Code Three
One Day In The Life of a Paramedic

Henry Lansing Woodward

© Copyright 2022 by Henry Lansing Woodward

Image by Oskars Zvejs from Pixabay
Image by Oskars Zvejs from Pixabay 

As a Paramedic, I chose to work for private ambulance companies. My company was subcontracted to provide 911 emergency responses to the general population, so we performed the same duties as the Firefighter Paramedics. We, however, had a whole different pay scale. There were no overtime, medical, or 401K retirement benefits, and we were paid about eight dollars an hour. We were very underpaid for the responsibilities of our job.

I did this because I had already spent my time in a military organization. I had been a Navy combat medical corpsman in Vietnam, “boots on the ground,” as they say, and that was enough. I did not want the morning musters standing in line in uniform and saluting the officer in charge.

That military mentality was not for me. The whole genre brought back too many bad memories. Because there were only these two options for working as a Paramedic, I chose the private ambulance sector despite the poor pay.

Whether working for a private company or a governmental agency, all Paramedics and EMTs do the same job. We try to deliver the best medical care possible in any particular emergency each time we choose to step into an ambulance and answer the call.
My peers and I would regularly encounter a life-or-death situation, and we were required to do the right things correctly within the first thirty seconds the first time we tried. Meanwhile, a whole lot of family or other people were watching. That was all. No pressure there, right? And this happened time after time after time.

I did this for years, working twenty-four-hour shifts for about eight dollars an hour. After completing my duties, I would turn the patient over to the ER staff or cover him at the scene with a white sheet from the ambulance, whichever was appropriate for the particular situation. Then, I left as if it had just been another thing to do and tried to prepare for the next. As I look back today, I realize I would not do it again for that pay. Actually, I realize I would not do it again at all, whatever the pay.

Most of my twenty-four-hour shifts would pass with four to ten dispatches. They usually consisted of a tragedy or two and a few assorted horrors. It was all quite routine. Then there were those shifts that were far more than that, so much more. This is the story about one of those shifts. Just one shift, just one day in my life. I leave it to you to decide whether or not I’m just a complainer about the pay. This is how it went.

8:05 am

The Vomit Room.
He never had a chance.

At every shift change the EMT of the on-coming crew washes the ambulance, and the Paramedic inventories its contents and checks every piece of equipment. This routine happens for every shift change, every time. My partner had just brought the long-handled washing brush, a bucket of soapy water, and the hose when our dispatch alarm sounded. I hadn’t even touched the ambulance.

The call came in as a “Man Down.” That was all the information we received. We had no idea what we were to find. We arrived after responding CODE THREE, lights, and sirens at a popular Reno downtown cafe. It was packed with the regular morning dinners, many tourists, and it was really busy. There was even a line waiting for those cheap Reno breakfasts and complimentary cocktails.

A man was standing in front of that line, frantically waving his arms above his head. We parked the ambulance at the curb near the police cars and the fire engine, and after getting out approached the man, and he said, “Follow me. The others are inside.” While the firefighter first responders brought our gurney, Oxygen, and the heart monitor from the ambulance, we followed the man with our First-Out box of medical supplies in hand. He was leading us to the restroom. As we entered, the smell of fresh, raw vomit and feces was so strong I had to hold my breath to keep from adding my vomit to that already there. The smell was debilitating.

After the initial assault of that smell, and as soon as I could refocus my eyes, I saw a huge man, a really huge man wedged into one of the two stalls with the door still open inward into the stall. At the very least, he had to weigh five hundred pounds. Five hundred pounds of human flesh covered with vomit. I was amazed he had been able to get into the stall, let alone sit on the toilet. The door was open because once he had managed to sit on the toilet, there was no room for him to swing the door closed.

He was sitting on the toilet, slumped forward toward the open stall door with his head tilted down at his thick neck with his chin on his chest. Then there was the vomit, a whole lot of vomit. As we stood before him, it was still coming out, going down his chin, over his chest and huge abdomen, down the front of his huge legs (he didn’t have a lap), where it covered his feet and where it had gathered into a pool around them.

Across from the open stall door, the wall was covered with a coating of vomit. The man must have initially experienced “Explosive or Projectile Vomiting,” with at least the first or second event. Of course, the floor between that wall and the stall also had a thick covering. All of it, all that ugly odiferous raw vomit, was a mixture of freshly eaten, undigested breakfast food and the “Breakfast Marys” included with the cheap Reno breakfasts. His face was as blue as I had ever seen a face in death, and he was not breathing. The vomit continued to ooze from his mouth.

Before we arrived, the Firefighter first responders had been trying to dislodge this huge man from the stall. Because of the vomit on the floor there wasn’t any footing, and they had not been successful. Also, there wasn’t any space in the stall to get a good hold. Finally, the stall wall was sawed away with one of those saws with the big, round blade the firefighters carry on their engines, and the door came away with it. In the meantime, my partner had brought several white sheets from our ambulance and placed them on the floor to provide the needed footing. They were very helpful.

With the side wall and door of the stall gone, the man was pulled out and onto the vomit-covered restroom floor. His head was in front of the toilet where the stall door used to be, and he vomited again.

It was like a fountain. The vomit stream went about a foot or two straight up into the air above his face and sprayed those of us who were closest to him with fluid and chunks of his breakfast. It was an ugly thing, and the smell was suffocating.

Then that vomit fell back down onto his face and splashed vomit on all of us again and went back into his mouth. We tried to roll him onto his side to keep it from going into his lungs, but it was a futile effort. Even with the white sheets in place, it was like trying to roll a water balloon.

The man had been “down” for over twenty minutes without Oxygen or CPR. The Fire Chief kept track of those important things. I tried to attach the gel electrode pads for the cardiac monitor to his chest, but, again, because of the vomit and sweat they would not stick. Finally, I used the defibrillator paddles against his skin, not to defibrillate but only to visualize his cardiac activity. There was none. Flatline. I ran a paper strip showing that flat line to add to our report.

The man had probably died immediately from a fat embolism. Fat emboli are pieces of fat (cholesterol) plack collected on the inside wall of a vessel. It can break free anytime. When that happens, they float in the bloodstream to a place where the blood vessel becomes too small to float any farther. There they obstruct the blood flow so everything downstream from that spot dies because of lack of blood, or rather, Oxygen. It had probably blocked a vessel in one of his lungs, heart, or brain.

If this had not taken his life, the time involved for us to reach him and for the Firefighter first responders to cut away the stall wall and door and pull him out could also have done the job. As a result, too much time had passed without Oxygen or CPR. There was nothing to do for this man. He had eaten his last cheap breakfast in Reno.

We gathered our equipment and placed it onto the gurney. The Firefighter first responders pushed it and our gear out of The Vomit Room, and we all walked with it back through the dining room to the ambulance and fire engine. It was still packed with people eating their cheap Reno breakfasts, and there wasn’t an empty chair at any of the tables. That is except for the one our patient had been sitting in. That one was empty.

I stopped and spoke with some of the people at that table. They were still eating as if nothing had happened. They said he was eating as usual and was on his third breakfast and drinking his fourth Bloody Mary. He hadn’t complained about a thing when he suddenly let out a loud moan which everyone heard. Then he stood up, said he had to use the restroom, and rushed away from the table. A friend checked on him when he didn’t return. That was it.

When I radioed the ER, the doctor told us to do no more and clear the scene. It was already a busy morning, and he wanted our ambulance back in service as soon as possible. This time we needed two white sheets from the ambulance. The others already in the restroom could not be used. The radio spoke again when we were about ten minutes from our station. There hadn’t even been enough time for the smell of the vomit to fade from my clothes.

8:55 am

The Missing Brain.
The mystery MVA

The call came in as a single car MVA (motor vehicle accident) located beneath the North McCarran Blvd overpass on HWY 395 as it leaves Reno. It was about nine to ten minutes away while driving CODE THREE, with lights and sirens, and I would still be stinking of vomit when we arrived. My partner, too.

Highway 395 is the “business” route northwest of Reno, so we thought there might still be a lot of late morning rush hour traffic. My partner, who was driving, looked at me and said, “why only one? In that place, there should be more than one.” We were soon to find that one was enough.

Under the overpass, the highway consisted of four lanes separated only by double yellow lines. The Police had all four lanes closed well before and well after the location of the lone jeep involved. “Why are the other lanes closed?” my partner asked. “They only close the other lanes when there is a death. Where are the other cars?” It didn’t take long for him or me to have an answer to his questions.

As we pulled into the scene, we passed the Firefighters and the Police who were the first responders to this call, and none of them seemed to be in much of a hurry. They were just standing around, away from the jeep, not doing much. They only did that when they were waiting for someone to arrive to pronounce death. They couldn’t clear the scene until that happened.

There were no other vehicles involved, or they had driven off. There were no other people involved, or they had run away.

It was an open-air jeep with a roll bar behind the two front seats, and all the windows except the windshield were rolled down. It was sitting in the right-hand lane as if it had been parked there purposefully, and it showed no marks or scratches of any kind. There was no evidence of an accident, and there were no other vehicles involved, or they had driven off. There were no other people involved, or they had run away. Sitting behind the steering wheel was a young guy slumped downward and forward with his forehead resting on the steering wheel, and he wasn’t moving. Things didn’t look good at all.

We parked and I got out and walked to the jeep to examine the driver. I went empty-handed because I thought I wouldn’t need the first-out medical box, and I was right. As I approached I was amazed at what I saw. This was a first.

The top part of the skull had come off, and I could see directly into the empty bottom part of the skull where the brain should have been. The “Brain Pan,” as it is called, was empty. I mean absolutely empty. Not a speck of tissue, not a spot of blood. The inside was shiny and glistening like the inside of an oyster shell where it is covered by Mother of Pearl.

The guy’s face was unmarked, and except for the obvious problem of no top to his head and no brain in that head, the rest of his twenty-some-year-old body was visually undamaged. It was the most surreal accident scene I had ever attended or would ever attend. Nothing else ever came close.

The Firefighter first responders were always nearby. I could always depend on them to be ready to help. Always. That was just the way they were. I did not ever thank them for that. I should have.

