“Mr. Gorbachev, tear down this wall”
I’ve been on the fence with sharing stories from my career. I look at it 2 ways:
1) It is a good way for me to get all this stuff out of my head, good and bad, so I can move on with my life and
2) I change the personal information about those involved so that no one has their privacy violated.
Still, it is not easy writing about some of these things because I do feel I am breaking the trust of the people I served. Also, these are serious things that happen to people and it doesn’t seem cool to make light of it. However, everything I write about is real, it happened, and I want everyone to know about it. Public service is a world that get’s shit on constantly. Unless you live it you don’t know what it is like. There is no way I would ever defend bad actors like the ones you see on the news. The ones you see beat up people and the like. With that said, I have witnessed the progression of good people turn bad from the constant verbal and mental beating they take working with the public. I get it. I don’t approve of it but, I know how a good intentioned person can devolve into someone that ends up violating the rights of the people they are sworn to serve.
It’s funny working in public service because you literally place yourself in the most likely place to experience the craziest things that happen to people. If you took a proper sampling of the public and asked them if they had ever called 911 the vast majority, about 90%, would answer no. I’ll estimate the remaining 10% of them have called at least once. Of that 10% you’ll have about half that have called less than 3 times. Then there is the remaining 5% of the original sampling. These are the people that call religiously.
They call every time they see a fender bender on the roadway. They call every time they see a homeless person sleeping on at a bus stop (which is not a crime). They call every time they see a homeless person sleeping on the sidewalk (which is not a crime). They call every time they see someone sleeping in their car (which is not a crime). They call every time they see someone that does not look like them in their neighborhood and assume the worst about said person. A lot of the time the people that have been called on have mental health issues like bipolar disorders and the like. They are in need of long term mental health treatment. 911 is not built for these people. 911 is for immediate help. The traditional 911 system can assist these people in stabilization only. Long term care is not something the government is truly interested in. I’ll save that rant for another post.
There are those that call because they rely on 911 for there daily medical needs. They call because they have trouble getting off the floor when they slide off their bed or recliner trying to reposition themselves. They call because the daily pollen count is high and they have a headache or their asthma is acting up. They call because they’ve been out of their medications for weeks and their hypertension is flaring up.
Then there are those that get 911 called on them constantly because they are always involved in some type of legal trouble like domestic fights, drugs, theft, and all the shitty things human do to each other. I’m sure you can see where I’m going with this group of people.
So with that said, you almost always, statistically speaking, put yourself in odd and bizarre situations as a public servant. That’s the job. That’s why we all have stories about crazy things we saw and heard on calls. That’s why we always have something cool to share at parties. That’s also why a lot of us turn to alcohol and pills to deal with it. I’ve been fortunate that I have a great support system to lean on. With that said, I have my own bag of despair full of shitty things I’ve seen on the streets. Slowly I’ll share those.
So on to today’s story.
You may be asking yourself, Tony, why is the Ronald Reagan being referenced above? Why, is that quote from the Berlin Wall? I would answer why yes, it is. Congrats, you get a cookie. Be patient my friend, you will soon see how it comes into play.
It was a Sunday morning and I was on the ambulance. Shocker. For fire departments that run both the fire and EMS primary response for a city, the ambulance is the necessary evil. Most firefighters hate working EMS. They get into the field to do pushups, pose for calendars, and slay the dragon. Most had no idea that fire are almost non-existent in the modern world so fire departments must participate in EMS to remain relevant and receive funding.
Don’t come at me and say, but Tony, what of all those forest fires we see every year? Those are not fought by the guys that are stationed in your neighborhood. Those are fought by specially trained firefighters who live in those regions. As part of my basic fire training I spent a whopping 4 hours learning about fighting forest fires. They are so dangerous that you must fight them from the black. That means you chase the fire, you position yourself in the areas that fire has already destroyed and moved on from. If you come at it from the front you are standing on the material that the fire is coming to consume. That means you will be incinerated in seconds. When you come at it from the front you have to keep a far off distance so you have time to dig trenches to keep the fire from moving forward. If you predict the incorrect path of the fire and dig trenches in the wrong path you have just worn out your crew and wasted precious time.
I digress. Back to the ambulance. It sucks. When all you want to do is be a firefighter the ambulance sucks. And since I was low man in the department due to my newness and therefore lack of seniority, I was on the ambulance full time. I really didn’t mind it. I enjoyed getting out of the station and the autonomy it brought.
So back to the story, it was a Sunday morning and I was on the box with my partner, Jessica. Sundays are a chill day at the FD, minimal chores and everyone basically keeps to themselves and rests. It was our first call of the shift. A traumatic injury. An adult male fell off his bike and suffered a head injury. The call was outside of the city limits in the county. The county roads outside our city limits were great for cyclists on the weekends. There was very little traffic allowing for great stretches of vehicle free biking.
