|The camera rolls as emergency room trauma team goes into action.|
To be honest, I was hoping for something dramatic to happen in the ER that agreed to accommodate for a few nights my hanging around, asking medical staff and paramedics and patients questions and taking voluminous notes. Nothing much did. That is to say, a stream of patients came through presenting all manner of problems, but nothing over the top sensational occurred. I think I still managed a good story out of the assignment. You be the judge. The article appeared in The Reader (www.thereader.com) as a kind of companion piece to another story I did based on ride alongs with paramedics. You can find the paramedics story on this blog as well. It’s titled “Merciful Armies of the Night.”
ER, An Emergency Room Journal
©by Leo Adam Biga
Originally published in The Reader (www.thereader.com)
Hours of Boredom and Minutes of Terror
Hollywood portrayals of hospital emergency rooms depict white hot action zones where medical drama and staff intrigue continue nonstop. What’s a real ER like? Recent visits to the NHS University Hospital ER found a medical treatment center, social laboratory, educational classroom and last refuge all in one. An intersection where the gallery of humanity meets and various trends surface. A mission, a haven, a hell. Or, as one ER nurse put it, “We deal with the heart of Omaha here.”
Like many staff, nurse Susie Needham feels the ER is THE place to be on the frontlines of medical care due to its fluid nature, one she summed up as “hours of boredom and minutes of terror.” Unlike television’s ER, long tedious stretches can grind by before a single trauma arrives. Then again, a run of critical or extreme cases can suddenly pile-up, kicking a slow shift into high gear. As Needham put it, “From moment to moment, it can change.
Most people that work here are attracted to the fast changing pace and the variety of different patients we see. It’s never the same. You have to know a lot about a lot of different things, and that’s what keeps you on your toes. It makes it interesting.” On a Friday night in April Needham, a pretty freckled blonde with an impish smile, tended a diverse mix, including a bronchial pediatric patient with difficulty breathing, an adult drug abuser suffering withdrawal pangs and a drunk woman ostensibly there for stomach pain but whose battered body and frayed psyche told a more sinister story.
For the most part, ERs treat a procession of fevers, coughs, sprains, aches, cuts, bruises, breaks. Purely routine stuff. Unless it’s happening to you, of course. Since one person’s trivial complaint may be another’s dire crisis, everyone is treated the same. No condition is refused. Nothing is taken for granted. Trained to assess and treat serious problems, medical staff try first ruling out any life-threatening cause before looking at non-critical or non-medical issuses. Most ER medical staff possess extensive critical care backgrounds, but it seems all ERs (the step-child of acute medical care) are not equal.
On busy nights (Sundays are worst) patients stack up and long waits ensue. Triage nurses sort cases on an as-needed basis, with the severest seen promptly and the mildest set aside for a kind of walk-up window service, Fast Track. But again, unlike TV, where patients sweep through the ER unchecked, the real world entails staff documentation-communication for all patient admissions, treatments, releases. In terms of volume, University Hospital recorded 27,018 ER visits last year, a slight rise from 1998. Traumas typically account for about 3.25 percent of all cases.
Not long past dusk on St. Patrick’s Day things were unwinding surprisingly slowly in the ER considering this was a designated trauma night (meaning area rescue services were to feed trauma patients there) on a Friday holiday known for alcohol-related injuries. Earlier in the day, staff treated a 43-year-old Omaha man knocked unconscious in a bar fight. Michael Kimball was brought in comatose. Massive swelling in his brain forced doctors to remove his skull to relieve the pressure. (Editor’s Note: Kimball never regained consciousness and, two weeks later, was pronounced dead. Police cited insufficient evidence to file charges in the case.).
Hours later, during a protracted lull, staff lingered about “the hub,” the ER nerve center, bantering in the irreverent MASH humor used for stress relief. Attending physician Dr. Paul Tran made a colleague, Dr. Rick Walker, envious by describing his sound sleep the night before, a rarity after the rush of a nine-hour trauma shift. When not hanging at the hub or crashing in the staff lounge, docs, nurses, techs and residents use computers and charts to monitor the condition of patients in surrounding non-critical care rooms and trauma bays (a total of 16 beds), to track the progress of lab workups, x-rays or other procedures and to file paperwork. A large grease board hanging high on the wall is smudged with running patient status reports. This checks and balances system aims to avoid patient-bed-meds. mixups
The staff perked up that night at the static-filled emergency band radio (always droning on in the background) report of a CODE 3 (critical medical) case en route, with an ETA of five minutes. Staff are uncanny at hearing the calls headed their way and ignoring the others. The paramedic’s sketchy details described an elderly man who fell and hit his head outside a Bag ‘N’ Save. The man, whom paramedics found minus vital signs, had been shocked back to life. With the clock ticking, Dr. Tran, a slight Vietnamese native with a gentle bedside manner, conferred with colleagues on whether to summon the trauma team, a kind of in-house medical SWAT squad on call to treat the most severe critical care cases, or to handle things themselves.
It Never Gets Better
Dr. Walker, a beefy man whose pockets are invariably overstuffed with paperback novels and stethoscopes, has spent his entire medical career in emergency medicine. He said part of the appeal for him and others is the extreme nature of the work. “I think it’s very challenging, and that’s a large aspect of it. It’s also a big adrenalin rush, and as I’ve assessed my life and career I’ve come to the conclusion I’m an adrenalin junkie, and I think that’s probably what did it for me.”