After taking it all in, I turned to the Firefighter who had walked up next to me and asked, “Where are the top of his head and brain?” He turned a little to his left and pointed down the road toward the two oncoming lanes on the other side of the double yellow lines. “The brain is down there,” he answered. “And, what’s that smell?” he asked incredulously.

The last call was a tough one,” I responded. “The morning is busy, and I haven’t had time to change my clothes.”
Hope you can soon,” he remarked. “Me too,” I responded. “Could you show me where the brain is, please?” I said, trying to change the subject.

Sure,” he said. “Come over here.”

Together, we walked about fifty feet from the front of the jeep into the two oncoming lanes. In the inside lane lay a perfectly intact human brain. It was slumped over like so much Jello out of its mold and shining rose pink in the sun.

The driver had not been wearing a seat belt, and from the skid marks he had needed to stop fast. The steering wheel was broken from the impact on his chest, and he had crushed his ribs. I applied pressure to his sternum with my fingers, and it sounded like I was popping bubble wrap. I remember thinking he probably didn’t have an intact rib in his chest. If that were the case, he probably also had crushed his heart and torn his Aorta. This guy must have hit that steering wheel hard, followed by his head hitting the top edge of the windshield frame.

He had died instantly. The top of his head had traveled about thirty feet farther than the brain before coming to rest on the side of the road about a foot or two off the shoulder. It was one round piece of bare, clean bone just about the size of a Yamaka . All the hair, scalp, and other tissues under the scalp were gone. I never heard, but I suppose they found all that somewhere.

That was it for us. We covered him and the front seat part of the jeep with a white sheet. We also placed a white towel over the brain and one over the skull cap and left everything undisturbed for the Coroner. Then I radioed dispatch and asked permission to go home for a uniform change, and they said, “yes.”

Meanwhile, we placed our ambulance back in service and headed for my apartment. We planned to drive to my partner’s house after that. Hopefully, we would do all this before the next call. At some point, we also wanted to squeeze in breakfast.

No witnesses ever came forward. The cause of the accident remained a mystery for the rest of my days in Reno. Sometimes there just aren't any answers.

9:35 am

The Razorblade Lady.
She took a warm bath.

We had been driving for about five minutes when the next one came in. We still hadn’t been able to change our uniforms. It was a dispatch to a possible suicide at a private house in an upscale neighborhood about fifteen minutes from our present location. The husband had been the one to call 911.

After our CODE THREE, lights and sirens response, we arrived at a grand house, if you could call it that. It was more like an estate. There was a long, horseshoe gated drive leading to the front door, where there was a portico under which we came to a stop. Standing outside the house patiently waiting was a man wearing a good-looking business suit with a blue french cuff dress shirt and a gold silk tie. These people had money.

As we pulled to a stop, he calmly approached the passenger side of the ambulance, and we rolled down the window. “She’s inside, upstairs in the master bath. She had threatened to do this many times over the years, and after rushing home to find her drunk and completely out of it, I finally stopped believing her. But, today, something in her voice was different. Something told me I should probably come home this time to check on her.” With that, we grabbed our “first-out” gear while the Firefighter first responders grabbed the gurney from the ambulance, and we all began to run upstairs.

There’s no hurry,” he continued as he slowly followed, “I’m sure she’s gone.” He pointed us to the bedroom and the master bath, where we found a naked lady lying in a bathtub filled to the rim with red water. I remembered what he had just said and agreed. She was probably “gone.”

There were two long and horizontal, linear lacerations on the inside surface of each wrist. Actually, they were more like incisions a surgeon would make. Each one extended approximately three inches from one side of the wrist to the other. They were deep, wide open, and efficiently done. Most people, when they cut their wrists, don’t cut them deeply enough. They also do not extend their cut side to side, so they cut the arteries on both sides of the wrist. Rarely does anyone do it correctly. It appeared this lady knew what she was doing.

There are two main arteries in the wrist, and they are parallel to one another. One is on the thumb side, and the other is on the little finger side. They travel in straight lines coming from the arm into the hand. That means they are as wide apart as the wrist is wide.

Most people attempt suicide by cutting their wrists from the middle to one side. Along with that, they usually don’t cut deeply enough. Mostly they only cut veins, and veins bleed out very slowly. That’s why we usually arrive in time for a suicide attempt by wrist cutting. The few who succeed with these inefficient cuts have a long, drawn-out dying process. They only succeed because they don’t call anyone to tell them what they are doing. No one came over in the nick of time. Instead, they are found hours later when someone comes home. This lady did things correctly. She cut from one side of her wrists to the other and made very deep cuts. Because of this, she successfully cut both arteries in both wrists.

And think of it, she had to do one wrist at a time. After cutting the first, she had to change the razor blade to the hand of the just cut wrist with the two arteries squirting blood. Then, she had to do the same to the other wrist. Can you imagine the grit and determination that must have taken?

Also, I believe she knew what she was doing because she was in a warm bath. I didn’t think she just wanted to soak in a warm bath with a drink and smoke while doing her thing. She knew how to cut her wrists properly, so I believed she knew that hot water would cause her to bleed out faster. I believed she knew that heat would dilate her arteries and veins, thus allowing the blood more room within her vessels to flow faster. I believed she had thought of everything.

When we walked into the bathroom, I touched the water in the tub. It was still warm. Also, on the inside flat edge of the tub, where the side wall meets the rear wall and forms the corner, there was an ashtray with the butts of two filtered cigarette butts. She had smoked them until there wasn’t anything left to smoke. Nothing but the filters were left, and they had been crushed out forcefully. They were still bent over in half and squashed flat. She made sure they were out. Her lighter and pack of cigarettes were next to it, and they both had blood on them. She must have smoked her second cigarette after cutting at least one of her wrists.

On the outside flat edge of the tub was a chimney glass. It still had ice and a few drops of a yellow liquid at the bottom. There was also orange juice pulp clinging to the inside. Perhaps she had finished a screwdriver cocktail and smoked her cigarettes while making the cuts. The outside of the glass also had blood on it.

So, there she was, her feet toward the faucet and drain and her head resting on the back rim of the tub and the wall. The ashtray, cigarettes, and lighter were on the right side of her head and the empty glass on the other. She had just laid there in her warm bath and fallen asleep into death.

All I did was touch the water and feel for a pulse in her neck. There wasn’t one, and she wasn’t breathing. The warm water was so red that it was doubtful any blood was left in her. One of the Firefighter first responders who happened to be Jewish remarked, “well, at least she had a kosher death.”

Please understand, a lot of us who do this kind of work are members of an affected group. Not all, but a high percentage is. I certainly was. Sometimes things are so horrible, so gruesome, so ugly we need to find a way of dealing with them at that moment. If we let it affect us, we probably wouldn’t be much good for the patient.

One of the ways we do this is to use humor. But it’s not “funny, Ha Ha” humor. What the Firefighter used was Sardonic humor. It is humor that is dry, understated, and sort of mocking and is known for clever remarks that sting because they are so accurate.

Our Firefighter did not mean to mock this patient or her suffering. We all knew that. Rather, he was trying to be humorous to deflect the full impact of what he was experiencing. In our ways, we all were. My partner brought a white sheet from the ambulance and covered her in the tub.

We gathered our equipment while the Firefighter first responders helped return the gurney to the ambulance. As we began to pull away, I radioed dispatch that we were back in service and available. Before we had driven the length of the other leg of that long horseshoe driveway and out the other gate, dispatch contacted us again.

10:05 am

The Firefighter.
A story about pain.

There was a brush fire far outside Reno in an area near Pyramid Lake on the Paiute Indian Reservation. The Silver Sage was burning hot on a hot, dry day. A strong wind was driving it along at about twenty to thirty miles per hour enlarging it and keeping it out of control.

It was mid-morning, and my partner and I were working the Sparks One Paramedic ambulance. We were far from the emergency location but were the closest unit, so the call was ours. One of the firefighters had been burned when the fire circled back and trapped him within its flames. It was unknown just how badly he was burned.

Even responding CODE THREE, lights and sirens, it would take a long time to arrive. If the patient had any significant burns to his body, he would continue to suffer all the time we were on the way. And, as it turned out, this man was in a lot of pain.

It took about fifteen minutes to arrive. A long time. As we pulled up and stopped, I could hear screams. They were animal-like, high-pitched screams and were as loud and disturbing as I had ever heard. He had probably been doing it the whole time we were on our way. His pain must have been beyond imagination.

As we approached, a small bunch of firefighters was gathered around him, and all of them were waving frantically with their arms straight up over their heads. As they waved, the arms crossed over each other to form an “X” as they moved from side to side.

They had been with this man and his screams of pain during the whole time we were responding. I’m sure the anxiety and psychological trauma to these firefighter partners must have been similarly intense. The only option they had for helping was to keep him wet with their fire hoses, which had done nothing to stop the screaming.

Because we could hear his screams, we knew our patient was still alive, awake, and breathing. That was a good thing. However, we also knew he was severely injured and in severe pain, which was not.

We jumped out, ran to the back of the ambulance, and grabbed the gurney. We didn’t bring any other equipment with us. Only the gurney. We knew this would be a “scoop and run” case with all our treatments done in the ambulance. By doing this, The Firefighter would receive the hospital definitive care he required much sooner.

Because he was in critical or extremely critical condition with his life in danger, I was required to ride with him in the patient compartment while my EMT partner drove. One other firefighter came with us to ride with his friend and partner.

His screams continued while we drove and were amplified in the small space of the patient compartment. It was very disturbing. Along with those screams, the smell of burned flesh, hair, and his heavy firefighter outfit and boots assaulted my senses and were so oppressive it was difficult to breathe. We had exhaust fans, and they were set on high, but they made no difference. My partner opened the front windows, but it didn’t help.

I started The Firefighter on high flow Oxygen and began a liter size, 1000cc, IV infusion of Normal Saline, medical water. Then I handed it to the ride-along friend and told him to squeeze it until it was empty. While he was doing that, I started another one and handed it to him, telling him to sit on it and squeeze it too as best he could. During transport, his firefighter buddy ride-along squeezed three and a half liters of medical water into our patient before we reached the emergency room. Those fluids probably kept him alive, let alone conscious.

