I should’ve known I was weak from the morning, though” and we finish the list of things to be aware of, and when it really is time to be seen. The small person who retrieved the cane told me proudly he learned to call 911 just yesterday, so when mom plopped on her bottom he knew just what to do! I look at my patient beaming at him, color in her cheeks and hair drying in slight curls around her face, and tell her “great job, mom. You’re doing a wonderful job”. Her chin tucks and she’s shy, but she needs to hear that. In this small apartment where the detritus of small folks fills the floor in spots, a wriggly bulldog’s under bite is the closest thing to help with the kids she’s got on an average day. I imagine it can get a little overwhelming even when you’re not sick.

    A few minutes later, kids high fived, bulldog petted nearly to death, walkway and driveway shoveled, goodbyes said, refusal of transport signature obtained and promises to call if anything changes, I shake the family member’s hand and we make our way to the truck.

     I walk absently to the driver’s door, lost in thought of the days when my own kids were little and I was a newly single mom. I catch movement and look through the cab to the opposite window. My partner is gesticulating at me, pointing to me and then the passenger seat. I mime typing and point at him. He shakes his head, then at the driver’s seat. We exchange places and as we buckle, I say, “all done with your report huh?” and he replies “yep!” I laugh, “that was pretty good, a whole conversation in gestures” and flight nurse buckled in back, he pulls out of the driveway. I update Navigator, he tells MedComm we are clear with a signed refusal, and we make our way out of the little tidy neighborhood of duplexes. Radio up, we head back toward the four lane as the fat snowflakes continue to fall rapidly.

    That rhythm of street medicine is always just there, a memory away. Predicated by a desire to help others, rooted in strong protocols and talented partners, but fed oh so well by that human to human connection.

    There’s nothing like it. The patch is golden and the reward is infinite.

    “303, en route”.


  • Thursday, December 13, 2018 7:44 AM | PAAW Administrator (Administrator)
    By Crystal Wallin, NREMT-P, CCEMT-P, Gundersen Tri-State Ambulance


    In Wisconsin, our lights are red and white. Other states use some blue lights, but we leave those to law enforcement in our state. No matter the weather, lights are always our companions on each shift.

    I always feel like a navigator of a spaceship when we're making our way through the dark winter nights with the strobes picking up falling snow. Anyone who's ever driven an ambulance in the wee dark hours is likely nodding in agreement right now. There is a boggling monotony after a matter of minutes as the dancing snowflakes pick up the white strobe lights. It begins to look as though the flakes are stars, and the ambulance is passing through a foreign landscape in the far reaches of space.

    There are the many outside lights of homes and businesses, and one of the beauties of working for a company with system status management in an urban environment is that as you rotate throughout the dark cold winter nights, you get to see a lot of lights. There are the streets with the large ornate homes and those are the streets where it is truly a winter wonderland. But there are also cozy bungalows with winking lights that emit a sense of peace and harmony of their own. One house south of the main town where my company is located is renowned for its lights. The house is pretty but blends into its companions during the rest of the year. But when the season of lights comes, this house draws cars to stop and park to look at its beauty. Luckily for the sake of traffic safety, there is a wayside just across the highway, and this is where the cars park. I wonder every year if the owners light this house, or if they pay to have it professionally done. The house has a round room which extends from the ground up to the top floor, and porches. When the lights are woven about the exterior of this home, it looks fit for a Juliet to ponder where her Romeo may be. Not just the sheer quantity, but the exquisite attention to detail is truly unlike any other home I've ever seen.

    I've written about and forever remember the lady we walked through the adjacent glow of neighbor home lights. The lady who was wearing footie pajamas and had eyes that could see twenty years in the past - but not a gift, not to her. She had overdosed in her yearly attempt to forget the things that were done to her as a small girl, beneath the Christmas tree, by her father. Every year Christmas is a nightmare, a time of year from which she cannot escape, echoes of a past not alleviated by therapy. I think of her often, think of the beauty most of us find in the season. A beauty robbed from her that I wonder if it is possible to ever return.