He said being exposed to the tragedy that accompanies trauma extracts a certain toll:
“You see bad stuff happening here, and it’s stuff that, you know, can make you cry, like kids dying. It’s tough and it can really get to you emotionally, and so what you have to do is build up a wall because otherwise you’d be breaking down every time you saw something like that and you could not function. That wall tends to stay up most of the time and the last few years it’s become an issue in my personal life.” Nurse Jackie Engdahl said it takes a special breed to work there, “Oh, definitely, Type A personalities make good ER nurses. You have to be very aggressive…very assertive because of what you deal with. You deal with not only ill and injured people, but intoxicated people and drug-induced and psychotic people. You gotta love a good challenge and you gotta be strong enough to whip into shape when the going gets tough.”
For trauma nurse coordinator Kathy Warren, it’s a matter of staying focused no matter how horrendous the reality before her. “Some of these cases are just horrible looking when they come in. You just have to totally ignore that and focus in on the task, so whether you’re starting the IV or helping the docs with procedures, you detach yourself and just click into gear. You can’t get nervous. You have a job to do,” she said. Warren, whose job entails her dealing with family members, said staying composed is hard when working with parents who’ve just lost a child. “Sometimes I have to step back for a few minutes and take a deep breath. When I get home after a case like that, everybody knows its been a bad day as soon as I walk in.”
Added Susie Needham, “People think you get callous or something, but you don’t. Some of the things we see are heart-wrenching and no matter how many times you’ve seen them it still really bothers you. It never gets better.”
Things finally began heating up again on St. Patty’s Day once the Code 3 patient was wheeled in on a gurney by paramedics and lifted onto a bed in the T2 trauma bay. The heavy-set man of about 65 lay there in a coma, a breathing tube inserted in his throat and an IV snaked into one arm, his big hairy belly billowing up and down as a bevy of ER medical staff hovered over him to keep him alive. “I need, STAT, six units of platelets…” a nurse called out. “Tell respiratory to bring a vent, please,” called another.
Then, when someone barked, “I need another set of hands up here,” a tangle of arms belonging to eight nurses, techs and docs converged to perform, seemingly at once, multiple tasks, from hooking up a ventilator to running a blood pressure line to starting a new IV to drawing blood to attaching EKG electrodes. “Sir, there’s going to be a tube going down the back of your throat,” one of them said more out of habit than out of any expectation of a response. Lying there, totally exposed and vulnerable, his life completely in the hands of these angels of mercy, the man, referred to then only as John Doe due to a lack of ID, was an anonymous soul brought back from the very brink.
Time is of the Essence
Time is critical in trauma or near trauma scenarios like these. That night’s charge nurse, Scott Miller, said it involves quick, precise coordination and communication. “Everybody swarms in to get the job done as fast as possible. In a case like this you have Dr. Tran coordinating and everybody trying to feed information to him as to what they’re finding at the same time as they carry out his orders.”
When the whole trauma team is activated, a whole slew of specialists — from surgeons to anesthesiologists to radiologists to lab techs — converge on the spot, making teamwork even more essential. According to Kathy Warren, “You have a lot of people and everyone has a different role and, hopefully, they know their role so they’re not getting in your way and you’re not having to tell them everything. It usually works pretty well, and it’s amazing the amount of things that can be done for a patient in a short amount of time when you absolutely have to. But that’s what a trauma center is supposed to be able to do.”
Emergency care often starts with the rapid response of rescue squads on the scene. Paramedic Tom Quinlan was among those responding to the 911 call that found Doe lying unconscious. “He was not breathing. He didn’t have a pulse. So we started our CODE 99 (for clinically dead cases) protocol, which is intubate him, start an IV and do CPR. We ended up shocking him a couple of times. We finally got a pulse back and he continued to breathe for us on the way to the hospital,” he said.
Added Dr. Tran, “Time is of the essence here. After so many minutes, it doesn’t do any good, so it’s all speed and skill. The man probably experienced sudden death when his heart went into fibrillation, meaning it didn’t pump any blood and, so, the brain promptly became unconscious and he fell down and hit his head and only by actions of the paramedics did he come back. He was extremely lucky to have had everything done in that time, otherwise he would be dead by now.”
Dr. Tran said the fall resulted in “about a five-centimeter hematoma on the back of the head.” Since Doe was found unresponsive and bore a scar on his chest indicating a history of heart surgery, the question on Dr. Tran’s mind was whether the patient’s vegetative state was due to the fall or to some new cardiac event. Not wanting to overlook a potential cerebral cause, he called in part of the trauma team after all. As Scott Miller, explained, “We’re assuming now he had some sort of heart event that caused him to fall and hit his head. We will be doing a CAT Scan to make sure there’s not something else going on, like a big bleed in his head. We don’t think that’s the case, but you can’t always tell for sure.” Later, it was confirmed a cardiac event did trigger the trauma.
As for the long-term prognosis, Dr. Tran said, “I’m not sure of the condition of his brain function later on.” By then, Doe was identified and his family contacted by nursing resource coordinator Regina Christensen, who met with family members. Part of hers dutie entails fielding inquiries from news hounds looking for material. She noted with incredulity some sound disappointed when a case is upgraded from critical to stable condition.
When treating a trauma, there is no room for bruised feelings. The required care must be delivered NOW. Hashing out differences can come later. One of the reasons nurse Jackie Engdahl likes working in the ER is the maturity of the people working there. “When I worked in other hospital areas there were very clashing personalities and people always bickering back and forth. But here, it’s not that way. You say whatever you want to say to someone and then it’s over and done with. There’s never hard feelings.” And, she said, where some physicians resent or reject nurse input this ER’s docs welcome it. “The doctors here work really well with the nurses. The doctors trust our judgment and they really listen to us. They allow us to do a lot of things, which is nice.” What about departmental romances? “There used to be between the nurses and paramedics,” nurse Janie Vipond said. “It just depends on the group you have at any given time. But, yeah, it happens.”