When tissue is burned, human or otherwise, the cells are cooked. Others burst, and in both processes, their inside fluid escapes and seeps out of the body. Depending on the extent of the burns and their severity, the body can quickly become dehydrated to a significant degree. This man’s burns covered about half his body and were mostly third-degree.

A first-degree burn is a sunburn, and second-degree burns have big, water-filled blisters. For a burn to be third degree, the tissue is cooked. A fourth-degree burn is when the tissue becomes charred down to the bone. Besides the third-degree burns on our patient’s skin, I had to consider that the fire had also burned his lungs when he inhaled the hot air. He had to be losing a lot of fluid. This man was in big trouble.

Once the Oxygen and the two IVs were running, I contacted the emergency room to give a report. The EMT or Paramedic must do this to validate the treatments already administered and receive orders for any further treatments the doctor might want to add. In this case, however, I didn’t wait for the doctor. Instead, I asked permission to immediately give our patient Morphine for his pain.

Each emergency room doctor deals with the EMTs and Paramedics in the field according to their style. This doctor was well known to have a “Doctor-God” attitude where-in only he could correctly treat the patient. Usually, he did not give orders for advanced treatments in the field, and Morphine was an advanced treatment. He was the doctor and would initiate the advanced treatments in the emergency room.

He would not allow me to give this man anything for his pain, and I knew this was a bad decision. This patient needed Morphine now. So, I did something I’d never done before. While he was still talking, I keyed the microphone and cut into whatever he was saying. Then for a full fifteen to twenty seconds, I held that microphone about two inches away from the patient’s mouth while he was screaming his animal-like scream. I just held it there, and held it there, and held it there until I was fairly sure the doctor thoroughly understood the severity of the situation.

It worked. Right after I closed the microphone, the doctor began talking again. Immediately he gave orders for the Morphine I had requested. I gave it to the patient through one of his IVs, and in about thirty seconds, the screaming reduced in volume and intensity, and then in a few more seconds, he stopped screaming altogether. The moaning continued, and he was still in critical condition and shock, but it stopped his screams. However, it did nothing for the smells.

Morphine doesn’t take away the pain so much as it allows a person to not care about it. At the same time, it reduces anxiety and, to a point, acts as a tranquilizer. It is classified as a hypnotic class drug and works well to alter the level of consciousness and anesthetize the patient allowing him to calm down and perhaps sleep. When given directly into the blood flow via the IV, as I had done, it works very fast, and this guy needed it to work very fast.

The Morphine was enough to last until we arrived at the emergency room and turned our patient over to the doctor and the staff. I reported to the nurse and ignored the doctor. All I needed from him was a signature on the ambulance medical report signifying he had authorized the Morphine. I presented it to him, and he signed it and walked away without saying a word. Again, this doctor was known by everyone in the emergency room to do this sort of thing regularly with the Paramedics and the nursing staff.

As I was leaving with our gurney, one of the emergency room nurses came up to me and smiled. She then moved close to my ear and softly said, “nice touch with the microphone.” As I continued to push the gurney, I looked directly at her, returned her smile, nodded my head, and said, “thanks, I was hoping it would work.”

She continued, “what’s that smell?”

I responded, “We are having a busy morning. We had a bad call earlier, and I haven’t had time to change.”

She responded, “sure hope you can before you return. That’s a terrible smell.”

Thanks,” I replied. “I know,” and continued toward the door and the fresh outside air. That doctor never refused to give me what I asked for ever again, and The Firefighter received the medicine he needed when he needed it.

Outside the emergency room, the firefighter ride-along was waiting for his buddies to arrive to give him a ride back to his station. As I pushed the gurney into the ambulance, he walked up to me and stuck out his hand so we could shake hands. As we did, he firmly squeezed my hand in a friendly way and, at the same time, in a very nice voice, said, “Thanks, doc. Thank you for what you did. I will never forget it.”

It was a good moment.

11:15 am

The Reno Syndrome.
The man who didn’t want the ambulance.

After leaving the ER, I radioed dispatch and asked permission to drive to our respective houses to change our uniforms and have some lunch. The time for breakfast had long passed. They said, “yes,” but in less than five minutes, we were once again alerted. It was for another “man down.” This nebulous term is used a lot by dispatch services. Some others similar to it are “fall case,” “domestic,” “MVA,” “Difficulty breathing,” “Possible choking,” and none of them tell us what we need to know.

Perhaps it’s a throwback to the fifties or sixties when ambulances were little more than taxis with red lights and sirens. Then the attendants were “ambulance drivers,” not trained medical caregivers, and especially not RNs or Advanced Life Support Technicians - Paramedics. The dispatchers were the same, no medical training, so instead of an Intracranial Bleed, it was just a “fall case,” and so it remains today. Change comes hard. Change scares people.

This case was at the Nugget Casino in the City of Sparks, Nevada, “across the street from Reno,” as the town is known. We were informed the man was on the floor just inside the north parking lot entrance. After responding CODE THREE, lights and sirens we found a casino official with a man and his wife standing in the middle of the carpeted hallway inside the casino doors. The man had just told the official he didn’t need the ambulance and was trying to leave. He had gotten as far as the door where the official and the man’s wife were trying to talk him out of it. We had arrived just in time.

As my partner and I entered the hallway, the man approached us. Before anyone could say a word, he passed out cold turkey and hit the floor. This was not a good thing for a man who looked to be in his sixties or so.

Reno and Sparks are at an elevation of more than four thousand feet above sea level. Because of this, the air is thinner with less Oxygen, which can be a problem for many visitors. It happens to so many visitors, it even has a name. We called it The Reno Syndrome. Maybe they still do.

Most people who come to Reno do so by airplane. Thus they must walk more than they ever did at home. All that extra walking, eating, and drinking at over four thousand feet can take a toll, especially if a person is an older male, carrying a little extra weight, and has underlying health issues.

With this man unconscious on the floor, I immediately felt for a pulse. I found he had a good one, strong and regular. At the same time, I was thinking about this syndrome and how he didn’t fit the picture. This man was thin and looked healthy. As we put him on Oxygen and applied the heart monitor, his wife was telling us he didn’t smoke or drink, and he ran marathons back home. Something was very wrong with this picture.

Before I could apply the monitor and put on the Oxygen, he awoke. “I’m fine,” he said as he pulled himself into a sitting position. “I don’t need all this stuff, and I don’t need the ambulance or the hospital. All I need is a little rest.”

No matter what I said, he just wasn’t going to go with us. He was adamant. I checked his pulse again, which was regular and of normal speed, so there wasn’t much I could say. I did tell him there might be a problem happening that was not yet visible, but he would not listen. Then he stood right in front of me and said, “I don’t need…” and passed out again and hit the floor. I again checked for a pulse, and this time could not find one. Not at the wrist or in his neck. There was no pulse. His heart was not beating, and I didn’t think he was breathing.

Just as my partner was about to start CPR and I was about to put a tube into his windpipe so I could breathe for him, he awoke once again. I felt his pulse, and it was regular but a little too fast. He had been out longer, and his heart and breathing had stopped. This time, he was confused, probably due to the lack of Oxygen in his brain. Still, he would not go with us.
I knew this man needed to be in a controlled medical environment, so I would not give up. “You must see a doctor,” I told him. “Something is going on with you, and if you were my brother or father or uncle, I would insist you go now. You must come with us. If not for yourself, do it for your wife.” Finally, with his wife insisting, he agreed.

We put him on the gurney and got him into the ambulance. My partner started driving as I inserted an IV and put him on Oxygen. I also attached the heart monitor so I could see his heart activity. His wife was in the patient compartment riding with her husband, and my partner was driving along with normal traffic when he passed out again. This was very bad.

I looked at the monitor, and there was nothing, no heart activity at all. I yelled to my partner, “Mitch, let’s go! No heartbeat!” I heard the sirens kick on and felt the ambulance lurch forward as we changed our driving to CODE THREE.

Then I hit him right in the middle of his chest on the breastbone with the side of my closed fist, and he awoke immediately. His heart began beating fast with a smooth, regular rhythm. What I had done is called a “Precordial Thump.” It generates a low electrical shock within the heart tissue to stimulate it so it begins beating again. This was the first time I had ever done it, and it worked. I was so surprised I yelled to my partner, “Mitch, the thump worked! His heart is beating again.”

At the same time I said that, his heart stopped again and he passed out. I thumped his chest one more time and immediately, he awoke. I continued applying soft thumps to his chest with the frequency of a beating heart in a technique called “fist pacing.” As long as I continued, he remained awake but was disoriented. I thought that if he was talking, even though his words were nonsensical, he was breathing on his own, and this was a good thing. I was still thumping when we pulled into the ER.

As we pulled in, I jumped out of the back doors and began sliding the gurney out of the ambulance. I had told my partner to keep the sirens on as we pulled into the ER parking lot. This just wasn’t done. All sirens were supposed to be turned off before arrival. We hadn’t had time to use the radio to notify the hospital of what we were doing. I was hoping this would get their attention. I was right. A nurse stuck her head out the ER door, and I yelled, “Pacemaker!” That was all I had to say. Immediately she turned and disappeared back into the ER.

My partner pulled the gurney with our patient on it from the ambulance. As he then pushed the gurney toward the ER doors, I rode on a lower railing near the ground that runs along the side, front to back, and continued to fist pace. The external pacemaker was ready and waiting by the time we had our patient on the ER bed.

An external pacemaker is a device attached to the skin in the area over the heart and does the same job as fist pacing. It uses a low voltage electrical charge to stimulate the heart to beat and does it in a controlled manner. It is adjustable in voltage intensity and frequency of discharge.

While this device was supporting the patient, the doctor was inserting a catheter pacemaker through the big vein in the patient’s neck into the ventricle of the heart. When he had completed the procedure, and it was working, the nurse removed the external pacemaker. Finally, the patient’s heartbeat was managed and he had a good chance to go on to survive. Then the doctor turned to me and asked, “What’s that smell?”

Once again, I explained the situation. The doctor offered to lend us some ER green “scrubs” worn by the staff in the OR and the ER. We accepted his offer. At last, after about four hours, we were out of our smelly clothing.

