Lights Out

Death is not like a light switch.

I was thinking today about a few of the more interesting events I've witnessed in the back of an ambulance (or at the scenes it takes me to). It got me contemplating the way we go.

I've always been with the crowd that says when the lights are out, the party's over. There's nothing else. We are, and then we aren't. It's my hunch more than a strong belief and of course there's no way to know if I'm right until my own lights are turned out. I'm in no hurry to find out.

Just because our lights can go out doesn't mean we run like a light bulb. The one thing I've noticed is that death isn't a black and white deal. Life for us carbon based organisms is not binary -- not simply on or off. Life is messy and death is not a light switch; it's total system failure. We shut down part by part.

Sometimes, we kind of coast to a stop, slow and easy. Other times, we have a catastrophic breakdown that causes a chain reaction. It's those catastrophic malfunctions that I deal with most often and I'm constantly amazed how common it is for part of the body to fail while the rest of the body ticks away completely unaware that it's already dead.

I've watched a couple of sudden cardiac arrests happen right in front of me. In both cases, the victim didn't know he or she was dead until I pointed it out.

I didn't exactly say, "Hey, do you know you're dead?" Instead, I asked both of them if they felt OK after I saw the heart stop beating on the EKG monitor. She was in the middle of telling me about her recent vacation cruise and was still talking when I interrupted her.

Patient: "...so we had a great time and came back just Thursday night. It was fun, but I didn't like the food all that much. I did get to eat as much as I wanted, though."

Me, looking at the fact that during the last ten seconds, her heart hasn't been beating: "Are you feeling OK?"

Patient: "Ummm..." (eyes roll up in her head and she shudders one last time)

Me: "Sorry I asked."

The second time it happened was just six months later. This time I had a grandpa and his grandson in the back with me. He was feeling pretty crappy and didn't talk much.

Me to the grandson: "So, what are you gonna be when you grow up?"

Grandson: "The President."

Me: "Oh. You're not planning on doing too much with your life, then?"

The hospital RN on the radio interrupts, and I start telling her what's going on. The report is a couple of minutes long. I'm near the end of it when Grandpa's heart decides it's done.

Me: "...started an IV and given nitro and aspirin. I'm just about ready to give him some morphine for the pain." I notice Grandpa's heart is no longer beating, but Grandpa is still looking at me. I continue on the radio. "Susan, my patient just coded. I'll have to call you back." I toss the radio down and look at the patient. "How are you feeling?"

Grandpa: "Arrrggghh..." He has a seizure.

Me (Note to self: stop asking the dead patients if they're OK) to the grandson: "Do you ever watch medical shows on TV?" I'm now digging the defibrillator patches out of the EKG case.

Grandson nods his head.

Me: "You ever see them shock somebody on those shows?" I'm now peeling the backing off the patches and placing them on Grandpa. "You know, they say 'clear' and then the person kind of jerks?"

Grandson nods his head.

Me: "I'm gonna do that to Grandpa right now, but it'll be alright."

Grandson closes his eyes (good call, kid).

It worked, but Grandpa was about as Hollywood dramatic as I've ever seen a patient when they get shocked. He found me several months later and thanked me with a big hug.

Many times I've witnessed death in progress and it's never been an on-off switch. It's a system shut down, kind of like when you log off your computer. Or, when the power goes out. It doesn't happen everywhere all at once; it's more of a block by block, city by city, state by state kind of thing, the messiness of total system failure.

Are You Myopic?

It means nearsighted, but I'm not asking about whether you can read roadsigns without glasses. I'm wondering if you can see past the nose on your own face when it comes to understanding what others are doing and thinking.

When you are interacting (read: arguing) with others, do you see their point? Do you get where they are coming from?

I posted a few weeks ago about my epiphany regarding heroin addicts. I have become convinced that ice down the pants must work sometimes to wake up those narcotic overdoses that we don't get called on.

I also believe that convalescent home nurses always say the patient isn't their normal patient because it's true. How often do we pick up nursing home patients and get the same line from the nurse? Maybe, just maybe, it's because that's the most common reason for a convalescent home nurse to call an ambulance.

Just do the math. There are a lot more nursing home patients not going to the ER than there are patients going to the ER. Why? Because the vast majority of the patients have the same caregivers today that they've had for the last 3 months.

I was in a heated discussion today about customer service and work ethic. The person I was talking with believed that the current lack of work ethic commonly viewed in our society's younger workforce is a problem with the workers.

Maybe not.