I Felt I Was in Good Hands
Amid the controlled chaos of an unfolding ER trauma, staff attend to myriad details, not to mention other patients. For the trauma patient whose life hangs in the balance, it can be a surreal experience of wailing sirens, flashing lights, antiseptic smells, probing instruments, strange faces and endless questions. There is fear, confusion, agony. There is even a strange sense of peace. Beverly Harter, a 62 year-old wife, mother and grandmother, has been there. How she got there is a story in itself.
On May 16, 1999 the Logan, Iowa resident was attending a graduation party at the nearby trailer home of a daughter. Various family members and friends were present. The weather was threatening that afternoon. When the sky turned ominous and a tornado warning sounded, the 12 partiers fled the trailer for their cars in an effort to outrun the storm. But it was too late. With a twister bearing down, they left their vehicles to take refuge in a roadside ditch. Huddled on the ground, exposed to the savage winds, the group was deluged by parts of farm machinery ripped asunder in the cyclone and propelled like shrapnel. The metal shards rained down on them, tearing skin, cracking bone, crushing organs.
When it was over, Beverly’s daughter was dead and two grandkids, both injured, left motherless. Her son endured a broken clavicle. A family friend died. As for Beverly, she suffered a punctured diaphragm, a perforated bowel and two crushed vertebra. Her house was leveled. Ironically, the trailer escaped unscathed. Transported by a local rescue unit to Missouri Valley, Beverly was then taken by ambulance to the nearest trauma center, the University Hospital ER.
Beverly, who remained conscious during much of her ordeal, did not have to be told she was badly hurt. “I knew I’d suffered spinal cord damage because my legs were on fire, and they stayed on fire.” she said. She also knew her daughter “was gone” and other loved ones injured. As for her Omaha ER odyssey, she recalls “bright lights,” a sense of “time standing still” and “a lot of people doing a lot of things and asking a lot of questions. I was really hurting and kind of fading in and out from the sedation, but I was able to answer a lot of questions. They explained to me what they were doing at all times, and that was reassuring.”
Indeed, despite her pain and grief, she recalls feeling calm. “You just have a sense that everybody’s taking care of you and that they’re all working together doing their jobs. I felt I was in good hands.” She also felt the staff’s compassion. “They were extremely sensitive and caring and protective about what happened to me and my family. They knew the devastation and loss we had. I was just overcome by their concern for our well-being,” said Harter, who today is confined to a wheelchair.
Kathy Warren said she used to doubt whether the time she spent with families who suffered a loss made a difference until her own father died in the hospital and she found comfort in the support her colleagues gave her. “I realized how important it is to have somebody treat you with kindness and to let you grieve however you want to and to explain things to you. Ever since then I’ve really pushed staff here to sit down with families and to talk to them. It’s not an easy thing to do as a medical person. Some people are better than others. But people don’t expect us to be super men and women. To save everybody. They just need us to be there.”
Not all exchanges are so pleasant. Patient complaints over long waits get expressed along the sarcastic lines of, “I’m sure glad I wasn’t dying.” Before things get nasty, staff try defusing the matter. “The basic strategy is to make them see you as being on their side,” said Dr. Bob Muelleman. “On the other hand, you want to be very much in control of the situation. If it’s just a matter of them yelling and cussing at you, well, that pretty much comes with the territory. Once in a while there’s kind of a thrashing or flailing out. If you think there’s the potential of them really getting violent you can call in security or police, but normally you can handle it on your own.”
When care complaints cannot be appeased, they are passed-on, in writing, or addressed on-site by managers like Regina Christensen. “It can be anything from somebody upset that their mother’s IV is out to something as complicated as a gang-related situation where the patient himself or his family is threatening staff. It’s just an array of things,” she said.
The Truth is Stranger Than Fiction
Meanwhile, back on St. Patrick’s, a drunk middle-aged woman involved in a domestic dispute came in with an aching gut. However, the night’s triage nurse, Susie Needham, recognized bruises and marks as signs of physical violence and sexual assault. After questioning the woman, a horrific tale of prolonged torture and bondage emerged that prompted ER staff to follow procedure and report their suspicions to police. Acting on the medical staff’s input two officers, who earlier arrested the woman’s boyfriend on misdemeanor assault charges, returned to open a rape investigation.
According to Needham, “If people come in here with traumatic injuries that don’t really fit their stories, we call the police.” Often, she said, such patients prove to be victims or perpetrators of a crime. Surrounded by staff and police in a room concealed by drawn curtains, the woman cried out, “I can’t take it anymore. I don’t want to take it anymore.”
After examining the woman a visibly shaken Dr. Tran said, “It’s one of the most remarkable cases of domestic violence I’ve ever seen. She has multiple problems. Number one is domestic violence and sexual assault. Number two is chronic alcoholism. Number three is a low platelet count. Number four is what appears to be an upper GI bleed.” As part of hospital policy in such cases, staff called in a domestic violence-sexual assault counselor to apprise the woman of her rights and refer her to appropriate community resources. But, as ER staffers say they’ve seen far too many other victims do, the woman rejected police-medical entreaties to undergo a forensic exam, something required for a criminal inquiry, and declined pressing rape charges. She was admitted and treated for medical problems.
“What do you do?” a frustrated Needham asked. “That’s tough,” Dr. Tran said, “because once enough time passes, the evidence is lost. We can’t do anything. You have to respect the patient’s wishes. Patient autonomy is everything. Why did she refuse? Oh, fear, love rejection, sensitivity. Who knows? Unfortunately, it’s common.”
