Thursday, May 31, 2012

Two Deaths & a Beating

**When I write about work, I blend and blur details so as to not write specifically about patients and victims. I keep the essence accurate while smudging the defining lines. I might switch aspects and alter chronologies, but I never lie. These scenes have happened, likely more than once.**
We see such a range of incidents at work, from the absurdly mundane to horrific catastrophes, that it’s sometimes hard to keep things in perspective. What is a normal emergency?
I’ve found myself recently with a dearth of patience for Code-99 crybabies. I’m cognizant that each of us has differing pain & discomfort thresholds, and that in the moment, we each can lose perspective. That said, considering most of my work takes me into proximity with people suffering all sorts of ills, I have a decent barometer of actual vs. perceived vs. self-indulgent suffering. I can be wrong, which is crucial to keep in mind, lest I fuck someone over. But, generally, we can read a patient. And with every crushing injury or soon-to-be-fatal condition, I appreciate the human capacity to suffer and the gap between living, dying, and death. So when we get called to patently ridiculous non-emergency issues, it can be taxing to maintain professional neutrality. Really, the proper thing would/should be to take the person by the lapels and pointedly explain difference between a boo-boo and an injury.
The standard pain-level spectrum (‘On a scale of 1-10, with one being nothing and ten being the worst you’ve ever felt, how would you rate your current pain?’) is worthless. If they can tell me their pain level is a ten, a. they’re breathing just fine, and, b. it is far from a ten. I told the ER intern when I was there for a dislocated shoulder that my pain was about four or five. I was in ghoulish agony when I moved, but I was fine. ‘I’ve seen people at a real ten, and I don’t want that, so I’m not going to inflate it.’ He stared at me then repeated, ‘So, if one was nothing, and ten was the worst you’d ever felt, how would you rate your pain today, Mr. Norton?’
I taught my daughters early to identify pain vs frustration when they got hurt. I wish that was a universally proscribed skill. We responded to a woman who slipped stepping onto a curb. She fell over, scraping her back. She was upset and began yelling and crying at her old man. They called 911. Fire and medics responded with lights and sirens. The woman walked across the parking lot to meet us, saying that her back hurt like shit. (By walking and moving to point to where she fell and where it hurt, she demonstrated there was no paralysis, by the way...) 
Me; ‘So, you tripped, scraped your back, and you called 911?’ 
She: ‘Yes.’ 
Me: ‘Is there anything we can do for you? You appear to be moving appropriately. You have a small scrape on your back. You have full range of motion and sensation to your extremities [except, perhaps, your brain]. What is your complaint, ma’am?’ 
She: ‘My back hurts.’
With enough calls like this, the futility of a common-sense approach to health care, any sort of preventative intervention, education--it feels like we’re fucked for fair, and the waiting rooms will remain clogged with Code-99s forever more. Staff will be overworked, frustrated, prone to sloppy or error-pocked assessments, discourteous, numb. Insurance will keep the paperwork churning, the fees rising (largely to cover all the folks w/o insurance who keep coming through the doors w/ no real issues (nothing actually emergent).
The other night, though, we caught several that were reminders of the weight of this job, as well as providing stark contrasts (counter-points?) to all the nonsense calls.
The first came in later evening, before midnight. SOB call, updated en route to one unconscious. We arrived at a duplex, headed upstairs. Small unit, teenage kid on computer in small living room. Woman down narrow hallway still on phone with Dispatch. She waved us toward her then pointed into doorway. ‘I just dozed off. When I realized I didn’t hear his usual loud breathing, I woke up. He sleeps loudly.’
I stepped past her into a small bedroom. There was a large man face-up on a queen-sized bed. He was shirtless. His belly protruded even while horizontal. I touched his arm, ‘Sir? Sir!’ The skin was cold. I rubbed his chest then checked his carotid pulse. ‘He’s cold,’ I said while searching for (hoping for) a pulse.
‘The fan,’ his wife said. ‘We had the fan on.’
