It Ain't Ozzy and Harriet..

Television shows would have you believe that ambulance crews spend their days pulling one life after another back from the maw of death, rushing from rescue to rescue in between bouts of  supply-room sex with hollywood-gorgeous members of the opposite sex.  The reality is sadly less interesting.  Most of our calls are little more than expensive taxi rides.  Few of our patients need anything more than a lift.  Few of us are hollywood-gorgeous, and the supply room contains an abundance of spiders and a lack of places suitable for love-making. 

Still, we sometimes get to do things that approximate life saving.  A month or two ago, we were called for a man down at a local factory.  It was early summer, just starting to get really warm, and factories tend to be hot and poorly ventilated.  As we went en route, I reviewed treatments for heat exhaustion and dehydration.  Of course, diabetes was another possibility, and I reminded myself to grab the glucometer and some dextrose.

We were met at the gate by a manager, who explained that the patient, a man in his 60s, had suddenly collapsed.  "What was he doing before that?" I asked. 

"He was just cleaning up when he grabbed his chest and fell down," the manager replied.

"He grabbed his chest?  Does he have heart problems?"  The manager says none that he's aware of, but I'm already shifting to double-time movements.  I snatch the cardiac monitor out of the truck and speed walk inside.  There, I find the patient laying on the ground.  He's awake, but pale and diaphoretic (sweaty.)  It's not all that hot in the factory, but his chest is so sweaty that I have trouble getting the monitor leads to stick.  When I finally do, I'm initially confused by what I see on the monitor.  Heart attacks usually show up on an EKG in the form of ST segment elevation.  Essentially one part of the QRS complex, that squiggly line that represents the heart's electrical activity, is higher than the rest.  This man's ST segment is so elevated that I initially have trouble figuring out which part of the complex is which.  After a few seconds, my brain engages, and the readout resolves into a complex that screams 'heart attack.' 

Several EMTs and firefighters have arrived, and my partner asks what I need.  "Load and go.  Let's get him in the truck now.  I'll do the 12-lead there."  If we were moving at double-time before, we're now in a full sprint.  We scoop the patient up, put him on the cot, and move him to the ambulance.  On the truck, we move even faster.  My partner hooks up the 12-lead (a more detailed EKG), and I start an IV and give nitro and aspirin, followed by Fentanyl.  The 12-lead prints, and I examine the tracings before looking at the machine's diagnosis.  For once, the machine and I agree.  It's a STEMI, medical speak for heart attack.  Kevin jumps out, speed walks to the driver's seat, and we pull out with the sirens screaming.  In back, I recheck vitals and prepare another round of medications.  I grab the phone, hit the speed dial for the local hospital, and clamp the phone between my ear and shoulder as the ambulance rocks side to side, speeds up and slows down.  I tell the nurse on duty what I'm bringing in.  My usual laconic phone manner is gone, and I'm rattling off vital signs and medications in the same way I used to call out fire mission information in my days as a Marine artilleryman. 

Moments later, we pull in to the hospital.  We wheel the cot in, and the hospital staff quickly sets up their own EKG, and draws blood.  The local hospital doesn't have a cath lab, and I step out and visit the bathroom, knowing we're going to be taking the patient down the road to a bigger facility.  By the time I come back, the doctor has confirmed my diagnosis.  The patient has never even left our cot, and we wheel him back out to our truck.

Over the next forty minutes, I'm busy with medications and monitoring.  I contact Midtown hospital and call a Code STEMI, alerting them that the cath lab needs to be up on running on our arrival.  When we arrive at Midtown, the cardiologist and cath lab nurses are waiting for us at the ER door.  We don't break stride, and I hand the EKG print outs to the doctor and give my report as we speed walk to the cath lab.  Moments later, our patient is on the table, and Kevin and I are making up the cot and getting ready to return to the station.

A few hours later, I call the hospital for an update.  Our patient is doing well, and expected to go home in the next several days.  At the beginning of my next shift, I find an image of the patient's heart and the cath lab report on the day room table.  The left anterior descending artery had been totally blocked-not only had the patient had an MI, he had one of the worst ones possible.  But he survived.  Sometimes you get a good save.  But there's still no sex in the supply room.

Let me tell you about my morning...

Let me tell you about my morning.  It started at 4 AM, when we were toned for a patient at the jail having a breathing problem.  It was a simple call with an easy fix (Albuterol and Atrovent work wonders for asthmatics), but the timing was just right to ensure that after finishing my report, there was no point in going back to bed.  And, as soon as I was off at Riverton, I had to drive to the next town over for another 24 hour shift.  Such are the joys of making a living in EMS.