Bizarre, believe-it-or-not episodes are also common in the ER. Take the time an obnoxious drunk showed up with a fierce but inexplicable pain in his belly. After sleeping it off, he staggered up from his cot and only then did the ER doc notice a speck of blood, on the sheets, which upon closer inspection turned out to be from a tiny hole, splayed by burn marks, in the man’s back. Apparently, he had been shot but was too drunk to recall it. Sure enough, an x-ray revealed a bullet lodged in the abdomen.
Or, take the time a stabbing victim arrived cut entirely from stem to stern, his entire rib cage exposed, yet conscious enough to describe the whole bloody fillet job some whore performed on him. Or, the time a man fell at home on a fireplace iron and walked in the ER with a small wound on his neck which, upon further exam, proved to be a deep puncture penetrating his cervical spine. For Dr. Muelleman, who treated all these cases while working in a Kansas City, Mo. ER, such incidents fall under the heading of “the truth is stranger than fiction.”
Perhaps the most frustrating cases are those involving entirely preventable injuries, especially those incurred while victims engaged in some high-risk, reckless behavior, like a young man Dr. Muelleman treated in Omaha who crashed his car while out joy riding and ended up paralyzed from the neck down. “I don’t call them accidents anymore,” he said, “because an accident suggests an act of God. I call them injuries because when people put themselves in these circumstances something is going to happen that didn’t have to happen.”
As ERs are traditionally the 24-7 stop-gap or catch-all of American medical care, the entire spectrum of need shows up there. In most public hospitals, no one is turned away, regardless of insurance status or ability to pay. “The emergency department is the safety net for many people seeking care who really have no other place to go, said Dr. Paul Tran. “Admittedly, there’s going to be abuse of the resources because this is reserved for emergency cases, but who’s definition of emergency is it? A toothache at 2 a.m. may be an emergency to you, but it may not be to someone else. We are here to take care of people from all walks of life and with conditions as minor as a toothache or as serious as a heart attack. And from that standpoint, it is very satisfying to provide people the last resort they need and to get the instantaneous gratification of turning them around.”
Given its open door policy, “the ER is where you really see the cross-section of humanity and so, if there are social ills, you seem them in the ER,” Dr. Muelleman said. “Some of the ills we deal with are domestic violence, drug and alcohol issues, child abuse, lack of immunization and lack of access to health insurance. Another segment the ER picks up on are the acute psychiatric and homeless populations.” He said in an era of managed care, ERs play an increasingly large social service and public health role. “
So, if we’re dealing with intoxicated people we try to get them in a shelter or detox center. If it’s an abuse case we bring in social workers, police and protective agency professionals. If we’re dealing with domestic violence, we make sure patients understand the resources available to them.” Nurse Scott Miller is “troubled” by how many kids he treats who “are not well cared for” at home and “very frustrated by the large number of people with legitimate psychiatric problems who can’t get seen” due to a lack of psychiatric beds locally. He said, “I’ve spent many hours fighting on the phone, calling medical staff at home, to get people admitted in the hospital when they don’t really have a medical problem. But when no psychiatric place will take them, we can’t just send them home.”
Dr. Muelleman said where ERs have always tried educating patients about prevention safeguards and optional resources, “Some have gone to the extent of smoking cessation and substance abuse counseling. I’m just reviewing a grant for a hospital to screen Type II Diabetes, which is not something you’d traditionally think of as an ER doing. There is a real move toward ERs getting involved with public health, even things like bike helmet giveaways. Some have even gone as far as to give pneumonia and flu shots. Even here, during seat belt awareness week, we do educational stuff to let people know about the importance of seat belts.”
As a survey of ER web sites will attest, there is debate in the medical community over the all-encompassing role of the ER. On this subject, Dr. Muelleman takes a pragmatic position. “You can’t select why people use the ER. Once they’re here, you can’t ask, Why are you here again?, although you may be tempted to. I mean, I support the notion public health policy in America should be changed to help take care of people’s health needs in a more comprehensive fashion than just having them go to the emergency room, but given that’s not the case, the mantra in the ER continues to be — anybody, anytime, anything. That’s exactly what it is. Should we change medicine so that doesn’t happen? Well, yes, we should, but in the meantime we’ve got to do what we can to help people.”
- Some ERs post wait times by text, billboard (msnbc.msn.com)
- Newly Insured are Likely to Congregate in Emergency Rooms (prweb.com)
- Timesunion.com: If it’s an emergency, they’re on the clock (timesunion.com)
- Text Your Way To a Short Emergency Room Wait [Medicine] (gizmodo.com)
- Lengthy waits in local ERs (windsorstar.com)
To date, the only ride along I’ve done as a journalist was for this story following paramedics. I enjoyed the challenge of reporting and scene description the assignment presented. It’s the type of project I do from time to time in order to push myself out of the comfort zone I sometimes get stuck in. The story, which originally appeared in The Reader (www.thereader.com), was meant to mimic and ultimately transcend the television and film depictions of first responders. Perhaps I’ll do a ride along with police officers or detectives sometime. A companion piece of sorts to this one is also posted on the site — a report I filed based on a few nights observing things at an ER.
©by Leo Adam Biga
Originally published in The Reader (www.thereader.com)
The Paramedics Corps
Cutting through the humid summer night, Medic 21 is a rattling five-ton metal box of thunder-on-wheels. The Omaha Fire Department (OFD) rescue squad rushes to another emergency on the near north side. Flashing red, yellow and blue lights pulsate with the same urgency as the wailing siren’s cry that help is on the way.