This man may or may not have been a victim of the Reno Syndrome, but it did turn out he had a full-blown heart attack in the part of his heart that regulated its beating. Perhaps the reduced Oxygen content in the air at four thousand feet was the trigger. Perhaps it was just his time. Whatever was the cause, the precordial thump and the fist pacing saved this reluctant man’s life that day in Reno.

A few days later, my partner and I visited our patient in the Intensive Care Unit. He didn’t remember talking with me in the ambulance on the way to the ER or about the entire experience. He didn’t even remember the carpeted hallway inside the casino’s door. His wife did, though, and was very gracious in her thanks.

I’ve attached a copy of my diary entry about the case. It was written three days after the call happened so it fairly abbreviated.

This one was a true “save,” and the patient lived to go home, where he probably didn’t run too many more marathons. We were still cleaning the ambulance when dispatch alerted us again. We hadn’t had anything to eat all day.

12:12 pm

Horseshoe to Head.
He wanted more beer.

Unconscious patient. Possible head injury,” came the message from dispatch, and it was in a location a long way from where we were. It would be a long twenty to twenty-five-minutes CODE THREE, lights and sirens response to a community outside Reno known as Sun Valley. That is too long for any serious head injury. And this one was. Serious, that is. Actually, it was terminal.

These were tough responses usually followed by tough cases. Because of the time required to arrive, if these calls were real emergencies, any chance of a favorable outcome was mostly lost. This case was over before we even received the dispatch, but no one knew that until we arrived. This is what happened.

After four and a half months in the county juvenile facility for minor offenders, mom’s sixteen-year-old son was released, and she had picked him up. He had been a county guest because he had a nasty habit of beating up kids around the neighborhood. It didn’t matter how old or young they were or how big or little, or whether they were a boy or a girl, he didn’t do it to win. It was his anger. For him, physical pain and injury from fighting were all about who and what he was. That had been his life, physical and emotional abuse, and pain.

By all accounts, he was a troubled youth. His stepfather and stepbrother were abusing him, and he didn’t care who he hurt in return. The neighbors said the two would team up and beat him and sexually shame him in public any time they wanted. And they did it a lot.

Many times the police had been called, but by the time they arrived, no one would go on record with an official statement. The stepfather and stepbrother were truly feared by all who knew them. Mom might have been the only friend he had left, and she was usually drunk, as she was today.

On the way home, the son had talked his mom into stopping for some beer and food so they could celebrate his homecoming. He had told the police she agreed and bought two six-packs and some snacks. He had said he wanted more beer, but mom didn’t have any more money with her. He said she told him they could get more money later at home, so he had settled for the two six-packs.

They arrived home for an afternoon of celebration without the stepfather or stepbrother. They were away for a week of hunting. Mom and son could enjoy being home with each other and some of the neighbors without any problems. Or so they thought.

When questioned, the neighbors said it all started when the beer ran out. The son wanted more, and mom said she didn’t have any money for beer if they wanted food for the rest of the month. The neighbors said the son went “ballistic,” yelling at his mom, “you promised, you promised!” They said he would not stop.

During this yelling, he ran out of the trailer, grabbed a horseshoe off the front yard gate, and ran back into the trailer. It was then his anger turned to rage. Threatening mom with the horseshoe, he yelled again, “you promised. You said we could get more money at the house.” He was crying, they said, and angrier than they had ever seen him.

Most feared him and had left the party immediately, with only two persons remaining when he first struck her. They later reported to the police he had continued to hit her with the horseshoe while crying and yelling, “you promised, you promised.”

By the time we arrived, mom was dead. Long dead. Her forehead was gashed open and missing. Brain matter was spilling over the area where the forehead used to be and down over what was left of her face to the chin. Everything above her nose was smashed into mush, and she was lying on the floor with a large pool of brain fluid and blood around her head.

The sixteen-year-old son was handcuffed and sitting in the back of the police cruiser. He was still crying and saying over and over to no one in particular, “she said we could have more beer. She said we could have more beer. She said we could have more beer…” He was on his way back to the county facility, and now, there would be no more mom to pick him up if he ever became eligible to leave.

There was nothing more for us, so we gathered our equipment and returned it all to the ambulance. At the same time, I grabbed another white sheet and covered mom, still lying on the floor of the trailer. We were a long way out of our response zone, and it would take a long time to get back. On the way, my partner and I looked at each other, and my partner said, “what a shift. What’s happening today?” “I don’t know,” I replied. “But, we’ve already used too many sheets.”

During our drive, we had time for a bathroom break and to buy some fast food which we ate as we drove. Before returning to our station, we had to stop at the hospital to replenish our supply of sheets. As we left the hospital, I grabbed the mic and called dispatch. When they answered, I asked, “what’s happening with the other ambulances? Are they as busy as we are?

No,” she responded. “You two are the lucky ones today.”

1:30 pm

The Ice Pick Story.
The ugliness of domestic violence

There’s something called the “Pericardial Sac,” and it houses or wraps around the heart. One of those reasons it’s there is to contain the heart as it beats. Another is to reduce friction as it rubs against the surrounding tissues.

The heart hangs like a pendulum from the arch of the Aortic Artery between the lungs on the left and right sides. The spinal column is behind it and the sternum in front. The top part of the sternum is called the Manubrium, and the lower part is the breast bone. If it were not for this sac, the heart would flop around all over the place in this open space. It is because of this sac, and some other reasons which do not pertain to this discussion, that we do not feel the heart rub against or hit our insides when it moves with each beat.

Beneath this sac and above the surface of the heart, there is a “potential space.” That is because the sac rides upon the heart, it is not attached to it. If it were attached, it would constrict the heart’s expansion as it fills with blood for the next beat.

It can also be constricted if a fluid of some kind were to collect within that potential space. When this happens, it is a true emergency and can cause death within minutes. Literally minutes. This was what was happening to the patient in this story. This is how it came to be.

We were dispatched to a “domestic” CODE THREE, lights and sirens to a place about two miles from where we were at the time. Our patient survived only because of this reason. Our care at the scene and on the way to the hospital was vital, of course, but if we had not arrived quickly, there would have been no need for our treatments.

Domestic violence is defined as any kind of violence between partners who are sharing a living place, a common domicile. In this case, the violence was physical, verbal, and emotional, and involved a deadly weapon.

As we pulled up after our CODE THREE, lights and sirens response, the police were already there. So was a large crowd standing on the sidewalk and in the street in front of a one-floor apartment building that extended the entire block length, from right to left. It was not one of Reno’s finest apartment buildings.

The front doors of the individual apartments faced the sidewalk and curb, and there were short pathways about ten feet long from the sidewalk and curb to the front doors. The tenets parked their cars along the curb as close to the front of their particular apartment as possible, as we all would do. At this time, the space along the curb was filled with parked cars, bumper to bumper. Not one space was left.

The crowd seemed to be standing around one car in particular. It was a VW “Bug” of an early vintage which today would probably sell for thousands of dollars. As we pulled up, we had to stop in the middle of the street because the crowd was so deep.

I jumped from the ambulance before it stopped and hurried to the center of the crowd, on the side of the VW against the curb. Everyone was looking down at the curb or street, so that is where I went.

When I got there, I found a woman lying in the gutter on her back with her head to my right as I faced her. She wasn’t moving, and she didn’t look like she was breathing. Also, there was a tiny hole in the upper part of the chest bone, the manubrium, I mentioned earlier. It was the size of a pinhole, just below and to the left of the “V” in the neck under the “Adam’s Apple.” She and her partner had been having a heated argument, and her blouse was torn. People in the crowd were saying he was beating on her. That’s why she had run out of the apartment and onto the sidewalk.

In the meantime, her assailant had grabbed an icepick (Why would anyone have an ice pick in their home in Reno?) and followed her. As they continued to argue, the man again grabbed her blouse with his left hand. Then, with his right, he plunged the ice pick into her chest. By the time we arrived, police had the man handcuffed and secured in the back seat of the cruiser.

The lady in the gutter was in critical condition, more like extremely critical. More like just about to die, extremely critical. She was “circling the drain,” as we say when a patient is about to die. It refers to the water draining from a tub or sink. We’ve all seen it. As it drains, it forms a vortex “circling the drain” just before it falls in, never to return. It’s part of that Paramedic and EMT sardonic humor to which I have already referred in the story about “The Razor Blade Lady.”

As soon as I looked, I knew this was a bad situation. To see if she would respond, I touched her eyelash with just the tip of my index finger. Nothing happened. She didn’t blink or move her eyelid at all. Not at all. She was deeply unconscious, and this was really a bad sign. There was no time to waste. I spun around and dashed back to the ambulance. As I did, I looked back at the crowd and yelled loudly, “Move that car!” Then I turned back and continued running to the ambulance.

I ran back to the ambulance to get the ”Scoop Stretcher.” The Firefighter first responders had already brought the gurney to the patient. On the way, a Police Officer came up to me and, while running with me, asked, “Is she critical?” Without stopping, I answered, “worse. Much worse.”

The scoop stretcher is an aluminum device about six feet long that opens and separates down the center lengthwise into two separate long pieces. Once separated, one of the two pieces is placed along each side of the patient, slid under their body, and clicked back together. Then the patient is “scooped” up and placed on the gurney with the scoop still in place. It provides a rapid and efficient method to lift and extricate a patient.

As I returned to the patient with the scoop, the crowd had moved the VW. They had banded together and lifted it completely off the ground, and moved it into the middle of the street. By organizing this action on their own, they became a part of the chain of events that saved this lady’s life. As we were rolling her to the ambulance on the gurney, I turned back toward them and said loudly, “You folks helped save this lady. You are all heroes.”

We loaded the gurney into the ambulance with the lady still on the scoop stretcher. They would need it at the ER. As I jumped in, the same Police Officer who had asked about the patient's condition followed. Whenever there is an impending death by a deadly weapon, police must ride with the patient in case they make a deathbed statement. I was glad he was there. I would do all her treatments in the ambulance on the way to the hospital to save time rather than doing them in the street. I knew I would need his help.