By the time I finished writing my report, taking a shower, doing station duties, and making a small breakfast, I had about an hour and a half to kill before shift change.  I took a cup of coffee from the thermos I always keep full of tungten-strong french roast and carried the novel I was reading to the picnic table out back.  The weather forecasters were threatening us with a hot, sticky day, but for now the weather was pleasant.  The sun had come up, but not so long ago that it had completely chased away the tendrils of dawn pink from the sky.  I reflected that although getting hauled out of bed at 0 dark stupid always sucks, now that I was up, there were worse ways to spend the morning.

That, of course, is when the tones dropped.  Before the cacophony of high pitched sqeals and whoops that call us to work had stopped, I was mentally figuring times.  If the call was close, and if the patient wanted the local hospital, I calculated, I might just make it to my next job on time.

"Attention Riverton EMS, response is needed to 17 Highway one mile South of 28 for a one-vehicle MVA."  Crap.  These calls often turn out to be nothing-the patient was out of the vehicle before we got there, and didn't want to go to the hospital, or the car has driven off before we arrive.  But when they're something, even if it's a minor something, they're time consuming.

I chugged the rest of my coffee down, and, on the way to the ambulance, stopped by my locker to pick up my bunker gear.  Our fire gear provides pretty good protection against the broken glass and sharp bits of metal that tend to litter accident scenes.  Climbing into the passenger seat of the ambulance, I glanced in the mirror to make sure my partner was on the way out.  He was, and I reached across to get the clattering diesel that powers our truck started.   A moment later, he climbed in, and we pulled out of the bay.  Kevin pushed the button that activates our LED light show, and I turned the knob that cranks up the noise makers.  I grab the radio handset  "Rescue 1, Central, we're en route, miles zero."

About a mile down the road, dispatch calls to tell us that a civilian on scene was reporting that the driver was still in the vehicle.  So much for getting to the next job on time.

The accident scene is on one of the main two-lane highways through the county where it intersects a gravel road.  A combination of highway department engineering and weird topography mean that the gravel road sits atop high, steep embankments on both sides.  The car, a Ford hatchback, is at the bottom of a ravine on one side of the gravel road.  It's about 60 yards from the road surface, and I'll be damned if I can see how the driver got there.  Usually, when a car leaves the road, the path it takes will be marked by churned up dirt and broken plants.  If the vehicle rolled on the way, bits of broken car, along with papers, purses, CDs, cell phones, and the other junk people carry in their cars will mark the path of travel like breadcrumbs.  As we get close, I can see some churned up dirt, but, while that trail leads to the car, it starts about 30 yards from the road.  Kevin says what I'm thinking.  "What the fuck did this guy do?"  A bystander is frantically waving at us and pointing to the vehicle.  He bounces up and down as he points, a gray haired gentleman looking like a toddler doing the pee-pee dance.  "We see it, jackass," I mutter.  "Calm the fuck down."

We pull up, and I hop out as the ambulance rolls to a stop. There's some water at the bottom of the ravine, and the ticks are said to be bad this year, so  I take a moment to pull on my bunker pants as I survey the scene.  A civilian, probably the one who had been talking to dispatch was squatting next to the passenger side of the car.  Of the driver, I see no sign.  Leaving Kevin to carry down the backboard and C-collar, I make my way down the embankment.  The civilian starts talking as I walk up.  "I've been trying to keep his head still, but he keeps moving it.  He was unresponsive when I got here, but he's talking now."

The patient himself is laying face-down, with his head slightly out of the open passenger door, his torso in the passenger footwell, and his legs draped across the driver's seat.  Both airbags have deployed, and the windshield is broken on the passenger side.  There's a small puddle of blood on the ground under the patient's head, and he has several abrasions on his face and forehead.

So.  He left the road moving fast.  He wasn't wearing his seatbelt.  When the steep angle of the embankment caused the car's nose to plow into the ground, he went flying across the passenger compartment. The broken windshield and abrasions suggest that his head hit the windshield.  Since the airbags deployed, there may have been two impacts, one that set the bags off, and another that tossed the guy into the glass.  His airway is open, and his breathing is regular.  There's blood dripping from his face, but not enough to be concerned about.  But I can only see the patient's back and face.  I can't tell what's going on in front.

Kevin walks up with the backboard.  Although he's the shift captain, and therefore the boss most of the time, I have a higher medical license, and on medical calls, I run the show.  "Have dispatch get a bird on air standby" I say.  In other words, have a medevac helicopter start flying our way.  I turn back to the patient.  "Hey, buddy, where do you hurt?"  He says something but I can't make it out.  "Do you know where you are right now?"