Two licensed paramedics are assigned Medic 21 on the C shift: Capt. John Keyser, 38, a fair-haired, well-chiseled 12-year veteran of the OFD and Kathy Bossman, 28, a pretty brunette in her third year on the force after a short stint with the Lincoln Fire Department. Partners since last October, the pair work out of a firehouse at 3454 Ames Avenue, one of nine stations in the city housing rescue squads alongside fire engine companies. Anymore, every Omaha firefighter is trained in at least basic Emergency Medical Technician (EMT) skills. Some own intermediate or EMTI ratings. Others, like Keyser and Bossman, are full-fledged paramedics with the most rigorous Advanced Life Support (ALS) training on the force. Paramedics are usually attached to rescue squads, although some serve on fire rigs.
The OFD paramedics corps numbers 147, nearly triple the total from five years ago. Omaha Fire Department Emergency Medical Services (EMS) Battalion Chief Jim Love said this planned jump in personnel came in response to an increasing workload caused by an ever-expanding city: “Last year our medic units responded to 23,558 calls for medical assistance and transported 16,400 of those people. The year before, we responded to 21,272 calls. Our calls are growing at a rate of 4 to 6 percent a year. The population is not only getting larger but it’s getting older, so we’re seeing an increase in the elderly and their associated medical problems.”
Paramedic training is intensive, entailing some 1,000 hours of classroom and field experience, including interning in clinic (hospital) settings and on ride-alongs. A more rigorous curriculum is being implemented in 2001. Omaha EMS Chief Medical Director Dr. Joseph Stothert, head trauma surgeon at NHS University Hospital, said today’s paramedics are more skilled than in the past: “They have better education and better quality assurance in place and I think generally the care in the streets is much better than it was 10-20 years ago. Not only are they able to do more, but they are able to understand more and sort out what’s going on with the patient and to begin treatment before they reach the hospital.” He said things have progressed to the point that medics follow protocols or standing orders to guide their assessment and care in the field where before they called hospitals and awaited orders via radio phone. “Through the years I think the level of confidence has increased in the paramedics because of their training,” he added.
Here I Come to Save the Day
As the gleaming ambulance barrels through traffic (most of which parts to let it past) to the scene of an emergency the vibe inside the squad is part thrilling and part somber as the laconic medics steel themselves for whatever crisis awaits them. With their hearts racing, they are like soldiers driving into a battlefield. Their reactions must be swift. Their minds sharp. As they run through routes and protocols in their head, they keep an eye out for rogue motorists and cock an ear to the radio for updates. They take seriously their role as rescuers. Theirs is a single-minded mission of mercy — responding to a frantic plea for help. It can be anything. A diabetic reaction. An asthma attack. A cardiac event. A gun-shot wound. A personal injury accident. Poisoning. Heat exhaustion. Childbirth. It can be anybody. A child. An adult. Someone hurt in a car, on the street or in their own house. It can be a cop or fellow firefighter, victim or assailant, average citizen or public figure. You name it — these professionals have seen it in the line of duty.
Medics pull 24 hour shifts and no matter when the 911 call comes in — the middle of the night or the fat of the day — and regardless of what it is — a routine health problem or a genuine medical crisis — they show up ready to lend aid. Even when driving conditions stink or the medics are starving sleep, they respond the same. There is a temptation to view them as heroic Calvary riding-in to save the day. That is not how they see themselves, however. “I certainly don’t feel like any knight in shining armor. We’ve just doing our job,” Keyser said. “I really do enjoy helping people. That’s probably the biggest reason why I chose this profession.” His partner, Bossman, added, “It’s nice to be able to help people and to be able to change their life or improve their life in some way. Every time they call us it’s an emergency to them. They appreciate us being there, and that’s a good feeling.”
The anytime-anything-anybody drama of the job is one of its major draws. Even though most runs are routine, no two are ever quite the same. “One of the most appealing things is the excitement,” Bossman said. “It’s a big adrenalin rush. When you get the blood and guts, it makes it more exciting and interesting. You know you’ve got to step it up. You’ve got to move faster. You’ve got to get more things done. You’ve got to use all your skills and training.” Said Keyser, “One of the reasons I went into this is because it’s very challenging. The sleep deprivation is hard to deal with and the stress level is very high.” That stress — of being on call all hours of the day and night to make emergency medical interventions — has a flip side too. “You can get too wrapped up in this job. If you let the pressure and stress mount, all it does is kill you a little bit at a time. That’s why I’ve always thought one aspect of being a good paramedic is recognizing when you need to get away from it,” Battalion Chief Love said. Field medics like Keyser know the demands can overtake them if not careful. “I’ve got at least another 12 years on the job, but I don’t want to be on the rescue squad that long because I don’t want to get burned-out. After a 5-day rotation, I’m exhausted. I have a wife and three kids I want to enjoy,” he said.
On the Run
Medic 21 is among the two busiest EMS units in Omaha. It annually vies with Medic 40, at 45th and Military Avenue, for the title of most runs. The unit is responsible for a wide swath of Omaha — from Bedford Avenue north and from the Missouri River to 72nd Street west. Given that Medic 21 serves a low income area, some residents rely on the EMS system as a mobile clinic and taxi service. “In our territory we seem to have a lot of patients who don’t have transportation to the hospital, so they call 911 even if they have the flu. You treat them the same even though you’re frustrated because it’s 3 in the morning and you’ve seen this patient before and you know there’s nothing seriously wrong with them,” Bossman said. “We tend to see a lot of really young mothers who don’t know much about caring for their kids. We try to educate them a little.” Then there are the repeat customers. “We’ve got quite a few regulars. Most have legitimate medical conditions, but some don’t necessarily take care of themselves very well. They don’t take their medicines like they should and that can worsen their condition.”
