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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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  • 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.

  • Thursday, August 02, 2018 7:03 AM | PAAW Administrator (Administrator)

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

    It’s her birthday, and she’s only got two years on me. But her eyes are world-weary, and in the slump of her shoulders lies a thousand different disappointments. Pancreatitis, she tells me. Acting up again.

    We talk about the outward manifestations of her functional health, as I run down the assessment steps. We stand in the confidential location of a woman’s shelter. The curved bannisters arch gracefully up and out of sight somewhere above. Stained glass windows filter the light falling in through them, dim on this gloomy day yet warmed by the colors of the old glass. Pocket doors slid behind us as we entered, preserving some semblance of privacy here in this gentle embrace of a genteel old home. Women and children pass through here in a never ending stream, and we meet some of them. I wonder now, as always, where they go, what happens to them, did this house of kind strangers afford them a new start, a fresh beginning? Or did the familiar pull to old unhealthy relationships win out? Did they return to the abusive partners from whom they sought shelter here? And the children - do they fall victim to the cycle or do they emerge strong down the line and find fierce ways to ensure they do not allow such treatment in their adult lives? How many fall one way - or the other? The awful sadness is the never knowing.

    Her hands are kind, and soft. Her mouth seems to have a hard time remembering how to curve upwards. I work at it, establishing rapport and extending gently honest respect to this woman who is before me. Something in her tugs at me. Maybe it’s the way she is in pain, maybe it’s the way she seems surprised when I realize her date of birth makes today her birthday and I exclaim, “Happy birthday to you!” It almost seems as if no one has been that exuberant about her birthday in quite a while. Maybe they haven’t. Maybe she just didn’t realize what the date was today.

    Her boy will ride with us, and the stranger who is the helper at the house today disappears in search of him. Soon they reappear, the child just under ten. His speech leaps and bounces from topic to topic as we make our way outside and towards the truck waiting at the curb. His eyes never linger long, scanning up the street and then down again. He surveys the ambulance and announces his desire to ride up front. My partner looks at me with a shake of his head and I guide the boy towards the back with promises to ride by mom. He shrugs. Climbs inside. Resists the seatbelt but caves when I stick firm to following the law. Mom is silent, docile, amidst the verbal stream coming from the boy. He asks about computer privileges at the hospital, will they have something to eat, what will he be able to play with? My patient speaks up then, quietly, asks him isn’t he worried about her, she’s sick. Again, he shrugs.

    Her eyes drop. The shoulders round even more somehow, as her chin nearly touches her chest. The shirt is worn. The boy’s shirt isn’t new but it’s in much better shape than hers. He rambles on in complete disconnect or disconcern for mom and her pain, mom and her fears about her health. She seems unsurprised yet saddened.

    I wonder as I give report to the receiving facility via radio regarding the outward, measurable data - who last made this kind, quiet woman a birthday cake? What man or men taught the boy that a woman’s fears and illness are so easily dismissed? Who models for him that his needs take such utter precedent? Or is this simply age appropriate egocentricity? Is he scared too and thus the chatter is a nervous avoidance of his fears about mom’s health? Who has he lost? The same person who left mom such a saddened husk of a lady?

    I walk them in and I give report to the receiving facility staff. I shake my patient’s hand, and looking in her eyes I let my heart shine visibly outward as I softly wish her a happy outcome ot this ER visit, and many happier birthdays to come - that I believe they will come. Her eyes flicker with surprise and a smile finally - finally! - lifts that mouth. Her eyes drop to her lap. I shake the boy’s hand too, and tell him to be a good man and take care of that sweet mama of his. That it’s ok to be scared, that kids can’t fix everything but my friends here in the ER will help with that. He just needs to love mama while she gets feeling better. His head cocks up at me and he nods vigorously.