As we drove CODE THREE, lights and sirens to the emergency room, the first thing I did was to administer Oxygen with a face mask over her nose and mouth. Then I started an IV with the largest bore needle we carried. I didn’t use an arm vein because it would take too long. Instead, I inserted it into her Jugular vein on the left side of her neck. As I did, she moaned in pain. I turned to the officer and said, “that’s a good sign. She’s still feeling pain.” Then I attached a 1000cc soft plastic bag of medical water to it, handed it to the officer, and told him to “squeeze it until it is empty.” Not only would we use this IV in the ambulance, but later in the ER, they would use it to administer any medications the patient might need.

In all emergencies, medications are administered through an IV except for Nitroglycerin which is given in pill form and dissolved under the tongue. We do this because when a patient is in shock from any given emergency, the body clamps down all arteries in an automatic response. The result is that most of the blood is diverted from the less important areas of the body, like the muscles, fingers, and toes. As a result, the blood is rerouted to vital organs such as the brain, heart, lungs, kidneys, and liver.

The arteries to these organs are also affected by this clamping down, but because they are so large, the effect is minimal. In this way, the body attempts to prolong its life by prolonging the functions of those vital organs.

There are side effects of this action. "For every action, there is an equal and opposite reaction.” This means that when the body shuts down the arterial system to protect some of its organs, the tissues losing their blood supply begin to develop new problems in addition to the initial problems of the actual emergency. The cells cannot eliminate their waste products because the arterial blood flow to them is reduced. As a result, this causes Ph changes in the tissues and Carbon Dioxide to collect in the cells. Should this condition last too long, the entire body will become toxic, even the protected vital organs. There’s always a side effect to everything.

Because of this clampdown, if we were to inject our medications into the muscle, they would just sit there in the area where they had been injected. There would be minimal arterial blood supply to pick them up and circulate them through the body. The patient would not immediately receive the therapeutic effect they needed.

Also, when the arterial supply returns, all that medicine would be dumped into the body at one time. This could be very detrimental to the patient. Thus, we always use IVs in the ambulance to medicate our patients.

Now that the patient was receiving pure Oxygen and the IV was being squeezed in by the officer, I had the time to radio the doctor and give a report.

I told the doctor about the patient's condition, the argument, the fighting, and the ice pick. I described the location of the stab wound by saying, “there is a small hole in the upper part of the manubrium at its left edge.” Because of the patient's status and the hole's location, he knew this patient not only had a hole in the pericardial sac, there was another in the upper left atrium. He knew this patient was collecting blood within that potential space between the heart and the pericardial sac. This condition is called Cardiac Tamponade. It develops when the heart loses blood through a hole each time it beats, and it begins to collect beneath the pericardial sac.

It begins to collect because the hole in the sac closes. The blood cannot bleed out into the void of the chest cavity. The hole in the heart doesn’t close because of the high pressure inside the heart caused by the contraction of the muscle when it beats. The pressure is needed to push the blood out of the heart to the lungs or the body.

Because it happens every time the heart beats, even if the amount of blood being pushed out through that hole is minimal, a lot of blood begins to fill that space. In turn, pressure is applied to the heart itself which restricts its ability to expand enough to accept the normal amount of blood returning from the body. In turn, again, this causes less filling of the heart chambers. With less filling, less blood leaves the heart. When less blood leaves the heart, less Oxygen is delivered to the body. Because the heart is beating sixty, eighty, or one hundred times a minute, you can imagine it only takes minutes or seconds for this process to decompensate or kill the patient.

When this happens in some remote location far from a hospital, we must deal with it. To do that, we carry a 6” cardiac needle and a large capacity syringe. These suck out the fluid in the sac. I only had to do this once during my time “on the road.” This time we were so close to the ER, the procedure was not indicated for this patient, but I did have the needle and syringe ready.

The first thing they did for this patient upon her arrival was to do this procedure. They pulled out about a cup of dark red blood. Immediately, the patient regained consciousness but was still very disoriented. Once they stabilized her, she was sent to the operating room for an appointment with the surgeon. She lived to walk out of the hospital on her own. Her domestic partner was sent to the Nevada State prison for thirty years.

This patient was a true “save,” as we say in our profession. Too many others just like this were not as successful.

4:15 pm

The Bathroom Birth.
She didn’t know she was pregnant.

This dispatch was another long CODE THREE, lights and siren response back to Sun Valley from Reno, bringing us to a small trailer house. They told us to expect a “CVA,” a cerebral vascular accident called a “stroke.” We soon learned it wasn’t that at all.

The group of neighbors outside the trailer directed us to the bathroom on the right side of a short hallway leading to the one bedroom in the back of the trailer. We expected to see “granny” crumpled on the floor between the toilet and the wall, and we were totally wrong. Instead, we found a seventeen-year-old girl sitting on the toilet, looking down at her cupped hands in front of her vagina. As we entered, she looked up.

There was a look of amazing surprise on her face. It was mixed with confusion and questioning sadness. I had never before seen such a look. Then she said, “It’s out. It’s out. I didn’t know I was pregnant, and it’s out.” I looked down into her cupped hands and saw it most certainly was.

There, in her cupped hands, was a very small fetus. It was probably at three to four months gestation and very blue. The umbilical cord and the placenta were still attached. My partner was a married man and had a kid on the way. Upon seeing the fetus, he released a loud gasp and later told me he had been totally blown away. He wasn’t the only one.

This one hurt. Both of us were suddenly and deeply shocked. I could only guess what was happening to the woman with her baby cupped in her hands. We gently assisted her as she stood up from the toilet. Then we walked with her four or five steps to the bedroom, where we helped her lie on the bed. She was still holding her aborted fetus in her hands.

The eyelids were fused shut, and there was meconium in the lashes and the corners of both eyes. I could also see it in the nose holes, around the mouth, and in the ears. There was a respiratory effort present, but it was happening without drawing any air through the mouth or nose and into the lungs. As it struggled to breathe and live, the chest tissue between each tiny rib retracted downward as the chest tried to expand. The tiny chest would rise, and the rib tissues would sink. No air was getting in. There was a heartbeat, but it was very slow. This fetus was dying. I tried bulb suction to clear the nose and mouth while my partner milked the umbilical cord to force the blood within it into the tiny body. Then he clamped it and cut it.

By this time, the Firefighter first responders had the gurney placed at the trailer door. Still holding her aborted fetus in her hands, she walked to it and laid down on it. Then we loaded mother and gurney into the ambulance and drove away CODE THREE, lights and sirens.

From where she lay on the gurney, she was able to watch as I tried to resuscitate her fetus/baby. I was sitting on the bench seat along the right side of the patient compartment just next to her holding her fetus in the palm of my left hand. With mom watching, I began mouth-to-face rescuing breathing and a soft “tapping” CPR with the tip of my index finger. We arrived at the ER without any changes in the conditions of either patient.

In the ER, we continued CPR and rescue breathing until the arrival of the Pediatrician. Upon seeing it, his first comment was, “we just don’t have a viable fetus here.” Wayne, my partner and father-to-be, said he had known it immediately. I think mom knew it while she was still in the trailer bathroom, and probably I did too. But, the only thing to do at the time was to try.

After cleaning the ambulance, my partner and I sat on the rear step at the open double doors of the patient compartment and discussed the whole event. We were trying to understand what had just happened. Remember, he and his wife were expecting, and he was still experiencing that initial shock. Talking about it helped some, maybe, but not a lot. We were both still deeply stunned by the whole experience.

The only thing left to do was the paperwork and get ready for the next one. It was now about 5:30 pm. Maybe we could return to our station and get some rest. About five minutes into our drive, the radio spoke again. They said it was a self-inflicted “GSW,” a gunshot wound by a shotgun.

5:45 pm

The Dutiful Nevada Wife
She drove him to death.

We had just discharged our last patient, the man with the shotgun wound, and were still parked in the ambulance parking area in front of the double doors leading into the emergency room. After each transport (not all dispatches result in a patient or a transport of a patient), there is always some cleaning and restocking. The four things always needing to be done, besides re-stocking, were to wipe down the gurney, change the linens, wipe all surfaces and mop the floor. Always.

On most calls, it was usually as minimal as that. On others, it could be a major cleaning involving the walls, floors, gurney, equipment, ceiling, cabinet doors, and passenger bench. In other words, everything. After the call we had just completed, the floor needed some special attention, or specifically, the corners where the floor met the walls.

Our patient had injured himself critically by shooting himself with his shotgun. Despite two tourniquets, pressure dressings, and tight wrappings, a lot of venous and arterial blood was still escaping. There was also leakage of intracellular fluids from all the individual cells which had been blown apart or open. This wound was too large to stop all the bleeding. It involved the loss of the entire front or top part of the left leg, from the groin to the knee.

The man no longer had the top front part of his left upper leg. Most of it was still back in his house on the linoleum. That is, of course, except for all the fragments and the remaining twenty percent of his liquids which were now on our patient compartment floor.

The patient's condition required a CODE THREE, lights and sirens transport from the scene of the incident to the emergency room. There was no time to spare. This man needed many infusions of whole blood. Because of our emergency transport, the rocking and tilting of the ambulance spread all that seepage, and the small pieces of tissue and bone included within it, all over the floor where it collected in the wall/floor corner junctions.

These areas were difficult to clean correctly, but there was no other option. It had to be done to sterilize the junction area. The removal of the solid materials prevented any bacteria from growing, thus preventing the unwanted smells of rotting human tissue.

I was applying the “toothbrush method” with alcohol to clean the corners when a car pulled up right behind the open double rear doors of the patient compartment. The gurney was still outside and was now between those doors and the car. We hadn’t yet slid it back into the patient compartment because I was still cleaning the corners. A woman was driving the car, and an older man was slumped forward in the front passenger seat. Slumping is not a good sign, especially for an older man. But we’ll get back to that.

When we pulled up to the house, the front door was closed, and no one was in sight. No one at all. Paramedics know it is not good to be the first to arrive at a call that involves a gun. The police must first secure the scene and then allow us to enter. That is the standard operating procedure, and there were no police.