Jim Love was a firefighter-paramedic on the streets before taking a desk job. He worked out of Station 21 and said his field experiences there opened his eyes to some things. “I didn’t realize the abject poverty that exists in certain parts of our city until I actively went there, walked into these places, took care of these people and transported them to the hospital,” he said. “I mean, I’d seen poverty on TV and read about it in the newspaper, but until you actually touch it and work with it, you really can’t imagine. For lots of people, we’re their source of medical care. They don’t go to doctors.”
With 3,113 runs made last year by its three crews, Medic 21 is the reigning champ among Omaha EMS units. Through August Keyser and Bossman are averaging 9 runs per 24-hour shift and are 50 ahead of last year’s pace, but on this day (August 10) they are still awaiting their first more than half-way through their shift. “This is highly unusual,” Bossman said. “That’s the thing about this job. A lot of times you’re waiting for something to happen and other times you leave the station and then don’t get back for six hours,” said Keyser. No sooner do the words leave his mouth than an alarm sounds on the overhead speaker alerting personnel to a rescue call. Keyser and Bossman clamber aboard the squad, fire up its engine, roll out of the garage and tear onto rush hour-choked Ames Avenue. With Keyser manning the wheel and Bossman the radio, a 911 dispatcher relays the nature of the call. “Medic Unit 21, there’s a 90 year-female with difficulty breathing…a neighbor became concerned when she didn’t her from her…called police…the female was found on the floor…apparently fallen…police are on the scene.”
Lady in Distress
Less than 10 minutes elapse from the time the call is received to the medics’ arrival on the scene. It is a red brick apartment house at 52nd and Northwest Street. Police cruisers and a fire engine are already there. Curious neighbors and onlookers gather on the small porch or watch from the street corner as Keyser and Bossman stride into the residence carrying an arsenal of emergency medical supplies, including a portable heart monitor/defibrillator and a case filled with meds, IVs, airway supports, bandages, slings, etc.
Police deny access to a reporter along for the ride, citing the tight quarters. The officer guarding the front door, Juan Fortier, describes the situation while Keyser and Bossman treat the elderly patient inside. “A friend hadn’t heard from the resident since Tuesday night at 8. She came by, hollered for her and got no response. She tried entering, but the inside chain was locked. So she called us. We came, we assessed the situation, notified our supervisors what we had and we decided to go ahead and force the lock open. We got inside and the 90 year-old resident was lying on her back on the floor next to her bed with one leg kind of folded up under her. She was still conscious but somewhat discombobulated. She had obviously been there awhile. We just tried to comfort her with our voice and let her know help was here,” he said. Police and rescue squads respond to several such calls each week. Most turn out fine.
Minutes later, firefighters hustle to fetch a backboard and gurney and soon are carrying the patient out on the stretcher, a bag valve mask applied to her mouth, and secure her in place on the squad. With the patient, Olive, designated a CODE 3 (critical condition) Keyser and Bossman tend to her in back while a firefighter takes the wheel. It turns out Olive lives alone and has no family in state. The only prescribed medication found is for some unknown cardiac condition. In cases like this, when a patient cannot provide answers and there is no family member to consult, medics lack basic information to complete a patient history.
“A big part of our job is information gathering,” Keyser said. “Our first job is to assess the patient and determine if there’s a life threatening situation. Then, the most important thing is to find out the history of what brought this person to require our care. We try to get as much of the history as we can for the doctors.”
Firefighters often reach a scene first and provide care up to their level of training. Once medics arrive to take over, firefighters remain to assist — providing extra sets of hands and eyes. This team concept is at the heart of EMS. “Most of us have worked together for a long time and everybody knows what needs to be done,” Keyser said. “Firefighters will get a stretcher or set-up an IV or get oxygen going. If we don’t see it being done, we’ll ask for it.” Bossman added, “The firefighters we work with are real good about helping out. They’ll jump in and do whatever needs to be done.” Love said having EMT-qualified firefighters on-site is essential to the continuum of care that extends from pre-hospital settings to the ER. “The important thing about having EMTs on the fire trucks is that not only do they get there quickly, but they take base-line vitals which give the paramedics something to compare with when they take their vitals. It gives us another indication as to whether the patient is getting better, getting worse or staying the same.”
In critical or trauma scenarios, time is everything. “We’re always racing the clock,” Love said. “Our goal is to get somebody to the patient’s side with at least basic level training within 5 minutes and to get someone there with advanced training within 8 to 11 minutes. We try to reach those goals at least 90 percent of the time.” According to Keyser, “Depending on how critically injured that patient is, their best survivability is if they can be treated in the ER within an hour of their injury. It’s called the Golden Hour. We try to get everything done we can in 10 minutes before the patient is loaded on the squad and we’re on the road to the nearest trauma center. We’ll do everything else en route.”
In Dr. Joseph Stothert’s view, “For about 90 percent of the patients paramedics see, their care is absolutely vital and life-saving, including persons in or near cardiac arrest and persons involved in (serious) motor vehicle accidents. Now that there is a defibrillator on every fire and rescue apparatus, there’s been a steady increase of patients we’ve been able to resuscitate earlier.”