    The entirety of my body is not yet through the doorway when I hear his querulous voice asking the patient care tech for a computer to play on. I look back at mom, framed by the doorway and placidly lifting her arms into a gown - and wonder what happens to the light in people when they don’t get loved enough. Do you suppose it goes out for good eventually, or does it lie dormant, waiting for the warmth of the right person to bring it to light again?

    Happy birthday, dear lady. I hope next year finds you happy and laughing - and loved.

  • Tuesday, June 19, 2018 3:18 PM | PAAW Administrator (Administrator)

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

    He was a year ahead of me in school, a joker and a clown and for awhile we rode the same bus until he got his license. I hadn’t seen him in a few years but here he was now. We didn’t speak. I didn’t know what to say, but I was too busy anyway. It didn’t matter even if I could’ve thought of something to say because he wouldn’t have heard me.

    I got there in my private vehicle soon after the others, so I didn’t catch the whole story. I just joined the mostly silent group, stepped in and relieved the responder doing compressions. The patient was slight, a young and pretty slip of a girl. She might’ve been a year or two older or younger than me. It was tough to tell. I tried not to think about the crepitus beneath the heels of my hands as I started in on the age-old rhythm of compressions. Tried not to think about the connection to my younger years as he stood with bowed head and slumped shoulders, weeping.

    We got her to the ambulance outside, the yard redolent in the heat with cicadas singing as we carried her to the truck. Got settled and then we headed down the winding country road. The siren seemed vulgar to my ears. I had been a volunteer a little less than two years at that point, I think. I remember I was wearing blue jean shorts and a white tank top with flip flops. I’ll get to why I remember that in a minute. For now, I rotated with the others, giving respirations with the bag valve mask thru the Combitube, then rotating back to compressions. There wasn’t a lot said. I knew him, but the rest of the first responders knew both of them. I hadn’t seen him in a few years, this was his girlfriend. One of the other responders told me he came home, found her. Still warm and apparently it may have been a recent code, or maybe it was the heat? Anyway, they started to work her and here we all are now. Going down a beautifully green leafed back road, winding our way down the rural landscape they must’ve driven together many times, laughing certainly – or maybe listening to the radio. But now she’s so little, and pale, and I see his pickup truck following behind us with the flashers on.

    Someone had called for an intercept with the paramedic service about 45 minutes north of the residence, maybe before I arrived on the scene. It seems like so long but eventually I can hear a second siren and we are pulling into the parking lot of a fish hatchery, and parking. Our siren stops; so does the second siren.

    The back doors open and a very serious man’s face appears. Brisk and businesslike, he begins asking questions. His hands are busy working on removing supplies and medications. I don’t remember what his partner looked like, or what was said for a bit. I kept rotating between compressions with another responder while both of the paramedics attended to the airway. The first man is younger than me, but the professional appearance of both made me suddenly aware of the shorts and white tank top – and flip flops. Time to transport, and the second paramedic gets back out. The first one, the one with close cropped hair, rapid speech and precise movements – he stays in the truck with us.

    As the second paramedic gets out, I see my schoolmate pacing, weeping quietly. We begin to transport again. I’m watching intently as the paramedic in our ambulance takes out a device I’ve never seen. He selects a site, and to my horrified fascination, and with A DRILL places a bizarre needle in the patient’s leg, just distal to her knee. He connects IV tubing, and hangs a bag that is inside a sleeve. He pumps up a bulb attached to the sleeve, much like the pump on a manual blood pressure cuff. He gives medication thru the IV line.

    About this time, he notices me for the first time, as a person it seems rather than a fellow body passing objects back and forth – and he meets my gaze. He’s serious but his eyes are kind and he asks me if I’ve ever seen the IO before. I shake my head, look down and say I’m a newer first responder, and this is only the 3rd code I have seen. He asks, “do you want me to tell you about what I’ve done?” and I reply in the enthusiastic affirmative. Horrible as the circumstances might be, it was evident from the moment he stepped foot into our ambulance that help was here, and help knew exactly what to do.