    My first year as a paramedic we worked a code with a family looking on, remnants of the holiday meal no one had any desire to eat, cooling and congealing on the table behind us. The family patriarch had gone down not long after they all sat around the table and now the array of faces, whenever I involuntarily looked up in between interventions or pulse checks, ran the gamut from grim to stricken to weeping copiously. The enormous tree stood an imperious observer against the two story windows, it's perfect white lights steadily regarding the scene. We got ROSC, and our red and white lights danced victoriously off the homes in that upper class neighborhood as we bore our hard fought battle of a patient into the hospital. I remember being giddy, and it seemed as if the lights watching through each window and eaves trough were congratulating this save.

    I responded in the grey light of early almost morning out into a rural home where the tree was modest in size and there were no ornaments down where small arms and hands might reach. A febrile seizure and a terrified mother and father, as well as a serious sentinel of a toddler brother watching us. Those lights were multicolored and danced to a tinny series of metallic sounding Christmas carols. That one turned out all right, too.

    Dearest to my heart when I think of paramedic Christmas lights, however, has to be our ambulance decorated for a holiday parade. You might well imagine what a bunch of tired paramedics & EMTs, sometimes disillusioned and distant-eyed themselves, turn into when wrapping Christmas lights around mirrors and the interior hand rails in the patient compartment. It is truly enjoyable to see how many lights one can get onto a truck with built in plugins and backed up with inverters. The grins and jokes between the work family members while decorating are full of shouts of laughter. But inevitably when all is complete, and we stand back to survey our work, the banter slows, the smiles grow quiet and eyes pensive. During the year that truck may see heartache, anger, residual remnants of what humans do to one another with weapons, hands, or words - even with a diet that slowly is killing so many Americans.

    Ah, but during the holiday parade, that ambulance is a beacon of beauty, driving through the night and surrounding the ground around it in a soft glow. I like to think that Christmas lights soften the edges a bit, not only of homes and yards, crew quarters and waiting rooms, but of hearts and minds a little, too. Sometimes as the season is upon us, we may find ourselves rushing everywhere whether at work or even more on days off. Trying to get all the things done that we think we should do. When really what matters is to perhaps sit in those lights on a sofa with a sleeping child, or at a wayside along the highway, and reflect on all that is important. I've never yet cared for a patient who wistfully told me of a time they should've cleaned more, cooked more, shopped more or worked more. At the crux of the moment, when heartbeats and respirations become work, what matters is always the things we take for granted. Time with the people we love.

    May this holiday season find you looking around a little more, slowing down a little more and reaching out to the people that matter. May we remember that the holidays are hard for some, that some are alone and hurting. I am trying hard this year to include those who seem a little on the periphery. Who says a family has to share a last name or the same uniform?

    Happy holidays to you and yours - however you identify the holidays to be. Let the lights take a little of the rough edges of every day off and allow you to enjoy the calm pools of clear or colored lights, leading the way towards a coming new year.

    Joyeux Noel


  • Monday, September 24, 2018 7:43 AM | PAAW Administrator (Administrator)

    By Crystal Wallin, NREMT-P, CCEMT-P, Gundersen Tri-State Ambulance

    We're sitting at the designated posting area. It's just past the middle of the night; that time when the boisterous crowds have filtered to their respective homes and a different kind of silence settles over the town. Because there are different kinds of silence; anyone who's rolled through the dark streets, in and out of puddles of yellow streetlights can tell you that. There's the lull as the bar scenes and theaters, restaurants and gatherings come together. There's the diminished sounds once the respectable crowds of a certain age or temperament head home. This is the next kind of silence, when the city is dark and silent, spent of even the loud partiers who spilled out last into it's streets after bartime, finding rides and partners to keep the loneliness of night time at bay. 

    It's that kind of night, past the fun time of the wee hours of the morning and into the hours where figures seen appear lonely. The sounds that do pierce the night seem intrusive, as the sleeping city hunkers down and all who have somewhere to be, are there. We're winding down too, my partner and I. We started the night catching up; it's been months since I worked a street truck and he was telling me about his day. Then we ran a few calls and the hours settled into their groove; before we know it, we've pushed through to the silent lonely side of 3am. We'd like to see the inside of our eyelids but that hasn't happened yet. 