Our city was a unique mix of wealthy professionals along side college students along side working class folks along side a ghetto. It reminded me of old school Austin. Not old school for those that transplanted here over the past decade or so. I’m talking as a native central Texan. I’m talking old school Austin where all the socioeconomic groups got along for the most part and we still had Aquafest and live music everywhere you looked. The town my FD was in was very similar in that way. A growing city that still had true small town feel.
The working professionals formed a cycling club and hit the road on the weekends. They would get all decked out in there cycling get-ups and hit the road in tight packs. They would ride so close that it would make me nervous that eventually someone would clip another from behind and cause a massive crash.
Well, that is exactly what happened. A group of cyclists hit the county roads and the EMS Gods decided today, after numerous rides with no incidents, would cause a wreck.
We arrived on scene to find a group of about 10 adults all dressed like Lance Armstrong. The only difference between anyone there was the shade of neon they elected to wear. Our patient was quickly identified. He was a normal sized male, sitting on the side of the roadway. From a distance he looked fine. No bleeding, no obvious deformities (meaning none of his extremities appeared broken/misshaped) and he was having a conversation with the person next to him.
We asked a few people what happened before talking to the patient. Apparently the pack of riders got too close to each other. Typically the lead would rotate to the back of the pack after a set amount of time. Due to unusually heavy traffic the riders were unable to rotate in a timely fashion and the pack leader began to tire. As the leader tired the pace of the group was thrown off and their formation began to break. The patient’s front tire clipped the rear tire of the person in front of him. Both lost control and crashed. The patient got the worst of the wreck as he flipped head first over his handle bars and landed head first on the pavement.
His riding partners reported he was conscious when they got to him but said he was apparently dazed. They all said he was able to hold conversation with them and was acting normally but, for the first 30 seconds of contact with him he was unable to speak to them and had a blank expression on his face.
We made our way to the patient and introduced ourselves
“Hello sir, my name is Tony and this is my partner Jessica. We heard about your accident. How are you feeling right now?”
“I’m good. My head hurts some but it’s not awfully painful. Just feels like I imagine it would after wrecking your bike.”
“As a precaution we’d appreciate you letting us check you out for any other injuries. Would you mind us assessing you in the back of the ambulance?”
“Yeah that’s fine. I can walk myself over there, I don’t need your stretcher.”
Cool. That is usually a good sign that the patient is not that injured. We watched the patient stand up of his own will and walk with no obvious injuries. Even cooler. No limps, no whimpering, no leaning on people for help. That means his balance is intact and he can bare weight on his legs. So far this call was turning out a lot better.
We examined the patient’s head and found nothing significant other than the abrasions on his forehead. He had no indentions in his skull from the impact with the street, his pupils were equal and responded appropriately to bright, focused light. His facial bones were all intact and he reported no pain when we touched his head. His neck and back were not in pain and he had full range of motion of both. His vital signs where fine and he answered all our assessment questions appropriately.
“Well sir, everything looks great. At this point of the assessment we offer our patient’s transport to the hospital. Typically after a fall like the one you experienced it is a good idea to have further assessment by a physician. I’ll be honest with you though, everything we have checked out with you looks totally normal. You are reporting no other injuries, your vital signs are all good, you’re injuries seem to be superficial. You are acting appropriately and have been able to answer all our questions. If you want, I think it is safe for you to either go to the hospital with a friend driving you or even waiting to see your primary care physician. The choice is yours, I feel confident that what ever decision you make is appropriate.”
The patient did not hesitate to refuse transport from us. As I had told him, he truly seemed fine so I saw no need to pressure him into going to the hospital. I know his friends reported he was dazed when they first saw him but he had fully recovered and was now fine. At this point I was confident in diagnosing the incident as a mild concussion. This means he was concussed but fully regained baseline mentation within a very short amount of time. Cool, just a few more questions and a signature on our report and we could split.
At this point in my career I was pretty, pretty, pretty good with my assessments.
However, there was a very basic part that I usually left towards the end. Mostly because I would always forget to do it. That is a formal assessment of the patient’s cognition. It is very simple. You ask the patient 4 questions: their name, current location, day of the week, and current president of the United States. These are questions you should be able to answer under normal conditions. A good paramedic will alter these questions to meet the lifestyle of the patient. For the homeless, you can’t expect them to keep up with days of the week. Some can based off of weekly routines and such but, others may not keep up. Elderly people in nursing homes that don’t socialize much will usually forget what day it is. This does not mean they are altered. So, for these situations you modify your questions to something they would keep up with like upcoming holidays or what season it is.
For this patient he was a professional, adult male. He was a banker. The normal 4 questions would be fine. Since he chose to refuse transport on the ambulance it was my responsibility to ensure that he was in the proper state of mind to make this decision for himself. It is called present mental capacity. Does this person know what is going on around them, does he know what just happened to him and does he understand it? Is he aware of his injuries and the possibility that internally he may have an injury that EMS was unable to detect? Does he understand his right to chose transport or refuse and the risk involved with refusing transport for his possible injuries?