I've always thought younger -- newer -- workers learn how to behave by emulating their older peers. It's the reason my daughter, a baby air traffic controller, and my son, a fairly new Army medic, think it's cool to complain about their jobs all the time -- even while they love doing them. Because they're mimicking the older, more burned-out crowd.

So if newer workers are looking to their older counterparts to figure out how to act, aren't they also taking cues from their employers? Doesn't corporate culture figure into the equation?

If an employer does only what's necessary to fulfill a contract, doesn't that give its employees the impression that the minimum is all that's expected? Haven't we all heard bosses complaining that employees don't do anything without being asked?

What message does that same boss convey when he refuses to refund a broken product because the customer was a day late returning it? The absolute minimum, folks, that's all we need to do.

That's what I mean by myopic. Are you looking at the world only from your own point of view, or do you see how things look from the outside in? The next time you complain about other people being lazy, stupid or making mistakes, try to see it from their point of view.

Maybe it's the message they were getting.

Why Do They Always Have Ice in Their Pants?

Narcotic overdoses have three signs that are universal, call it the holy trinity of heroin:

1. Apnea (not breathing)
2. Pinpoint pupils
3. Ice in the crotch

The first two make pharmaceutical sense. Opiates make you stop breathing and squeeze your pupils into tiny black dots. It's the third sign that has baffled paramedics for decades.

Ice down the pants.

Imagine: junkie shoots up with friends. Friends notice (after an unknown duration) that junkie isn't breathing. Friends attempt to wake junkie to no avail. Friends run to the ice machine in the motel hallway and dump the whole bucket down junkie's Wranglers. Junkie is still heading for the light. Friends call 911, gather up all the drugs and cash -- including junkie's wallet -- and skedaddle before the fuzz gets there.

We show up to find junkie lying on the bed, sweating profusely, blue lips, arms outstretched like Ted Neeley, cubes in his drawers and wallet lying open on the nightstand entirely devoid of any founding fathers. In no way, shape or form will we find any illegal substances on the premises. The fuzz, by the way, couldn't care less.

This presentation results in almost every paramedic I know shaking his or her noggin wondering how professional heroin users like this guy and his acquaintances haven't figured out by now that the only thing that's gonna wake him up is Narcan, a magic little concoction we paramedics carry to wake up junkies. It's like the heroin antidote and it's only available by special delivery.

Don't these guys get that the ice trick doesn't wake the dead?

The concept is solid, I mean a Big Gulp on the twig and berries should really give you enough of a jolt to come back from the edge of the abyss. It's like a convenience store defibrillator.

CLEAR! Jamba Juice all over your Fruit of the Looms -- ZAP!

So we, the self-righteous paramedics who obviously know how futile ice in the pants is, continue to shake our collective heads as we prepare our Elixir of Life and mainline it directly into our junkie's last remaining vein, smugly grinning as he rolls over and tosses lunch all over the motel room floor from his instant heroin withdrawals. The only problem with this line of thinking is that the junkies are still using ice. You'd think by now they'd have noticed they were still calling 911 and leaving Bubba for the cops to find even after dumping their smoothies down his tighty-whities.

Unless they're not. Maybe -- just maybe -- this ice trick works better than we sheltered, non-IV-drug-using paramedics realize. Maybe this is the ultimate junkie home remedy, and only when a deep freeze to the nether regions doesn't bring Bubba back from the brink do his junkie friends decide to jump ship and call out the troops.

Maybe. It. Works.

Maybe there are junkies overdosing three or four times as often as we think they are. Maybe overdosing is like the choking game, a way to play with fire and only when you get burned do your best friends make off with all your money and drugs and leave you to wonder how you got in this motel room with a rubber tube in your nose, puking your guts up, surrounded by firefighters and a paramedic with a Cheshire Cat grin.

The next time I find a heroin overdose patient with ice down his pants, I'll know that indeed his friends did everything they could before they called an ambulance -- and made off with his unemployment check.

Puttering Around the ER

Ah, to kill the clutter. There's nothing like a visit from a phone/cable/satellite/internet/exterminator guy -- anytime between the hours of noon and four -- to spur a little sprucing up around the abode.

Mel calls it "puttering." I don't know why exactly. She tells the kids we're not going to do major housecleaning, we're just going to "putter." I think the kids generally interpret that as, "we're going to keep cleaning until Mom is bored."

So, we puttered today (and yesterday, Thursday, and last Friday, too, but that's a different rant) in anticipation of the internet/phone/TV guy showing up and tromping around the house in his little paper shoe covers installing the new combo internet/phone/TV thingy.