    We are the last truck available for a number of square miles that is higher than you'd think one truck could cover. But we do, and the other trucks will become available shortly in a staggered fashion as they transport their patients and clear the hospitals. It's the dance of system status management, and we are all well versed enough to know it all works out. I remember when I was new, though. One night my partner rested their eyes and I sat in this same parking lot, contemplating the number of square miles that the two of us were responsible at that time. That was a poor choice; I remember being very wide awake after thinking down that path for a few minutes.

    But now the radio comes to life and the ambulance last dispatched to a call requests a second unit at their location. Their initial page was for a non responsive female. Now the female paramedic on the call is requesting a second unit for an RSI - rapid sequence intubation. She's with an EMT tonight and needs a second paramedic on location in order to intubate. We come to life, activate the lights and siren and are soon pulling up at the curb behind the first truck. Two squad cars and a first responder unit complete the ruination of the serene neighborhood's slumber.

    Inside, we are directed by family standing in the living room towards the far back bedroom. Why is it always a complicated or extended call seems to be in the far nether regions of a residence? Inside the back bedroom are three first responders, two police officers and our other crew. Everyone looks moist, they've clearly been at this awhile. IV access is in place, cardiac monitor is applied, CPR is ongoing and report begins. Complex patient, bradypnea upon arrival, unable to arouse. Bradycardia on the monitor. Pulses present and absent by turns. Naloxone ineffective. 

    Three paramedics in the room now, three dedicated first responders, one EMT who is working so rapidly and smoothly as we go down algorithms and protocols that she seems to be two people. Consultation with medical control by phone. Intubation by my partner who was most likely born with a bougie as I push drugs and the small cramped bedroom somehow continues to hold all of us. The patient is bariatric, and very sparsely clothed. She has been incontinent of stool, and the precious real estate that is the minimal floor space is taken up by her girth and her incontinence. We persist. Extrication approaches are considered, discussed, attempted, abandoned, re-grouping and finally thru massive human effort and loss of sweat, she is moved to the living room. Patient is rechecked there, interventions and vitals rechecked. From there to the cot, to the truck belonging to the first crew. Re-evaluation again of all interventions, medications evaluated and refreshed as necessary. An officer brings me one half of our scoop stretcher, fecal matter intact down the front. He asks me, "this yours?" I consider this a minute and then with a guilty, grateful grin I reply, "nope. Theirs" and wrap it in a sheet, slide it into the other truck's patient compartment at their rueful, accepting direction.

    The two crew members are getting things settled in the back, we ask if there is anything else we can do, and return to our truck. I stop at the door, pick up my feet in turns. Resting first one, then the other on the opposite knee, I inspect them for any souvenir fragments. None. I climb inside, shut the door, slide on the seatbelt and turn to my partner. Senior medic to me by at least a decade, he is grinning. "That's a good call. Do a lot of medicine, get back in a clean truck." Shaking my head, I have to agree.

    We turn off all the lights, wheel wide of the curb, head back toward the city and our station. The sun is brightening the intersection of horizon and cityscape, and I'm getting hungry for breakfast. House lights are winking on and the people are once again helping the city to waken.

    I missed this. The rhythm of the night and the imperfect reality of street medicine. This is where the pulse of the city lives.


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About the Author


Years ago my neighbor John from down the road told me there was a volunteer first responder class being held evenings. Since my bank job ended at 4pm he figured I could probably swing the time, and volunteers were needed badly. From those years of responding in a private car with a pager, to volunteering 30 miles away as an EMT-B, the EMS bug took hold. Roles over the years have included working for a private inter-facility transport service, rural emergency room EMT for five years, emergency medical dispatcher for helicopter and ground EMS for six years, then on to the paramedic classroom and critical care licensure. The more I learn, the more I see I have yet to be taught. The more people I meet, the more stories I'm told. The front row seat to the human experience never grows old.


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