I checked his wrist. There was nothing. His neck was crimped forward from the pillow. A bad angle. A trickle of drool spilled from his mouth down his cheek to his shoulder. I put my hand under his back then beneath his neck. There was warmth between the skin and the mattress. I opened his eyes. They were gauzy. Fuck, I thought. I adjusted his head on the pillow, in case there was a gulp of air waiting to come forth.
The woman had left the room. I turned to my crew, still waiting behind me at the door--not enough space to crowd in beside me. ‘He’s fucking cold. I can’t find a pulse.’ I stepped back, motioning to Sandy. ‘Check, will you. I can’t find anything.’
While she checked for a pulse, I felt up and down his body. The surface was cool. There was warmth only where the skin connected to the mattress. Sandy shook her head.
He was dead.
In most circumstances, we will work someone, if only to give the family something to grasp onto while the reality sinks in. Unfortunately, once we start the process, the medics have to continue it, and we all work really hard for someone who is and will remain dead, and, after working hard in the apartment, we load the person and carry him/her down to stretcher and into ambulance and whistle to County, doing CPR and breathing for (the corpse) as the ambulance bounces and jerks down the city streets, and we pull into County ER, wheel the stretcher into the STAB room, and the doctor looks at the printout then at the medics and proceeds to criticize them for working someone who is clearly not coming back.
Thus, many medics get pissy with us for working someone whose condition falls clearly into the un-savable category. No matter how genuine or noble our intentions, ignoring the science of it makes for cranky doctors. 
Good faith efforts. Good Samaritan gestures. Customer service...
I sighed, touched the man one more time, and shook my head to my crew. We would not be working this man.
They looked at me. I looked at them, and him, then around us. There was not space enough in the room to work him, nor in the hallway. The living room, possibly. The landing outside the apartment? He was large, and cold. She’d said she’d just dozed off, but if a person is down (without circulation or breathing) for ten minutes there is no chance for a positive/normal resolution. Brain damage occurs by the minute. I had to weigh what I was seeing & feeling against the word of his frantic wife.
I walked down the hall to the main room, where the teen still idled on Facebook. The woman came out of the kitchen, looking at me expectantly. ‘Well,’ she said. I stared at her a moment, nonplussed. Our perspectives are so different. Her normal is that her husband is alive. My normal is people call us when someone is hurt or dead. ‘Is he okay?’ she asked.
‘I’m sorry. He’s dead.’ 
(That is an existential phrase. I am decreeing something significant. It’s fucking eerie to be the arbiter of existence.)
The other hard part about my job is what follows such statements. The woman’s world dropped away, leaving me standing before her, the emissary of death. ‘Noooooooo,’ she shouted. ‘No! No! No!’ She moved as if to hit me. ‘No! No! No! Do something. You do something!’
‘I’m so very sorry, ma’am. He’s gone.’
No! Do something. You do something!’
For the next several minutes, we repeated this. She screamed, yelled, wailed, implored. I stood in front of her, receiving her grief, repeating my paltry condolences and firm assertion that her husband was dead. The medics arrived, having not received the information of the DOA from Dispatch. They left. I sent my crew out to drop the equipment. Sandy came back up, standing behind me in the hallway. At some point, the teenager realized what was going on (belatedly, to be honest. I was disconcerted at the full-on involvement with Facebook, which, looking over her shoulder, was the same nonsense as on all of our screens. Perhaps she was accustomed to her mother screaming, a lot) and began crying, too. The mother was still yelling at me, but it was tapering, replaced by inconsolable wailing. I cannot do justice to the grief. The mom shoved her phone at her daughter, telling her to call (family).
Although he looked 55+, he was under 40.
His wife was pregnant. ‘Our baby--we have a baby coming! His baby!’
Their first kid was barely a teen. ‘Your daddy’s dead, baby! Daddy’s gone!’
There was no upside to this situation. ‘Nooooooooooooooo!