We contacted dispatch and were told they would arrive in about five minutes. We were also told the caller was currently talking with them and it was safe to enter. The emergency was an accidentally self-inflicted wound, and the gun was empty. The guy was alone in the house, and the front door, although closed, was unlocked.

It’s not that I didn’t trust the dispatchers in the Emergency Call Center. They could only act on the information they received. However, there were many times when there was a big difference between their information and what we found upon arrival. Anyway, the Police rolled up as my partner, and I discussed entering the house. With their hands on their weapons, they slowly opened the front door, looked in, stepped in, then looked back out at us and waved toward us to enter.

The house was a small older house built many years ago and still had the original linoleum on the floor. The room was furnished as any small living room probably would have been, with one exception. In the middle of the room, covered with gun cleaning supplies, was a card table, the folding kind. There was also one folding metal chair. It was tipped over backward and resting in a large pool of blood. A huge pool of blood.

As I stepped into the front room, I saw a broad streak of smeared blood on that original linoleum floor. It was a straight line trailing away from the huge pool of blood. It almost looked like someone had done a long, wide, red finger painting. Mixed into that finger painting-like smeared blood were small pieces of fabric and chunks of tissue. The tissue chunks included red muscle pieces, white skin, yellow fat, and some ivory-white bone. Not big pieces, all of them were shavings and small chips. At the same time came the smell of gunpowder hanging in the air.

The finger painting-like smear of blood stretched to and through a door on the far side of the room about ten feet from the table. It went directly into the kitchen another eight to ten feet and ended at a guy sitting on the floor and talking on the phone. He had somehow managed to drag himself almost twenty feet to the nearest phone.

There was so much blood on the linoleum between the pool and the streak he should not have been alive, let alone conscious and talking intelligently. He was sitting upright on the floor with his back against some drawers to the left of the sink, and he had the phone in his hand.

It was one of those old-style wall phones designed so when it wasn’t in use, the handpiece could rest in the cradle over the dialing wheel. It had one of those long curly cords from the handpiece to the phone and was mounted on the wall about five feet above the linoleum floor. How this guy reached it is a mystery I’ll carry forever.

It must have been the closest, if not the only, phone in the house, and to say this guy needed a phone would be one of the greatest understatements of the year. He had been cleaning his “unloaded” shotgun, and then “Bang!” He was missing the top part of his upper left leg. The little pieces of bone in the blood had come from the top of the Femur. It sustained a lot of damage. He had not immediately bled to death due primarily to the incredible engineering of the arterial circulatory system of the human body.

When arteries are severed by a blast like the one from this guy’s shotgun or by a crushing injury, they automatically pucker and constrict to close themselves. Automatically. It’s an ingenious and sophisticated method of stopping blood from squirting from the high-pressure arteries. Only the arteries do it. Blood escaping from the low-pressure veins flows much slower and is, therefore, less life-threatening to a point. I have no doubt it was designed by the Master Medical Engineer.

After rapidly applying a tourniquet and some pressure dressings, we moved the patient quickly to the ambulance. He had lost so much blood he was in critical condition, perhaps extremely critical. Because of this, we did our additional treatments, including two fluid-replacing IVs, some more pressure dressings, and applying high flow Oxygen in the ambulance on the way to the hospital CODE THREE, lights and sirens. This saved time and this man’s time was running out, just like his blood. We arrived at the emergency room in time for him to survive his blood loss.

So there we were at the emergency room doors. I was on my hands and knees using that toothbrush method to clean the corners of our patient’s tissues and blood. My partner was inside getting replacements for the supplies we used to treat our patient when that car pulled up with the slumping man in the right front passenger seat. I stopped what I was doing, got out of the ambulance, walked to the car, and looked in.

The man’s face was blue, and he was not breathing. I turned and ran to the emergency room doors, pushed one of them open, and yelled, “Cardiac arrest in the parking lot!” All the right things began to happen. In an instant, the Cardiac Team came out with a gurney and pulled the man out of the car.

As they laid him onto it, two members of the team, one on each side of the gurney, stood on the bottom rails, so they were riding along with the gurney. One began CPR. The other began mouth-to-mouth rescue breathing. At the same time, two other people, one at the head and the other at the foot began rolling him and the two riders on each side of the gurney into the emergency room. It was all done very quickly and efficiently.

The man’s wife remained outside with me. She was telling me what happened, and it seemed important to tell her story and that I should listen to her. She even delayed going inside to be with her husband to talk with me. This seemed very strange. Usually, you can’t pry the family away from their loved one(s) in an emergency. But, here she was, talking to me.

Her husband had admitted he wasn’t feeling well. She said this was a big admission for this self-reliant-read stubborn-Nevada pioneer. “He never complained,” she said. “Never. His whole life, he just did what he felt needed to be done when I could see he should not be doing it.”

He would say,” she continued, “It has to get done, Ma. Who else is going to do it?” “There was no use arguing with him,” she added. “For over fifty-five years, he would never give in. He would never let me or any of the kids have our ways. It was always his way. He surprised me by admitting he wasn’t feeling well. He didn’t ever do something like that.

She had suggested calling 911 to send an ambulance, but he would have none of it, and that was it. He had made his decision. Once again, things were going to be done his way. “Drive me in the car, Ma,” he had told her, and that was what she did. They then walked to the car, got in, and she started driving.

She said, “He told me to drive him, and all our lives, we always had to do things his way. I didn’t want to cause him any discomfort, so I drove really slow. Real slow.” It seemed to me there was a double meaning in her tone.

The hospital was about ten minutes from their house. Not too far. I knew this because she had told me where they lived. On the way, there were several traffic lights, and it was just about dinner time, so the traffic was somewhat heavy. She drove slowly and carefully, watching the traffic and managing to stop at each light along the way. It had taken her about twenty minutes to make that ten-minute drive to the hospital. She said, “At the third stoplight, he fell asleep. I knew he was probably gone.”

After a long life of doing things his way and keeping her vows of loyalty to her husband, she had once again faithfully completed the last task he had told her to do. She slowly and dutifully drove “that stubborn bastard” (her words) to his death.

After talking with her, I felt confident she knew what she was doing and what was happening with her husband. I was also pretty sure she knew I knew what she was implying. It was as if she wanted me to know. While she was still talking, a nurse came out and asked her to come in. They needed her to register her husband.

My partner and I finished cleaning and restocking the ambulance and began our drive back to the station. I didn’t say anything to him about the conversation with the wife. I considered it private and was perfectly content to keep it between us. I felt honored she chose me to hear her story.

The patient with the shotgun blast to his leg needed a lot of blood and had his leg amputated just below the hip. The man in the right front seat of the car could not be saved.

We actually made it back to our station and were able to sleep for about four and a half hours, but it was not to last. This shift would not end.

12:05 am

The Elevator Game.
The story of two brothers at university
It was a little past midnight when the alarm went off. The call was at Juniper Hall on the campus of the University of Nevada in Reno. We responded CODE THREE lights and sirens, and because we were close to the University, we arrived at the scene about four minutes after receiving the dispatch.

As my partner and I approached the dorm's front door, we could see a large crowd gathered. It was so large it had spilled off the sidewalk and continued into the street, and it was silent. Not a sound. Usually, people wanting to be helpful are volunteering information like, “He’s in the lobby,” and other such comments. This time on that Reno night, amid all those people, there was nothing, and it was very strange.

As we entered the building, we encountered a smaller group of people in the dorm lobby. This time, it was limited only to Firefighters and Police Officers. They were standing in front of the elevator, and they, too, were silent. Again, very strange indeed.

The door to the elevator box was open, and it had stopped short of the lobby floor by about a foot and a half. There was also a liquid dripping from above the elevator onto the lobby floor, and I looked up to see where it was dripping from.

As I did, at the upper left corner of the box, I came face to face with some “thing” staring down at me that did not appear to be human. The liquid was oozing out of the “thing’s” skin as if it was sweating and then collecting at the point of what appeared to be a chin. From there, it dripped onto the floor.

The “thing” I saw staring down at me was a human head. At first, I only knew this because the Firefighters and Police Officers had told me. It was “facing” forward with the “chin” downward, was perfectly round, and about twice as large as a basketball.

There wasn’t a neck visible, and really, there wasn’t a chin. Or a face. Or a nose, or ears, or mouth, or eyebrows, or eye sockets, or cheekbones, or forehead, or anything else that normally provides depth and texture to a human face. Everything, every recognizable facial feature, had been stretched smooth. I guess they were there, but they appeared to have been drawn or painted onto the surface of one very large, perfectly round balloon which was inflated way beyond its normal capacity. It was so swollen it looked like it would explode any minute. I didn’t know why it already hadn’t. And then there were the colors.

Forget the normal healthy pink skin of a Caucasian. There was nothing of that, nothing at all. The colors I saw were mostly black-purple and maroon, so dark it too looked black. Some pale, yellow areas were spread through and blended into and under all the dark colors. This appeared to be fat tissue from beneath the skin that had been forced onto the surface and had mixed in with the dark colors. Dark red patches of various thicknesses were also on the surface. These probably were from the blood that also had been forced through the skin and was now clotted. It was very difficult to look at, and it wasn’t only because of those horrible colors.

Also, on the surface were two flat circles that looked like eyes, except there were no corners or eye shapes. Between them were two holes that used to be part of the nose but the nose that should have been between the eyes, if they were eyes, wasn’t there. The circles and the two holes between them looked like someone had painted them onto the flat, round surface.
These circles were at least twice the size of a normal eye, and inside each were two more circles. First, there was one of white, the sclera of the eye. Inside that, there was one of green, the iris, and inside that was a huge dark round center. Huge and dark. It was like looking into the black hole of stark terror. They made me shudder as I looked up at them, looking down at me.

I knew those eye circles were staring down into space, but it seemed they were staring directly at me, and the terror I saw in them was not to be believed. They were frozen in time, screaming in amazed shock, incredible pain, and stark horror. Even today, over thirty-five years later, I can’t stop seeing them. I would say they were the worst things I had ever seen, those eyes and the burned human flesh in the Vietnam war. I can still see everything as plainly as I saw it on that night in Reno.