He sort of showed up, but not really (again, that's for another rant on another day and I'll explain how puttering ended up with me at La Morenita's, my favorite Mexican restaurant, having a grande margarita and drowning my sorrows in chips and salsa).

What did happen is a gloriously clean office devoid of clutter thanks to the putter. Of the twelve thousand (give or take) pages of incident reports, paramedic student evaluations, old faculty contracts, EKG strips, dispatch data and other banal paperwork Mel had me sorting through I came across a copy of an incident report I wrote concerning a patient I delivered alive but who did not survive.

In my not-so-humble opinion I felt the care this patient received at the ER contributed to her early demise (which is exactly how I wrote it in the incident report -- an indicator to me that I was pretty damn pissed off at the time). The full story -- minus names and such since things like medical error can be so litiguously touchy -- will be in some future book, but today I was simply sad that mistakes like the one I witnessed can just slide on by.

The doc isn't one I would ever have counted as a star in the medical field. It's like the old joke: what do you call the person who graduates last in the class at medical school? Doctor.

No, this particular MD is mediocre at best, and the mistake in question was the kind of stupid error that mediocre docs (and to be fair, mediocre paramedics) make when their mediocrity is offset by the confidence that comes with their license to practice medicine, which too often becomes a license to kill.

I've made mistakes in my career. Still do -- all the time. I've probably even killed someone from a mistake I've made, and worse yet, couldn't tell you when it happened because I never realized my erroneous action and therefore will never learn from whatever it was I did that was wrong.

That's the issue in this case. This doc is never going to understand that there was a mistake and that the mistake led to the demise of the patient (or at least greased the skids a little). I hope that if I have made a mistake like that, that it was no more than once and that I will someday understand my error.

I tried to make a stink after it happened, but how exactly does a paramedic rat out a doctor for a medical decision? It's not like seeing a doc practicing medicine drunk after a 3 martini lunch. That's an easy one.

No, this is more like the drafting student telling the master architect that his design isn't safe. The architect is going to tell the student to mind his own business and let the architect draw the plans. Who was going to listen to the medic about the bad doctor?

Worse yet, the doc was pulling quality assurance duty that quarter. When there was a question about the clinical practice of a physician in that ER during that time, this was the doc who had the responsibility to investigate it. So a complaint about clinical care would go to the very doc the complaint was about.

A physician friend, whom I have great respect for, pulled me aside and suggested that I drop the issue. He assured me that the doc in question would never face discipline for the mistake, despite the fact that my physician mentor wholeheartedly agreed with me.

So, despite the fact that I had puttered for nearly three weeks, this particular bit of housekeeping never got finished and the clutter remains to this day. I'm just waiting for the next colossal blunder (hopefully, it won't be mine).

Docs, nurses, medics, respiratory therapists, EMT's, we're all human. We're going to screw up. If anyone on that list screws the pooch (remind me to look that term up) except for the docs, he or she will pay for it. Docs, on the other hand, only have other docs to watch over them, and doctors are a protective lot.

Until there is a new way to hold doctors accountable for their mistakes, I guess we'll all just worry about our own care and try to steer the docs in the right direction if we think they're veering off the path.

Or I can go be an internet/phone/TV guy. I don't have to do anything, then.

So Sue Me!

If I pull you out of a burning car or rescue you from swirling waters, don't you think I deserve something?

The California Supreme Court thinks I deserve a lawsuit. Hogwash!

Four of the stodgy jurists believe the location of California's Good Samaritan Law - not what it said, mind you, the location - was the determining factor in deciphering what lawmakers meant when they wrote it. Based on the location, these brain surgeons decided the law was meant only to protect actions like bleeding control and CPR.

All fine and dandy, unless you pull a coworker out of a car you believe might blow up. In that case, says the court, the victim is free to sue your butt for any supposed injury you may inflict.

Umm...why help anybody?

To their credit, the other three jurists disagreed and their analysis of the situation is right on target. They got the point of the law. Of course, if there was any question, why didn't they just ask the guys who wrote it. Most of them are still in office, the thing was written less than 30 years ago.

Oh well. Luckily I'm getting paid to save lives (not that saving lives is a full-time commitment or anything) and wouldn't be covered either way. Let's just hope the guy who drives by when I'm laying upside down on the side of the road with my car on fire and the wheels still spinning didn't read the newspaper or watch TV. Because, let's face it, ignorance is bliss when I'm about to fry from a roadside slip.