Merciful Armies of the Night, A Ride-Along with Paramedics
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)