At first, I thought perhaps it wasn’t a human head. Hopefully, all these people gathered in the lobby were wrong in their collective assessments. Perhaps it was one of those mythical creatures called a gargoyle that was placed on ancient buildings to ward off various evil spirits. Perhaps some mischievous college student had put it there, at the corner of the elevator box, as a joke. But this was no joke, and this dispatch turned out to be the worst ambulance call I had ever experienced, before or after, in my entire tenure as a Paramedic.
It was a game they played, the student residents of Juniper Hall. Only on this occasion it had suddenly stopped being a game and turned deadly. There was no getting around it. There really was a college student up there jammed between the corner of the elevator box and the wall of the elevator shaft, and all of us gathered in the lobby, the Firefighters, the Police Officers, my partner, and I had to deal with it.

As the box corner began squashing him against the shaft wall, the student must have suffered from the conscious, terrified, horrified, and painful disbelief of knowing what was happening until the end slowly arrived. This is the story of how it came to be.

Two brothers had been playing The Elevator Game. It was easy to do. All they needed was a chair and an elevator. After placing the chair in the elevator box just below the ceiling hatch, the older brother used it to climb up and open the hatch. Then he climbed through it onto the roof and pulled the chair up after him.

With his freshman brother at the controls, it must have been a fun ride sitting in that chair or standing on the box roof while the elevator rose or descended within the metal framing of its tracking matrix. Up and down he rode, up and down until, of course, that wasn’t enough. That’s when they added the “Ride, jump off, jump on and ride” extra component of the game.
Juniper Hall had four floors. The Freshman brother was inside the box at the controls of the elevator. He began The Elevator Game by pressing the fourth-floor button. Once pressed, the elevator rose from the ground floor to the fourth floor without stopping. That was how the elevator was programmed.
As the elevator began to move up, the older brother readied himself to jump off the top onto and into the metal matrix in which the box was tracking. He had to jump quickly and a little upward. Doing this would allow him enough time to embed himself within the metal matrix. It was necessary to do this so the box could continue its excursion upward without hitting him after his jump.
The third floor was the jumping floor. It provided the proper amount of time for a fun ride back on top of the box down to the ground floor. As The Elevator Game was happening, both the students were lost in unthinking enjoyment. So they could hear themselves talk and laugh, they left the ceiling hatch open.
It was a fun Friday night for two brothers enjoying time away from home at university. The college years were supposed to be like this. Some of the best years of our lives. What could happen? After the older brother made his jump, the box continued rising to the fourth floor and stopped. He then yelled, “I’m ready. Send it.” Thus began the tragic events. When the top of the box was in the correct position at the third floor, the older brother jumped.

During the week just ending, the elevator chains, wheels, and pulleys had been serviced, leaving behind a small pool of oil. It was right where the older brother had landed after his jump. Upon contact with the oil, he continued forward, sliding right off the roof and down into the space between the wall of the shaft and the corner of the elevator box.
As he slid, he must have been on his back and tried to turn to his left, probably to grab onto something to stop himself. Because of this, when he slid down into the shaft, he was still partially turned at the waist with his back toward the shaft wall and his front toward the corner of the elevator box. This turn to the left allowed the point of the corner of the box to push directly into his upper abdomen.

It was in the spot where the ribs come together at the upside-down “V” formation. The corner point pressed deeper and deeper into him as the box continued its descent. While this happened, he was screaming ever louder, “Stop it, stop the elevator! Oh God, stop it, stop it!”

Inside the elevator, the freshman brother could hear everything and was in total shock and fear. He had heard his brother land on the top of the box and slide across it. Then he heard the screaming and the noise of his brother’s feet kicking the outside box wall right next to his ear as he stood at the button panel. He knew what was happening to his brother.
His brother’s cries and kicks became less frequent and softer and softer and softer until there was silence. He tried, again and again, to stop the elevator, hitting every button over and over and over, again and again, in a vain effort to stop it. Every button, that is, except one.

Because he had pressed the first-floor button, there was no way to stop the elevator's descent. It was designed to continue without stopping until it completed the initial command. In his total disorientation caused by the terror and fear of the moment, he had pressed every button on the control panel except for one.

It was the one button that, had it been pressed, would have immediately stopped the process. That button was the bright red emergency stop button in plain sight on the panel next to all the other buttons. But he had not, and because of that, his brother was slowly squashed to death as the elevator box descended.
While I was getting this report from the Firefighters and Police Officers, we all were still standing in the lobby in front of the open doors of the elevator with those huge, round eye circles staring down at me. The liquid was still dripping from the chin onto the lobby floor. The freshman brother was there with us and kept repeatedly saying, " I killed my brother, “I killed my brother, I killed my brother, I killed my brother.”

I walked up to him and, placing one of my hands on each shoulder, I looked him straight in the eyes and said, “No, you did not. An accident killed your brother, not you.” He stopped saying it, but I doubted he had accepted what I said.
His eyes were empty. No light. No glistening. No blinking. No tears. No movement at all. If our eyes are the windows to our soul, his windows were closed, and at that moment, I feared they would never re-open. He was just gone. On that night in Reno, Nevada, the family of those two brothers lost two sons. What a horrible night for that family.

I had to climb onto the top of the elevator box to ensure death had occurred. It was already obvious, but it had to be done to make it official, and because I was the senior medical person at the scene, the task fell to me.

The setting was surreal. On the box top was the chair knocked over onto its side. Next to it was the pool of oil with a straight-line smear leading directly to the edge of the box where the older brother was still in place, squashed between it and the wall. He really was there. It wasn’t a nightmare, and yet, it was.

In the dark elevator shaft, the smells of that oil, and the ozone smell of the electric equipment, were hanging thick in the air. There was also the sick-sweet smell of old blood mixed with alcohol. That odor always reminded me of pancake syrup. I had smelled it too many times at countless auto crash scenes.

I walked over to where the student was jammed between the shaft wall and the corner of the box, being careful not to step in the oil, and looked down at the top and back of his head and then on down passed it. His upper body was still turned to the left, toward the corner of the box, toward me, but his head and face were turned to the right a little, toward the shaft wall, and were tilted downward.

That is why we could see those horrible eye circles while I was standing in the lobby, looking up at the corner of the box. After he had slipped on the oil and was sliding on his back, he must have twisted around to the left to find a handhold. After not finding it, he must have turned his head back to the right a little to look down at what was happening to him. It was in this position that I found him.

It had only taken two or three seconds for him to slide to the edge of the box. Then, it only took the time needed for the elevator to descend from the third floor to the lobby for the corner of the box to become embedded deeply into him. But, that had been enough time for him to turn his head back to the right and down to see and know what was happening to him, as it was happening to him. As I was standing over him in the darkness and smells of that elevator shaft, I could see this boy had been the victim of a cruel, short but drawn-out death process.
As the box corner squeezed into his body, the pressure it caused inside him increased and increased. As a result, the contents of his upper abdomen and the chest cavity were displaced upward, passing through the neck like it was a tunnel to the floor of the skull. In that skull floor is a round hole through which the spinal cord passes as it descends from the brain. This hole is about an inch wide and about two inches around.

That meant all his organs, including the lungs and heart, the pancreas, the gallbladder, the liver, the spleen, the kidneys, the aorta, and the other arteries and veins and other tissues, including a lot of blood, had been pushed up through the neck tunnel and then through this small hole into the brain cavity.

The pressure probably liquefied all these tissues before passing through that small hole in the bottom of the skull. There was no other way for them to enter the brain cavity where there was still a brain. As they entered, the skull had to expand to about two and a half times its normal size to allow for all that incoming tissue.

This process could not have been an easy physical process. The pressure needed to liquefy and squeeze all those tissues through that small hole must have been incredible, and in the beginning, when still awake, so must have been the pain.
After climbing from the top of the elevator box, I approached the freshman brother. As I did, he turned and walked toward me without saying a word, not one word. Then, the two of us walked to the ambulance. He was limp and mute and seemingly in total shutdown. As we walked, I thought he was going into a catatonic state caused by acute and severe PTSD.

As we approached the right-side double doors of the van ambulance, and in total silence, without any urging or assistance from me, he stepped into it. Automatically he laid down on the gurney on his back and just stared blankly upward toward the ceiling without blinking or moving his eyes.

As I reached under him to unbuckle the two gurney safety belts, he didn’t move an inch. Not one inch. I needed to unfasten them to re-fasten them over him to secure him to the gurney. Then, I closed the double doors and sat on the bench seat that ran along the right side of the patient compartment. I was as near to his head as I could get.

As my EMT partner began to drive us to the hospital, all I did was join him in his silence. I didn’t even take any vital signs. I didn’t want to intrude. I let him lie there, staring blankly at the ceiling.

The patient compartment in this van-type ambulance is contiguous with the driver's compartment and the two front seats. There is no wall separating it and the front two bucket seats from the patient compartment. As I sat near the freshman’s head on the right-side bench seat, I was directly behind the right front passenger seat and had an unobstructed view directly out through the windshield. The two windows of the side double doors were to my right.
About two or three minutes into the transport, I catch a glimpse through those two windows of a large, white-panel delivery truck at full speed coming directly at me and those double doors. There was no way it would not tee-bone the ambulance. It simply could not miss hitting us.

I threw myself over the patient to cover him on the gurney. As I did, I looked out through the windshield, and there, in plain sight, was a red traffic light pointing right at us. We were driving through a red light without any change of speed. Then, bang! The truck hit us with a glancing impact. The driver had managed to turn just enough to avoid hitting us full-on.
As I was lying on top of him, I could feel he didn’t move an inch when the truck hit us. Not one bit. There was no response at all. No surprise, no startle reflex, no flinch, no change in expression, and not a sound. He maintained the same silent demeanor throughout the entire event.