With Olive in tow, Medic 21 speeds to the nearest hospital, Immanuel Medical Center, as Keyser radios her condition: “We’ve got a 90-year-old female who has been down apparently since…” During the bump-and-grind ride Olive is dimly conscious. She cannot speak, responding to questions with only her tired eyes or feeble nods of her head. “Can you point for me where it hurts?” Keyser asks. “Olive? Olive, we’re going to give you some nitro on your tongue. Your lungs are full of water. I want you to lift your tongue up for me. There you go. Good girl. Here it comes. Open wide.” Olive weakly responds. Her mottled face is splayed by vomit and pinched in pain. Her eyes close. She is barefoot. Totally vulnerable. Her vital signs are continually taken and any abrupt changes noted. All the while, Bossman comforts Olive by holding her hand and applying pressure to a bag valve mask over her mouth, timing her squeezes in concert with the patient’s inhalation.
“For the short amount of time you’re with patients you just want to try to do something positive. Sometimes, that’s nothing more than holding their hand and talking to them while you’re riding to the hospital,” Love said.
Keyser tries getting Olive to respond again (“Olive, we’re going to help breathe for you, okay? Olive, can you open your eyes again?”), but she has fallen unconscious. The medics scramble to intubate her with a breathing tube and suction out excess fluid clogging her airway. Amid the cramped space the medics handle equipment and perform procedures in a kind of choreographed dance. They anticipate each other’s moves well. Few words need to be spoken. They work with calm precision and dispatch, forming what Love likes to call “a fine-tuned patient care machine.”
Later, after delivering Olive to the ER, Bossman recaps the run. “She had fallen out of her bed and was on the floor since Tuesday night. She was already dehydrated. She’d been vomiting and had it in her mouth and in her lungs. That caused her to choke and quit breathing. It could have been real bad. If her neighbor hadn’t checked on her and called the police she could have choked to death. She got a little bit worse en route. She quit responding, although her vital signs stayed pretty good. We intubated her to clear her airway. She’s actually pretty stable now. Her airway’s secure. She’s getting plenty of oxygen. They’re going to x-ray her to make sure she didn’t injure her back when she fell.”
Breathing difficulty is a call medics often respond to and make a life-saving difference in. “Outside of critical emergencies, the assessment and treatment of airway problems is where they tend to help people the most, such as people with asthma or people with chronic airway diseases,” Dr. Stothert said. Medics also routinely help diabetic reactive patients make dramatic turnarounds.
Heeding the Call Again
After its crew restocks supplies and completes paperwork in the ER, Medic 21 no sooner pulls out of Immanuel when a new call presses them back into service. It is a new mother seized by severe back pain. The squad heads east and in no time at all reaches the wood frame residence near 46th and Bedford, where a fire engine crew is present. The petite patient, Sandy Dace, sits in a kitchen chair doubled-over in a spasm of pain. Her tall bearded husband Dennis stands over her, holding their red and wrinkled 5-day old baby boy in his arms. At the bottom of a staircase a boy of perhaps 8 peers with wide-eyed wonder and fear at the rescuers tramping in and out. It turns out Sandy underwent a prolonged labor marked by acute contractions, before a Caesarean section was performed. It is thought her pain is related to the childbirth.
“I got up to go to the bathroom when I heard Sandy crying. I found her just like that. She couldn’t get up. And with him (the baby) here, I had to call somebody. It was maybe 40 seconds before I heard the sirens. It was great when you showed up. You guys are excellent,” Dennis tells the medics. As he follows his wife to the door, he says, “I’ll be up at St. Joe’s as soon as your mom gets here. Okay, dear?” “Okay,” she replies through clenched teeth.
En route to St. Joseph Hospital Sandy grimaces with each jolt during the shake-rattle-and-roll run. She tightly clutches the handles at the side of the gurney to brace herself. “It’s kind of a bumpy ride, so we’ll take it easy on the way there,” Bossman tells her, but while the ride proceeds at a slower than normal pace it is just as jarring as ever. Dace remains stoic, only uttering a sound when answering Bossman, who tries taking her mind off her discomfort with easy chatter.
Built on an unforgiving truck frame, rescue squads are notoriously noisy clatter-traps that ride like bucking broncos. Many have been in service for a decade or more. It is not unusual for odometers to read 100,000 plus-miles. And those are hard, stop-and-go miles. Units often break down with a wide array of mechanical problems, forcing even older, less reliable reserve units into service. “Our rescue squads are on their last legs,” is how one paramedic put it. With so much wear-and-tear, it is no surprise then that perhaps the number one complaint by customers is that “the ride is terrible,” said Love. Squads are nicknamed “puke boxes.” Three brand new units were purchased recently (for $117,000 each) and their increased size and smoother ride makes medics stuck with older models rather envious.
The squad transports Sandy Dace to the ER just before 7 p.m. and by the time Keyser brings the empty gurney back out, a LifeNet helicopter lands to stretcher-in a middle-aged patient critically injured in an industrial accident. As for Dace, she is logged in as a CODE 1, which signifies no real medical emergency and no treatment performed in the field. She simply gets a check-up in the ER.
Stories from the Frontlines
On the way back to the station, the medics make a fuel stop at a City of Omaha depot where broken-down cruisers, squads, rigs and plows are warehoused for repairs and spare parts in what is known as “the boneyards.” Life at “21s” or any firehouse is a communal thing. Except for captains, who rate their own rooms, everyone, men and women, share spartan dormitory-style sleeping quarters. It is a high testosterone environment. We’re talking big men wielding axes and saws and handling mammoth rigs.