"At work." he says.  Not good.  At all.  He's almost certainly suffered a head injury, and his level of consciousness is altered.  By ground, we're at least 40 minutes from the nearest level 1 trauma center.  And this guy needs a level 1 trauma center.  I turn back to Kevin.  "Go ahead and have the helicopter come to the scene. We're going to fly him from here."   By now, I can hear the engine coming, and after calling for the bird, Kevin radios the engine crew to set up a landing zone.  The best option is to shut down the highway and land the bird right there.  We're about to piss off a lot of commuters.

I pass off c-spine (control of the patient's head to protect his spine) to Kevin and jog back up to the truck.  I need more stuff.  I grab the trauma bag from the shelf and yank down the IV start kit I keep taped to the wall of the ambulance.  I mentally chastise myself for not grabbing this stuff in the first place.  Blame it on a lack of caffeine in my system.  On the way back down, I yell to the engine crew.  "Hey, we're going to need some help here!"

Back at the car, the first order of business is to get the patient onto a spine board.  Given the mechanism of injury, there's a good chance he's got a spine injury, and I need to see his front.  As firefighters and EMTs arrive, I climb over the patient and into the back of the car, where I perch with my boots on the seat.  That position will give me the best access to the patient once he's rolled over.  Climbing in, I hear dispatch advise us that the bird is 20 minutes out.  Too damn long, but I'll think about that once I get a look at the rest of my patient.

The board in place, we roll him over.  At first, I don't see any other serious injuries.  Both sides of his chest are rising and falling equally.  His pelvis looks intact.  No jugular vein distention, and his trachea is midline.  His face is scraped and bruised, but I don't see double black eyes or the shadowy bruises behind the hear that can indicate a skull fracture.  Then I notice his right arm.  The hand is pointed at a 90-degree angle away from his forearm, but the bend is several inches down from the wrist.  The skin of the wrist is pulled tight across what looks like the distal (far) end of the radius.  "He's got a broken arm!" I call out as I grab ahold of his forearm.  For a moment, I'm baffled.  I need to splint it, but the hand is in such a weird position that I'm not sure how.  I turn to Kevin.  "How in the hell should I splint this?"  Kevin's not a medic, but he's a damn good EMT and has been at it for a long time.  As he has many times in the past, Kevin demonstrates the truth of the saying, "Medics may save lives, but EMTs save medics."  Kevin suggests using a flexible splint rolled and bent to match the distorted shape of the forearm.  It works.

But there's a problem.  I'm manipulating the patient's arm.  The patient's obviously and colossally broken arm.  He should be screaming.  I shouldn't be able to do this without dosing him with high-octane narcotics.  But, although he's awake and talking, he's not showing much reaction to the pain.

Dispatch advises us that the helicopter is making better time than expected.  Good.  The other crew members slide the patient out of the car and began carrying him up to the ambulance.  I take a moment to look more closely at the car.  It hasn't rolled over.  The damage to the front is minimal.  The roof has no dents, even at the top of the windshield.  The broken glass has to have been caused by his head.

In the ambulance, Kevin and I get to work.  Carl, the Assistant Chief, jumps in too.  We continue the oxygen the patient has been on since shortly after we reached him.  Kevin hooks up the monitor, which will provide an EKG reading as well as basic vital signs.  One problem: I need to get an IV started, and Kevin needs a place to put the blood pressure cuff.  But the patient has only one we can use for those things.  I yank off the patient's shoes and examine his foot for a possible IV site while Kevin gets a blood pressure.  There's nothing in the foot, but Kevin tells me he feels a good vein in the patient's left arm.  I look.  I can't see it, but I can feel it.  To get to that arm, I have to straddle the patient.  I hate starting IVs that way, but this time I get lucky, and I hit the vein immediately.  We run warm fluids wide open.

As we've been poking and prodding at the patient, I've been talking to him.  He's becoming more coherent.  He knows where he is.  He understands that he's there because he crashed his car.  He was in the hospital two days ago for extremely high blood pressure, but he doesn't remember how high.  I perform a quick stroke exam, and find nothing to suggest that that's what's going on.  The cardiac monitor looks good.  Kevin points out a small bruise on the patient's abdomen.  A bruised abdomen can be a very bad sign, but this one looks old, and when I felt the patient's belly, I didn't notice anything untoward.  Still, I make a mental note to tell the helicopter crew about that.