    He begins to walk through everything he did – layman’s terms but not insulting, outlining the indications for each and the expected outcome, the hopeful outcome. He explained what he was doing as he rechecked interventions, rechecked rhythms and what the medications he had given were for. I drank in every word, fascinated in my tank top and sweaty hair. I don’t remember if he ever had a visible droplet of sweat, but I do remember to this day how he made me feel drawn to the medicine despite the fact that the small pale form on the cot was not far removed from my little world at home. She looked like my small best friend, and that bothered me too. I focused more on the medicine. I told him I knew of her, went to school with and rode the bus with her boyfriend. He shook his head and said that was too bad, went back to his medications with not much more emotional response.

    I’d never heard a radio report like the one he gave; I was impressed by the succinct way he summarized this whole experience. Walking into the city ER, I tried to be as small as possible next to these two uniformed paramedics in their competence and calm. Standing outside shortly after, putting our ambulance back together, they emerged again. I asked how it was going and the paramedic that rode with us said briefly, “they called it.” I remember sagging against the ambulance, somehow just feeling like a balloon with all the air whooshed out. I had hoped that somehow all these people who were so far beyond my knowledge would fix things. I remember them explaining how the disease she had often meant patients didn’t live much past their early 20s. They were kind, explanatory and collected. Then they were gone.

    On the way home, I just sat, the details swirling around in my head like an out of order kaleidoscope. I had never seen my schoolmate diminished like that, head bowed, weeping. I kept thinking of their little home, and of him returning to it alone. Thinking of what I didn’t know how to do and if I had known all those interventions, would she have had a different outcome? Looking at my sweaty street clothes with embarrassment. Wishing I had thanked that paramedic with the rapid speech and professional competence. Remembering what he took the time to teach me.

    Wishing I could be like that.


    Years later, I’m a dispatcher for that same paramedic service in the city and that rapid speech replying back on the radio becomes familiar to me. Later, and I’m a paramedic student; he’s one of my preceptors, teaching me still with that medicine-based professional air and I try to remove the emotion from my approach to patients, to be so matter of fact like he is.

    It’s 2018 and I just graduated nursing school and I can tell you there is still so much to learn from this quiet and decisive educator. He watered a seed that was already in me, and his demeanor of efficient movements, ready to teach with equal respect both co-workers, students and those on the periphery of emergency medicine like I used to be.

    As I’ve been around emergency medicine now for 14 years, I’ve seen many alpha males and females, many Monday morning quarterbacks. I think we need a lot more of the seed waterers, the educators, those who teach and lead by example.

    His name is Nick. I think we need a lot more Nicks. I’m sure glad I met him, glad he ignored the tank top and flip flops and explained intra osseous intravenous access to me with as much deliberation and gravity as if I’d been a young medic. He was just promoted to program manager of clinical education of that paramedic service, very well deserved,

    Be a Nick. Light that fire in someone, show them what you do, include them.

    “See one, do one, teach one.”

  • Friday, January 12, 2018 7:13 AM | PAAW Administrator (Administrator)

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

    He’s the center of attention and he’s trying to be brave. It’s hard to be brave though when you’re lying on your back on a shiny brown cot in the nurse’s station and the room keeps filling with more grownups. All of the grownups are gathered around him when I add my uniform to the room, and they’re all peering down at him. He’s valiantly trying to lock it down, but the hiccuping kind of sigh/crying kids do when they’ve been at it awhile is going on. The sad noise out and the kind of inhale that’s short and sad; sometimes the lower lip gets involved. His face is red and splotchy, and if I didn’t have the dispatch information, if I saw him sitting in a chair somewhere without the accouterments of grown up people, I might’ve chalked up the discoloration to long-term crying.

    But we are all gathered here today in the presence of Mom and the school nurse, and I do have the dispatch information. So I come in with the knowledge that he has a tree nut allergy and he’s eaten walnuts in a muffin. The very capable and kind hosting nurse tells us he was given an EpiPen prior to any EMS arrival. She produces it and gesticulates with it, punctuating the close air for emphasis as she tells the story – or at least what she knows of it.