As the lone female (one of 20 among 600-plus fire division field personnel) Bossman is still something of a curiosity. While a Clint Eastwood pic plays on a big screen TV in the rec room, she explains how it takes a certain kind of woman to thrive there. “If you’re the type who gets real upset at a crude joke, you’re not going to last very long. You can’t be overly sensitive to those things. You just have to go with the flow.” She said when she started she was subject to a “feeling out” process that closely scrutinized her ability to handle the job and to be, “one of the boys,” in effect. “Once they saw I was okay with their cracks and I could pull my own weight, then there was no problem.”
Down time is variously spent doing paperwork (a detailed record of every run must be logged in a book and on the computer), washing down or cleaning out rigs, rapping with the guys, grabbing a bite to eat, zoning out in front of the TV or catching some Zs. When a visitor asks Keyser, Bossman and Love to share some stories from the frontlines, they gladly oblige. Like other EMS professionals, they say the toughest cases usually involve children.
“I remember the first SIDS (Sudden Infant Death Syndrome) case I ever went on. At the time I was an EMTI with a little baby of my own, so it really kind of hit me hard,” Keyser said. Bossman recalls a CODE 99 (CPR in progress) case. “What was thought to have been a SIDS baby was revived but it never regained consciousness. It later turned out to be a shaken baby. That had an impact on me because in the ER I was comforting the mother and father and, later, when I found out it was (allegedly) the parents that had done this to the baby, it really bothered me,” she said.
Suicide runs are hard to forget. “You go there and, of course, there’s nothing you can do. You call the police and while you’re waiting you see pictures on the wall of family and friends. It hits home that this was a human being that had a life. It gets you thinking, What got them to the point they felt they had to do what they did? Those are the ones that really stick with me.” Love said.
Bossman said a disturbing run she and Keyser made was to the residence of a man with critical pulmonary edema. “It appeared to be treatable when we first got there,” she said. “At his house he was talking to us, but then he went downhill real fast in the squad. And at the hospital, despite everyone’s best efforts, he died. Sometimes, despite a perfect treatment, the patient may still not make it. It can change at any time. That affects you because you see this person getting worse and worse, and you want to help them, but you can’t…Over time, I guess you just learn that regardless of what you do the outcome is sometimes out of your control. It’s kind of hard.”
“Bad runs” of this sort often prompt a Critical Incident Stress Debriefing or CISD, an informal talk therapy session for every EMS staffer at the scene. The fire division’s chaplain, Rev.. Chuck Swanson, leads the sessions. Select cases are also chosen for run reviews, where crews and supervisors analyze what went right and wrong.
Ready for Anything
At 8:50 that August night, the crew’s brief R & R respite is interrupted by another call. A young woman has dislocated a shoulder fending off an assailant near 24th and Camden Avenue. She screams in agony, “Oh my God. It hurts. Oh my God.” The police are there sorting out the incident. “They’re are always a welcome sight to us,” Keyser said. The patient, tears streaking her face, screams all the way to Immanuel. This is the first in a series of four straight runs Keyser and Bossman make that evening. Next, it is a young asthmatic, Reggie, with difficulty breathing. He’s tried his inhaler, but it’s brought no relief.
The medics arrive at his house and find a scared little boy struggling for breath. They administer Albuterol with oxygen. He breathes easier but a trip to the ER is advisable. Aboard the squad an IV is started. The medics calm the boy down, assuring him how brave he is. Calming kids is “half the battle,” say the medics. When Keyser asks “Have you ever ridden in an ambulance before?” Reggie replies, “Yeah,” and reminds them they treated him once before — for bruised ribs. On the way to Immanuel a much-improved Reggie points out the rear squad window, shouting, “There’s my mom,” waving to her following closely behind in the family van. Upon arrival at the ER a relieved Reggie announces, “I can actually talk now.”
The last two runs are routine. A woman complains of a host of problems, including difficulty breathing. She is quickly stabilized with oxygen, yet continues acting distressed. Her husband explains, “She gets like this when she’s upset.” It seems the couple had been arguing. The patient declines a trip to the ER. Later, Keyser attributes her symptoms to anxiety, which he said can mimic many medical conditions. Then it’s off to an assault call only two blocks from the Medic 21 home base. Police surround the victim lying in the middle of Ames Avenue. The intoxicated man has been beaten about the face by two or three assailants and has suffered cuts and bruises. Keyser and Bossman dress his wounds and take him to University Hospital. He smells of alcohol, sweat and blood.
By the end of the run it is around midnight and the medics are ready for a break. “When you’re super busy or you’re up many times over the course of the night you’re sleep deprived,” Bossman said, “and that just makes your reaction time slower. You have to think longer and harder about decisions that during the day might come real quick. That’s when it’s helpful to have a good partner. You work together and figure things out.” When a call awakens crews from a sound night’s sleep it is not uncommon, Keyser said, for hazy mates to slam into doors or each other amid the darkness and the mad dash that ensues to reach a rig or squad.
The wee hours find medics intersecting a surreal scene of crowds hanging out in parking lots or cruising the jammed streets. “It’s a different world down here at night,” Keyser said. “Once, we saw a family pushing a baby in a stroller at 2:30 in the morning.” Added Bossman, “It’s odd. There’s bumper-to-bumper traffic. We somewhat gauge how busy our night is going to be by how many people are out.” At time like these the intrepid medics are urban explorers in search of their next adventure. “It’s always something different,” she said. “Part of being a professional is being ready for anything.”
- Paramedic Saves Baby’s Life by Improvising Incubator with a Plastic Bag (neatorama.com)
- Many EMTs’ papers faked (boston.com)
- Paramedics frustrated by restrictions (cbc.ca)
- What sort of first aid do paramedics have (wiki.answers.com)