By now, I can hear the bird overhead.  Carl steps out of the back of the ambulance and drives us 100 yards or so to the landing zone.  The helicopter crew arrives, and I brief them as we transfer the patient to the bird.  A moment or so later, it lifts off and roars away towards the trauma center.  Everyone on the crew has seen the bird take before, but we all stop to watch.  I turn to Kevin and say the same thing I always do after a medevac, "No matter how many times you've seen it, or how many times you've ridden in one, helicopters are freaking cool."  And they are.

The highway patrolman on scene has examined the accident scene, and tells us what he thinks happened.  The guy drove off the highway, crossed several hundred yards of grass, then shot up the embankment with enough speed that he launched all the way over the gravel road before hitting the ground halfway down the opposite embankment.  The trooper, Kevin, and I look back down the road, mentally tracing the car's path.  After a moment, I turn to the the trooper.  "So, he did a Clark Griswold," I say.  I do my best Chevy Chase impression, hands on hips and staring at the horizon.  "Fifty yards...."  It's not often you can make a state trooper chuckle.

The back of the ambulance looks like a toddler has had a particularly destructive temper tantrum in it.  Bandage wrappers, saline flushes, needle caps and other detritus are scattered on the seat, on the cabinets and on the floor.  "Let's just get back and fix it at the station" Kevin says.

We get in front, and I pull out my phone.  I've got to call the next job and let them know I'll be late.

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Drunks-part one of many

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The beginning of a new project

“My grandmother says that Riverton was the place to be.”  So says David, the stocky 20-year-old riding behind me in our Deputy Fire Chief’s Truck.  We’re driving through the four or five blocks of downtown, and it’s hard to reconcile his grandmother’s statement with with what we see out of the windows.  The buildings are mostly brick, built up against each other in the late 1800s or early 1900s using what I’ve come to think of as firefighter-killer construction.  About every other building is occupied, mostly by antique shops that are open for a few hours a few days a week.

We pass a pair of buildings that, at first glace, look just like any others in the downtown blocks.  Look more closely, though, and you’ll see that they buildings are not buildings at all.  The front facades still stand, but behind that there’s nothing behind the brick fronts.  They burned in the first big fire I fought, and although people have talked of rebuilding them, even offered plans and obtained money, it’s never happened.

We’ve come from walking through several other buildings destroyed by a fire.  Only two of the buildings were actually touched by flame, but the other buildings on the block, feeling the loss of support from the burnt buildings, have begun to sag alarmingly.  Stand inside them, and you’ll notice that all the walls lean.  The whole block is to be torn down, but before that happens, we’re using them as training aids.  No one seems to know what will become of that block once it has been razed.

Those buildings seem like a symptom of small-town decay, and I suppose that’s what they are.  However, they’re also a reminder of triumph.  In the first moments of that fire, the duty shift saved the lives of two people, plucking them from a second-story window.  After saving the people, they saved the people’s dogs.  And they stopped the fire from spreading from building to building.

Looking at all of that, it’s easy to assume that David’s grandmother is deluded by nostalgia.  But the pictures hanging on the walls of the station prove that she’s speaking the truth.  On yellowed newsprint behind plain frames are pictures of a prosperous downtown full of people and businesses.  Look closely and you can see that the three-story building covering half of a block was once a large department store.  Now, the first floor holds a furniture rental shop.  The top two stories, I’m told, are used for storage.  Examine another photo, and you might see a corner bar with a beer sign hanging over the street and people coming and going through the open door.  That building is still there, and if you brave the buzzing attacks of the wasps that nest over the door and look through the grimed window, you can see the long bar.  It’s dusty and faded, but the wood still looks good solid.  A few hours of work, and it would be the showpiece of a nice pub.  For now, though, it sits forgotten.  As we drive past the building, the Deputy Chief notes, “That building is about to slide into the street.”  It is.  In fact, a few years ago, the back section of it did exactly that.

Decay isn’t the whole story, though.  On the next block, next to the local library, a bookstore and coffee shop does a steady, if not overwhelming business.  A pizza place next to that has hung on for several years, now.  The building next to it used to be a Bank of America branch, but sometime in the last year, with so little fanfare that I didn’t notice for a few months, the branch closed up shop, leaving another vacant building.  Next door, though, the Riverton Medical Clinic is doing a good business, as is the pharmacy conveniently located in the same building.

Past a few more antique shops, Pat’s Army Store always seems to have people in it, and the staff will be happy to sell you shoes for a track meet or a shotgun and ammo to go with it.  

Downtown today is, then, a bit underwhelming.  The days of “Block 42,” when retail businesses, bars, and cathouses jostled for space are gone, although many people still living here remember them.

Visitors to the town usually remark on the scads of antebellum homes and on the courthouse, where a cannonball (actually, it’s a replica cannonball-the original was removed for safety reasons) is lodged in one of the front columns, the result of a poorly aimed shot during the Civil War Battle of Riverton.