    Someone brought a snack, and when you’re 7 years old, you like snacks. Honestly, when you’re a tall human you love snacks too but I drag my mind back to the gesticulating nurse and resolve not to think about how many double digit hours since my own last meal. My abdomen grumbles but I prevail.

    So the snack was wrapped up and store-bought and (here he interjects) there weren’t any visible nuts. But as nuts sometimes do, they were hidden by their small size within the muffin and when he realized this fact, he was maybe four bites in. I’ve seen 7-year-olds eat snacks, so I know no assumptions can be made about the size of the bites. I hunker down by the small hiccuping sniffling miserable person on the cot and gravely introduce myself, shake his hand. I tell him he’s the star of the show, that nothing is going to happen that he won’t know about first, that I will explain anything he wants, and that he gets to choose what order we do things in. He’s intrigued but a tough sell. I press on. I am impressed that he didn’t cry from the shot, per the nurse. She nods and punctuates the air again with the depleted device. He nods. I ask him if he’d like to sit up so all these tall people aren’t looming over him, and we open the door and pretty soon he’s upright and looking like he feels a little more on even footing with the situation.

    Vitals. Assessment during all of the above, because it’s reflexive and interacting with him affords me his mentation, his lack of drooling, his speech is clear, he stops being red and blotchy and turns out yep, it was long-term crying. Or at least somewhat.

    Next step; Mom. Mom is at the feet of the man of the hour, and has been watching all of this with grave interest and no small worry. I establish with her number of times he’s been exposed to nuts (once before), and what happened (swelling, face and throat). Negative intubations, excellent response to medication. In fact, so good that there is no EpiPen with him at school. It might be at home but she isn’t sure. We all turn to look at the device which has been passed on to the first responders. It is expired. Is it the school’s? Unsure. The nurse is gone. To where, I’m not sure but I don’t see her again until we are exiting through the office.

    Soon inside the ambulance, transport is beginning. I’ve let the patient choose whether he wants the blood pressure cuff on first or the light on his finger for pulse oximeter. It doesn’t matter which is first, what matters is that he is calm and is beginning to have a small rapport with me. He’s perked up, he giggles when I complement his bright and busy coat and matching boots. He’s acting like a regular 7 year old.

    Mom and I chat on the way in. She’s a little frustrated that despite the numerous papers she filled out, there was this series of events. Little man’s brow furrows at this and he hangs his head. A lightbulb that thankfully no one can see goes off, and I put some of the nursing training to work – this is a teachable moment. So we discuss the honest way a tiny ground up amount of nuts could be in a banana muffin packaged from the store without anyone knowing. We aren’t even sure if the muffin was consumed in class or shared in a hallway in a free moment between structured times. She nods, shoulders relax.

    She asks why I wanted to know how many times he’s eaten nuts and reacted, genuinely curious. I explain the initial response, the subsequent responses and the need for hospital evaluation even after an EpiPen is administered. We talk about reoccurrence of symptoms, the window of time in which they may return and need immediate treatment again. She is struck by all of this and we go on to have a productive dialog.

    During the dialog I ask the patient questions both to keep him interested and so he understands the importance of telling someone each time he feels a symptom, even if he has been treated already that day or night. He is bright, asks appropriate questions, and throughout the conversation I am able to monitor his continued swallowing, breathing, as well as the pulse ox level, heart rate and blood pressure.