I stepped away to give them privacy. The only place to go was back to the bedroom. We must remain present until the police arrive, even in ‘routine’ deaths, which means we are present for the first five to fifteen minutes of grief. We then symbolize the reality of death, of loss. That is what I get paid for, to bear witness to the grief and suffering of strangers. To accept their rage, fear, panic, sadness so that they can move through the acute shock to the subsequent details.
I checked the man, again. He was dead. I had made the right call, but it did not feel good. It is strange to stand before a newly dead person, amid his/her quotidian surroundings: bedroom, kitchen, living room, clothes, food, papers, pets. I haven’t figured out if it’s the actual absence of life-energy I detect from the corpse, or if it’s childhood fascination or superstition that the dead will suddenly sit upright and grab me. It hasn’t happened yet. I don’t think it will. But standing in a small room with a fresh (or relatively recent) corpse, amid their normal life--which is no longer normal and no longer life--feels pitched with a strange tension. Paranormal activity, in my mind...
The police arrived. I briefed the officers on what we found, how we’d found him, and her, and that we hadn’t noticed anything out of ordinary (other than dead man in the bed). I said another useless condolence to the now ‘merely’ sobbing mother and daughter, and we left. The ride back to the station was heavy and sad. We discussed whether we should have worked him. Had the fan not been blowing, and he’d been that little bit less cooled already, we might have given it a shot. Under 40 years, at that size, he likely suffered a complete heart failure. There are actually very few conditions of cardiac arrest from which we can rescue someone. That doesn’t make us feel any better about it, though.
I was up for a while after this call, writing my report, feeling awful, questioning whether I made the right decision. There’s always room for doubt, or examination, of actions. There must be--even if the choice is correct. An hour or so later, trying to find the doorway into sleep, I caught the tones before the first bell sounded. A medical down the street from the station, an assault victim. We drove around the block looking for our patient, since no one waved us down and there were several people milling about the street. ‘Hey, are you hurt?’ is a funny way to approach someone. We found him slumped on a bench. He’d been jumped, he said, by two dudes and a woman. She’d lured him and they’d slugged him with something. He had a deep gash on the back of his head. He didn’t remember much else. His wallet was gone. ‘Why’d they have to hit me?’ he asked, then asked again, the familiar scared and sad tinge to his voice. We bandaged him and helped him into the ambulance. A squad arrived and the officers stepped aboard the bus to get their report. Sometimes, it’s a guy walking home who gets mugged. Other times, it’s a john getting set up by the street walker and her pimp. Or it’s a drug thing. We don’t ask particulars and we don’t really care. We address their wounds and help the medics get them to the hospital, then, if necessary, we spray the blood off the sidewalk.
I’d fallen asleep, perhaps forty minutes after finishing the assault victim's paperwork. The bell snapped me upright, another medical. There’s less of an adrenalin surge after the initial wake-up with medical tones than with fire tones. Fire tones force me to force my mind awake immediately, which is hard on the system. Medicals, I can climb more reasonably toward consciousness--even sticking my head out window to vacate the sleep as we respond. Dispatch stated it was an Assist the Police call, which can be anything from forcing open a door to using a ladder to get to the roof to a Tasered suspect having cardiac failure. We rolled out, getting no new information on our computer screen.
A block away we got notice that the scene was safe and they needed EMS code-three (immediately). We pulled onto the block and were confronted by a baker’s dozen of squad cars. There were officers moving around but no guns drawn and no discernible panic or frantic edge to their movement. The driver slowed, looking for a place to stick the rig, and I jumped out, walking swiftly down the street. I passed officers but no one was shouting or barking info or orders. Reaching the address, I saw three young men sitting against the chain link fence, wrists manacled behind their backs. Several officers stood over and around them, but I couldn’t tell from the cops’ expressions whether these were suspects or hostile witnesses. An officer held the front door for me and pointed up the stairs, which I hustled up, the AED banging against my leg.