History is thick here, and coexists with the quotidian present.  When I first moved to town, I lived in an apartment building steps away from where the Battle of Riverton happened.  A year later, I moved to an apartment that occupied the top floor of a building that once housed a bank said to have been robbed by the James gang.  From that balcony of that apartment, I could look down on the spot where Archie Clemmons, a notorious Confederate guerilla and all-around murderous bastard, had a drink before being accosted by federal troops.  After a chase on horseback, he was gunned down near the courthouse.

Riverton was a Confederate town, and if you stand on the steps of that courthouse, you’ll be standing where slave auctions were once held.  

Lots of towns have history, but in this town, the citizens are aware of it.  Every kid here knows that the Battle of Riverton was won when troops advanced up a hill behind large hemp bales.  Outside of Riverton, William Quantrill is a name known mostly to afficiandos of the Civil War’s border conflicts.  Here, everyone knows that he led a band of Confederate guerillas, and often holed up in town between raids.  So, for that matter, did the James gang.  Archie Clemmons’ grave is around here, but those who know exactly where are loathe to share that information.  Although Clemmons died nearly 150 years ago, the grave is still sometimes subject to vandalism.

****

If you were to ask me in an distracted moment how long I’ve been living in Riverton, I might answer, “a couple of years, I guess.”  But it’s been longer than that.  Every year, the fire department hands out certificates for years of service.  My last one read 8 years.  Every time I look at it, I think there must have been a clerical error somewhere.  But the arithmetic is right.  I’ve been in Riverton for nearly a decade, and I’ve been a firefighter for just a few months short of that.

I didn’t intend that to happen, of course.  Riverton was not to be a stopping place, but a spot to stay in for a few years while I got started on a new career.  It hasn’t worked out like that; I haven’t left, and the new career that brought me here has fallen away and been replaced with a very different new career.  Somehow, this boy who grew up in the suburbs of Kansas City before moving to Chicago for college, and then spending a few years going wherever Uncle Sam told me to go, has settled in this small town on the bluffs of the Missouri River.  The town is insular, and often feels too small to the kids raised here.  But it’s also a community.  And, somehow, it’s become my community.

Although Riverton is the community I inhabit, my life here is dominated by the time I spend with my second family-the fire department.  

The purpose of this exercise is not to write some elegiac hymn to small-town life, or to offer peans to the people who respond to fires and medical emergencies.  My ambitions are much smaller than that.  I’d like to tell you some stories, and I hope that they entertain you.  There will be a few stories about small-town life, a few stories about fighting fires, and a lot of stories about working on an ambulance.  If  I have any goal beyond that, it’s to offer you a glimpse into one particular way of living.  I’m not going to try to convince you that this way of life is the best way to live.  I’d only to to show you that it’s one way to live.

****

You’ve probably heard stories about fires in the middle of the night, and about accident scenes with bodies scattered across the road among the broken glass and bits of cars.  That sort of thing certainly happens, but this is the daily reality of the job.

It’s two thirty in the morning, and my partner, Kevinl, and I are driving down an empty two-lane highway, on the way back from dropping someone off at the hospital several towns over.  The moon is out, and its light slides like mercury across the snowy fields on either side of the road.  I’ve plugged my mp3 player into the truck’s stereo, and we’ve got Johnny Cash cranked up.  I’ve got my right leg kicked up on the dashboard, and am doing my best to get comfortable in a seat that is permanently set to bolt upright.  We’re both singing along with the music, but the stereo’s volume and the clatter of the diesel engine mean that we can’t hear each other.  This is probably a blessing for Kevinl.  We sing our way through Jackson, Folsom Prison Blues, and a handful of others.  As we approach Riverton, I put on some of Cash’s newer stuff, which Kevinl hasn’t heard.  The spooky notes and lyrics of “The Man Comes Around” end as we pull into town.  At the gas station, we stand in the biting cold and fill the tank.  The lights in the house across the street from us are out.  Sane people are sound asleep at this hour.  

We pull away and tell dispatch we’re in service.  Back at the station, looking at a screen made bleary by contacts that should have been taken out several hours ago, I finish my report.  It’s nearly three thirty by the time I crawl back into bed.  I take off my EMS pants, hang them over a chair next to my zip-up boots, and crawl into bed in gym shorts and the same t-shirt I wore on the last call.  Setting things up that way saves time when the tones drop.  In about three hours, if we don’t get a call, I’ll get up, perform last-minute station duties, and end my 24-hour shift in time to drive my daughter to pre-school.