    I give radio report maybe five minutes out. He says his throat is itchy and his belly hurts. Mom is asking about an EpiPen, she’s not sure where theirs is. I advise the ER physician can help with that, and she nods. Her shoulders slump though, and her face clouds. I tip my head and she tells me in a hushed voice that her husband’s company recently downsized and his position was eliminated. She doesn’t have $600, or insurance. I suggest an area free clinic, wondering aloud if they may have some resources with which I am unfamiliar. I am matter of fact, careful to keep any sympathy from sounding like pity to this proud, sad mama. My hands are busy, too, letting the patient pick which 18G needle he wants, which small syringe. I’m getting out our epinephrine vial, and he’s watching me with interest and some concern. Mom mentions the name of the doctor at the free clinic, whom I know well, and I tell her so. She’s struck by how small a world it is, and I’m able to explain to the patient that we might need to give him some more medicine. I remind him again though that he will know if I am and that he is the boss, applesauce. He grins. We’re stopping, now, and I realize we are in the garage bay.

    Mom hops out, my partner comes around and we take the patient out. He is jacked up, riding the automatic cot lift and I see no signs that worry me. We go inside, walking with Mom I ask her permission to approach the staff inside about options for covering the cost of that oh so necessary EpiPen. She agrees, and then we’re in, I’m giving bedside report and the small human is checking out the inside of this new environment. I see a red spot by his ear, and point it out to the nurse.

    Leaving the room, I find the most senior ER nurse I see, and quietly fill him in. He directs me to the social worker, who nods during my tale, then reassures me that I shouldn’t worry – the EpiPen can most likely be added to their ER bill for today. Which they aren’t going to be able to afford either, I think to myself. I ask if there are any programs, and she repeats that they will work it into the bill. I meet the eyes of another ER nurse who was once a street medic in my same uniform, and she smiles sadly. I nod, mutely, and head back to the truck in the garage so we can clear and enter the system, ready for the next call.

  • Thursday, November 16, 2017 8:08 AM | PAAW Administrator (Administrator)
    The whole way there I had pulmonary edema on the brain. Dispatch information wasn’t very alarming; “70s male, shortness of breath, coughing up blood.” But as soon as my boots hit the garage floor, that’s all I kept thinking. I’ve had three calls before with pulmonary edema – and two of those times it was the same patient. I’ve never been to this address, and despite nothing screaming clearly in the dispatch information, my gut says its pulmonary edema. 3am thoughts or gut instinct?

    So the trip out to the country road consists of me, all the way awake in a way you understand if you’ve ever seen pulmonary edema – bonus points for the pucker factor that is flash pulmonary edema – I’m chattering. My partner is an EMT tonight and he’s still waking up. He bears with me though. I explain what we will need to do in a short period of time if it is pulmonary edema. He gets it, he’s a great partner and I know I can concentrate on what I need to do. Knowing he will do what needs to be done and he isn’t the sort of partner who requires a lot of hand holding and validation.

    We arrive on scene, he puts it in park and I hop out the passenger side, round the side corner and spy a man approaching. He’s well dressed, fully dressed, and walking spryly. Coat neatly zipped up to the chin. Dapper hat atop his head. He looks like a retired cowboy, tan skin and western button up shirt. I ask if he’s the patient and he nods. I’m able to get the side door open and my patient is loading himself right up the steps before I can say much.  Climbing up after him, I catch my first auditory of my patient.

    Pucker. Factor. Right there. Right now. Yep, we’re about to do medicine. I nod at my partner, and we go to work in the choreographed steps we worked out while the truck winked and blinked its red and blue strobes down this back road and across the corn still waiting to be harvested.

    Sublingual nitro – check. CPAP – check. IV – check. Nitro drip – check. Furosemide – check.

    My patient is working to breathe, and working hard. The telltale wet sounds of crackles and rales are screaming the alarm for me, for anyone, to notice this man is attempting to exchange gasses at the alveolar level through liquid. Sternomastoids, scalenes, and intercostals – they’re all desperately doing their level best to move air in and out. The air is going in and out. The problem is that the air can’t pass into the blood through all the liquid filling the lung fields. He’s breathing fast, tachypnic, and blood pressure is high. His body is trying to compensate and from the looks of things, it has been for a while. There is no pink frothy sputum, and while acute, I’m not sure this presentation paints a picture of sudden, flash pulmonary edema.