Basically, can the patient make a sound decision on his own taking into account all the details surrounding the incident. Those 4 questions are the basis for proving a person is able to make that decision. There are more questions and assessment techniques you perform on a patient. In fact, if I had assessed this same patient today I would have begun with a full neurological field assessment while taking his vitals. But, back then I was still learning and developing my own style.
“Ok sir, we have no problem with you refusing transport. As a part of our assessment I just need to ask you 4 more questions to ensure you have present mental capacity and can sign a refusal for transport document from us.”
The patient had no problem and understood. Another good sign.
“What is you full name?”
“John Edward Doe”
“And what city are we currently in?”
“Well, technically we are outside the city limits of…”
Cool he nailed that one.
“And what day of the week is it?”
“It’s Sunday, close to noon now.”
Sweet he’s good to go, one more question left.
“And who is the current president of the United States?”
“Ronald Reagan.”
What?
“I’m sorry sir, who did you say was the current president?”
“Ronald Reagan.”
Wow, this guy was serious. And wrong. And still concussed. So Jess handed me the report she was filling out for me and left the ambulance to tell the patient’s friends we would be taking him to the hospital. I informed the patient who the president currently was and told him we were going to the hospital.
So legally, a person has the right to refuse transport to the hospital by EMS if they so choose. However, if they are not able to display for the medics that they have present mental capacity, the medics are required by law to transport the patient to the hospital to address their mental state. The law assumes that if a person is legally altered they would want to have had their injuries treated under normal circumstances. This is why a person having a heart attack can refuse to go to the ER if they so choose and are not altered but a drunk person on 6th street is forced to go to the hospital after passing out and awaking if they cannot prove they understand the situation they are in.
The ride to the ER only proved how bad a shape the patient was in. Every few minutes he would ask why he was in the ambulance and were we were going. Patiently I would tell him about his wreck and why we needed to have him evaluated at the ER. Then I would ask who the current president was and I’d get the same answer. Ronald Reagan. Jessica had asked his friends if he suffered from any mental disorders or conditions that would affect his memory. They reported none. So my diagnosis of mild concussion upgraded to moderate to severe as I was unaware if he did pass out before anyone got to him.
At the hospital we turned the patient over to the doctor and his team. We hung back outside the trauma room, a large ER room for patients suffering significant ailments that need extra staff to deal with. Since the patient was mentally altered, the call was upgraded to a trauma alert and the ER would respond accordingly.
As the staff was huddled around the patient a lanky male figure slipped out of the room and came over to Jess and myself. He and Jess knew each other and struck up a conversation. He was a former firefighter from our department that left for a larger city. He was in paramedic school now and doing his clinical rotations.
“Hey, where’s that fucking student at? Hey you, get over here now!” a nurse called out.
We told the guy bye as he hurried back into the trauma room.
“That guy is a jackass. I’m so glad he got hired at another department.” Jess said.
“What was wrong with him?”
“Well, he was just, I don’t know, it’s like…”
At this point both Jess and I looked in the trauma room. What we saw took our breath away. The patient was naked and had his legs held up in the air. The student we were talking to was standing at the end of the table facing the patient with his right arm pulled back. In his hand was a long thermometer.
“Do it damn it!” one of the nurses yelled out.
Wham! The student released his arm and rammed the thermometer into the patient’s rectum.
“Awwwwwwweeeeeee!” was the only sound coming from the once loud room.
“And that is why he is a jackass.” Jessica said.
I took her at her word and we headed back to station.
Though I didn’t do any awesome interventions to save this guys life it stuck with me forever. It was a reminder of the frailty of the human mind. I couldn’t see what was going on in this guy’s head and I was about to let him refuse treatment at the hospital. Hell, Reagan hadn’t been in office for over 20 years! This guy thought he was in the 80's! All from a hit on the head.
It’s crazy how our minds are built. We are born and for the first decade or so we have no subconsciousness developed. We are completely, literal interpretation beings. That is why raising children soundly is so important when they are young. What they see, hear, experience and are told make up the foundation for the rest of their lives. Sure people can change but, there instincts fall back on how they were raised as children. That is what seems to cause the internal, mental conflicts in people as they grow.
Our brains respond to various stimuli from the body and engage different mechanisms to maintain or health. Our brains hold memories and information for us. Sometimes they easily recall it when other times they seem to have lost it. And when our brains sustain an injury, they run like a computer that’s been infected with a virus.
I’m not sure what happened to this patient. Hopefully he fully recovered from both his head injury and probable rectal injury. Shockingly, no pun intended, rectal temperature is a standard vital sign taken for significantly injured patients. Because the patient was still suffering from the head strike he sustained so far from the initial injury time, he was considered a high priority patient which technically warranted the temperature taking.
Personally, I would have just asked him to hold the thermometer in his mouth.
Interested in becoming a paramedic and/or firefighter? Read this first.
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