I didn’t hear screaming, yelling, or wailing. At the landing, there was an officer putting evidence cones over a scattering of bullet casings. He looked up, I tilted my head toward both apartment doors, and he nodded toward the one on my left. ‘He’s in there,’ he said, motioning me to watch my step as I passed his work area. I opened the door and met several more cops in the front room. Three feet into the room splayed on the floor was a man, arms and legs spread wide, mouth ajar. I looked at him a moment as I took in the action in the room. ‘This guy’s dead,’ I blurted.
There’d been no info from Dispatch about a shooting. Nor about his condition. I didn’t mean to say it aloud, especially before checking him, but that was what came out. Free verse... I stepped to him, knelt and checked for pulses. His eyes were open, staring at the ceiling. ‘Hey, man,’ I said, ‘can you hear me?’
I wasn’t getting a pulse. I put my hand on his chest and rubbed it. ‘Hey, man,’ I repeated. I looked him up and down. There were blood droplets on his pants but not much, and no entrance or exit wounds. Suddenly, I felt a convulsion in his chest and neck. His jaw twitched and he took a breath. Surprised me. Hate it when they do that...
I watched him a moment, still feeling for a pulse. No further movement. I rubbed his chest again. It felt rock solid. I looked more closely at his shirt. Below and beside where I was rubbing his chest there were three or four holes in his shirt. Hmmm. Close-range chest entrance wounds... He was done. Then his torso and neck stiffened and quivered again, and his jaws gaped further open a moment.
The medics reached the front door at this point. I moved to the other side of the man so they could see. I said I had no pulse but there’d been a couple agonal breaths. The younger of the two knelt beside me, checked for a pulse, and said, ‘Let’s get him down to the bus!’ He dropped their canvas litter along the man’s left side and motioned me to grab his upper body; he positioned himself by the legs. The second medic came into the room, looked around and down at us. ‘Did he arrest?’
‘Shooting,’ I said, looking at the bullet casings everywhere.
‘No. Did he arrest? Do you have a pulse?’
‘Negative,’ I said.
His partner started saying he wanted to load and go so they could work him in the ambulance.
‘Leave him. He’s done. This is a crime scene. Just leave him. Don’t move him any more.’
His partner was still hoisting the guy’s legs, side-stepping over to the canvas litter. He looked perplexed. I understood. Dead is dead, especially with penetrating trauma--such as a cluster of bullet wounds to the chest. Yet the agonal respirations implied some form of life within the potted body. I glanced at the young medic, then at his partner. Dead is dead.
We lay his legs and torso back on the floor and stepped away. This was the police’s scene. I helped the medics get their bags and the canvas together and we left. My crew were wending their way through the police officers. I shook my head and nodded toward the rig. ‘Let’s go.’
‘Was he dead already, or not even hurt?’
‘Definitely hurt. Definitely dead.’ We walked past more cops, most of them were milling about inside the perimeter being established by several officers with scene tape. I spied the two from the earlier call and approached them. ‘Sorry I left you with that. She was devastated. Rolled over and her old man was dead.’
The officer shrugged. ‘She calmed down pretty fast. It wasn’t too bad. Sad deal, but she started to think clearly again.’
I said good-bye and we got back on the rig.
The driver asked, ‘So, the guy up there, he was dead?’
‘You know,’ I said, ‘he was less-dead than that guy we had earlier. But dead is dead. Shot to shit point-blank in the chest.’
‘Yep. Hell of a way to go.’
We found out the next morning that the man had been assaulting his lady and a neighbor called 911. Police arrived and he met them at the door with a knife raised. They fired and had good aim. He had several felony arrests for assault, abuse, battery. It’s hard not to say, Fuck him. I feel boundless sorrow and sympathy for that woman and her daughter and the unborn child who lost their man. I have no remorse for a dead abusive asshole.
And if either of them had been slightly less dead, we would have worked the fuck out of them, trying to keep them alive, pull them back from death. It doesn’t matter how you got shot, or if you are an abusive shit, we will work to keep you alive. Unless you’re already dead. And then, there’s nothing we can do.

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