    Transport begins. We’re maybe eleven minutes out and we need to be at the ER yesterday. He needs a tube, but out here on this pitch dark country road I’m the only paramedic in the county. State law states intubation is a dual medic skill and so we get to work. We’re making the pavement disappear between us and the ER with all of its equipment and people. I’ve always been one of those medics who is not fond of transporting emergent, and I do so seldom. Given the amount of medications and procedures we can perform in the patient compartment of our trucks, the due regard we need to demonstrate in driving, the aggressive protocols under which we operate, we are able to enjoy the ability to do many of the things on scene that the ER would do. There is not often a need to endanger ourselves, our patients, or the general public with the heightened level of adrenaline that comes with lights and sirens. Not to mention the effect on my patient, quite often the heart rate and blood pressure increase if we need to use the sirens and lights. Evidence-based practice is what we have learned, and we have learned to take the time to manage our patients before and during transport, driving non-emergent towards definitive care rather than just throwing them in the truck and “apply diesel therapy” as we used to say.

    But when my partner asks me if I want him to transport emergent, I consider it, then say yes if there happens to be any traffic, use the lights and sirens to move them, then just lights. It is the wee hours of the morning in this farming community and there is no need to awaken every coon hound between here and the ER.

    My patient seems determined to ask me questions and speak beneath the CPAP mask. It’s not as loud as the model we used to have, but it’s loud enough that I can’t hear him. PEEP is between 5 and 8 mmHg, the nitro is blurping along and the Lasix should be starting to kick in. His SpO2 shows oxygenation in the gutter though, and falling. He’s tiring out. I lean forward and speak quietly in his ear. I always do this and it seems to help them in their soundless mask, to feel less alone. I start with the basics; is he having pain, does he understand what is happening, has this been going on for more than a little while? He denies pain, indicates understanding and answers in the affirmative that this has been going on longer than a bit. Yes’s and no’s get me worked around to, he’s been up most of the night, he thought it would get better, he used inhalers, and he’s had this before. Then the big question I have to ask, has he been intubated before? He nods. I ask him, in the hospital? And he shakes his head, points to my gold patch. “By EMS?” I ask. He nods again, eyelids closing. He’s so tired, still hypertensive, still tachypnic. I keep speaking, verbally coaching him to remain awake. We cover that he is a former smoker, lots of years. He lives alone. It must’ve been a long night before 0300.

    I wonder if he wonders at my inactivity after the flurry when he first got in the truck. I explain to him what the nitro under the tongue – and now in the IV – is doing to help his breathing by reducing the workload on his heart. I tell him about the injection of Lasix, and its role in pulmonary edema management to begin to move the excess fluid out of the lungs. I promise him that the CPAP mask is helping push the fluid out, too, with positive pressure. He nods weak thumbs up. SpO2 is 74%. I give radio report. 71%. This is killing me. He needs a tube.

    ER. Bright lights. People. So much help, now. Handoff report at bedside. Remain and watch the C-MAC and Bougie make short work of the tube placement. Confirmation, tube is good. X-ray comes, lab. RT. I get a facility acceptance signature, accept the face sheet registration hands me. Walk out to my truck.

    There’s his hat and coat. Can clothing look forlorn? These did. Take them back inside.

    Hours go by. Flight team comes for him; he’s not hypertensive anymore now that the respiratory drive isn’t so desperately triggered. The ventilator is sedately moving air in and out of lungs that are much more baseline. RT tells me “his lungs were full”. I nod. Guess this nursing student does still have a medic’s gut instinct.

    Shortly after, I watch the EC145 spool up. The horizon is ever so faintly light, and somewhere over my head now, the hat and coat are dutifully following their owner.

    I wonder how many people would’ve put down their last cigarette and never picked up another – if they could’ve seen him, valiantly moving air in and out – and essentially drowning in front of me. I wonder what he would tell them, if he could.

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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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