Both vehicles stopped, and the EMT got out and handled everything while I remained with the freshman. After agreeing to meet the truck driver at the ER to handle the business of the accident, my EMT partner continued the transport. As we drove away, I leaned forward and, from behind him, gently asked, “What happened?” He turned his head to look right at me. His face was tense and stressed as he said, “All I could see were those eyes. Just those eyes.” I knew what he meant.
In the ER, I gave the report and released the patient into the care of the ER staff. He was unchanged from the time we had left Juniper Hall. I realized my partner had also been injured in this case and took him off duty. Then I wrote a medical report about what had happened and had him admitted. I listed a provisional diagnosis of acute PTSD with hallucinations. Then, I took our ambulance out of service until they could find a replacement EMT. I now wish someone would have written one for me. In about an hour, I had a new EMT partner.

I should have walked away that night in Reno, Nevada. I should have admitted myself as a patient. I should have applied for Social Security Disability for PTSD myself. I should have parked the ambulance and quit, and walked away. But like on so many prior occasions, I did none of those.
A few years before coming to Reno, my partner and I in Hawaii had a call that was also very tragic, as so many were. After it was over, I asked my senior Paramedic partner, “How are we supposed to handle this stuff?” He was driving and turned toward me and said, “We just eat our lunch and get ready for the next one.” I don’t think I ever got ready for a “next one” like this.

I have included a copy of the story about this tragedy as it was reported in the “Sagebrush,” the student newspaper for the University of Nevada at Reno. It was on the front page.

1:30 am

The Good Babysitter.
Do something.”

Our dispatch alarm sounded at about one-thirty in the morning. The dispatcher said it was an infant in distress, and she didn’t specify what kind of distress. Once again, it was in Sun Valley. Our response would require about twenty minutes. That was not good for “an infant in distress.” Already things were not going well.

When we finally arrived at the trailer house after our long response time, there was, of course, a crowd of neighbors gathered just standing around. A fire truck and two police cars were also on the scene. “Here we go,” I thought, “they’re all waiting for the Paramedics. This doesn’t look good.”
The crowds which gather outside a scene of an emergency tell a lot about what’s happening inside and this crowd, in their silence, spoke volumes. It was fair-sized, about twenty people, and was totally silent. They were standing in two’s and three’s, so it seemed they knew each other. A few were smoking, but basically, these neighbors were just there and silent. This, as I had thought, was not only not good, it was really not good.

Inside the trailer, my partner and I were directed to a five-drawer chest of drawers. The drawer second from the top was pulled open and inside that drawer was a very blue, very cold, and very stiff, long-dead infant lying on her stomach. She was maybe five months old.

She had been put to bed in that drawer the night before by the babysitter. I had seen this done in other situations on other calls, and it seemed like a safe thing to do. The baby slept there all the time.

The parents did not have a crib, and the drawer seemed to be a deep, safe place. She could not roll out, and it was high enough from the floor to be away from any pets. So, there lay this clean, blue, cold, and stiff perfect little baby on her tummy in clean bedding and with still-fresh diapers. In this trailer, the baby was well cared for by This Good Babysitter.

Her arms were bent at the elbows and extended up and above her head on both sides. Her legs were extended downward, bent at the knees with the feet and toes pointing outward in a normal, “frog-leg” tummy sleeping position.

Her head was turned to the right, and I could see her little baby face, which was blue. So very blue, and she wasn’t breathing. Because she was so very blue and stiff and cold, I knew she hadn’t been breathing for many hours.

Her entire body was covered with blue blotches, and the palms of her tiny hands and the soles of her tiny feet were solid blue. When I attempted to check for a pulse, it was like touching an ice cube.

Her whole body was as hard as a rock with rigor mortis. It was obvious this beautiful little infant was dead and had been dead for a long time, at least for more than four hours. She must have stopped breathing right after being put into her drawer bed.

It was so obvious she was dead, the Firefighters who were first on the scene had not even started CPR. There was no need. This beautiful little infant, again, was obviously dead to everyone. Obviously dead to everyone, that is, except to the fourteen-year-old babysitter. She had been the one who found her during the morning check.

This Good Babysitter had kept her responsibilities perfectly during many previous times watching this baby. She had known her from birth and had wanted one just like her and was now in full denial. After all, she was the babysitter, a neighbor, and a family friend. This infant was “her baby,” and in her tear-filled eyes, I could see she just was not accepting the fact that “her baby” was gone.

I could also see at fourteen her innocent days of childhood had just ended. At this very moment, she was experiencing a traumatic and fundamental life change, and it wasn’t a good one. Now the Paramedics were here, my partner and I, and she was pleading, “do something. Please. Do something!”

I can still hear her. She was standing close in front of me with tears streaming down her tortured face. Using just the tips of her index finger and the thumb, she had a light hold of my shirt where it came together at the buttons. It was so sad. So. Very. Sad.

My heart dropped to someplace below the floor of the trailer. There was absolutely nothing to be done that would bring “her baby” back to her.

The real and only patient here now was the babysitter. She was in a full-blown emotional crisis, probably driven by some imagined quilt. She also kept saying to no one in particular, “I let my baby die. I let my baby die.” It was absolutely crushing to all of us in that trailer. A real heavy moment.

So, to treat the only patient present, the babysitter, I desecrated a corpse and began a make-believe resuscitation. A little infant corpse pretend resuscitation. To do this, I needed to lift the long-dead infant from the drawer bed. As I touched her, she was cold as ice, stiff as a board, and blue, so totally blue. It was disturbing, very disturbing, to hold her rigid, cold body in my hands. Over three decades later, I can still feel that cold.

The head, arms, and legs did not bend or sag like they normally would have if life were present. Instead, her arms remained extended above her head, still bent at the elbows and her legs remained rigidly positioned in that frog leg formation. “I have to do this,” I thought to myself. “She needs it.”

I laid her on the coffee table on her back, a little dead infant on the coffee table with her head still turned to the right. I didn’t ask anyone to assist. I couldn’t do that to them. I was about to desecrate a corpse, and I alone had to do it. But, without asking, my partner joined me. I’m sure he knew what I was doing and why. I was partnered with a good EMT.
As the babysitter watched in silence, along with the Police and Firefighters, my partner and I desecrated that little infant corpse. After making a show of it for a while, I looked over to the babysitter and softly explained to her we had done all we could do. The baby was gone.

After using a sheet from the ambulance to cover her, we left the infant corpse on the coffee table for the coroner and transported The Good Babysitter to the emergency room for psychological support. No one knew the location of the babysitter’s parents, when they would be home, or how to find them. She was now the patient, and as a fourteen-year-old minor, we could not abandon her there. The Police agreed with our decision and would meet us at the hospital.

I recorded a diagnosis of “Acute severe psychological trauma” for This Good Babysitter. I was sure it would probably be life-long. We searched for and found her best friend, and I asked her and her parents if she could ride with her best friend. They both said, “Yes,” and followed in their car.

All ambulance runs and the medical care delivered in the field are reviewed by the County Medical Director. It is required for all Paramedics and EMTs to be ready and able to support their choices for the medical treatments we provide before consultation with a physician.

No one, not one single person, ever contacted my partner or me about this call. We waited for it, but it never came. In the eyes of those who review our actions in the field, this call and what we did must have been acceptable. It was a big load off my mind.

I never saw or heard of the babysitter again. The cause of the infant's death was diagnosed as SIDS, Sudden Infant Death Syndrome. I never heard anything about the parents, and The Good Babysitter was cleared of any fault. I would not want the job of trying to convince her of that.

No one asked how my partner and I were doing.

3:15 am

A Rude Awakening.
No rest for the weary.

We had been in our station long enough to park the ambulance and walk inside when it happened again. We hadn’t even sat down. This time it was a “woman in distress,” whatever that meant. We turned around and hurried back to the ambulance.

Because it was still late at night, we didn’t turn on the lights or sirens until we were out of our local neighborhood. That way, we wouldn’t bother the neighbors who were still sleeping. On some calls in these early hours, we didn’t use the sirens at all, just the lights.

We were rolling with the lights only, a silent CODE THREE, when dispatch contacted us again. “Sparks One, cancel your response. Cancel Sparks One.” We looked at each other, and my partner, who was driving, reached up to the buttons over our heads and turned off the lights. I responded to dispatch that we had canceled. In silence, both from the ambulance and us, we began driving back to the station. I turned to my partner and said, “well, it’s almost three-thirty. Maybe this means our ‘shift from hell’ is almost over.” Just then, dispatch spoke again.

I had experienced other shifts such as this one. Thankfully they were few and far between. The Paramedic and EMT teams in large metropolitan areas like New York, Chicago, Los Angeles, etc., didn’t work twenty-four-hour shifts for this reason. From when they come on duty for their eight-hour shifts to when they go off, they never stop running, just like we were doing. But for us, this type of shift was unusual. They didn’t happen like this in the smaller venues where the shifts were twenty-four hours. But today, tonight, it was happening, and I knew I would only have one day to rest before my next shift. I had had enough, and I just wanted this shift to end.

3:30 am

The Red Beanbag Chair.
The needle was still in his arm.

Possible DOA,” she said. DOA stands for dead on arrival. This time I was driving and turned to my partner and said, “another one? If they know he’s dead, why call us? Why not just call the coroner?” It was a rhetorical question, of course, and my partner remained silent. But I think he remained silent because he was still too sleepy to answer, not because he knew it was a rhetorical question.

I continued, “we are going to need another sheet,” At this, he turned his head to look at me and said, “at least we won’t need to transport anyone back to Reno doing CPR.” I looked at him and responded, “let’s hope not.”

For the third time in one shift, we were again on our way to Sun Valley. That had never happened before. We rolled another silent CODE THREE and, in about twenty-five minutes, arrived at the trailer. The police cruiser and fire engine were there with their lights still on, so I knew it was the correct trailer. As we pulled up and slowed to a stop, the fire chief came up to me and said, “I don’t think he needs you, doc. I don’t think he needs anybody.” I knew this chief, and his assessments were always “dead” on (Paramedic humor.) As we walked toward the trailer, I told my partner to bring another sheet.

When we entered, the first thing I saw was a dead man in a huge, red leather bean bag chair sitting almost in the center of the room. The television was still on without any sound. It was one of those bean bag chairs that were so big, a person had to roll out of it before they could stand. He was deeply sunken into it and looked very dead. Long time dead. The second thing I saw was a syringe hanging from his left arm with the needle still in him and an untied tourniquet still in place around his upper arm.

His wife or companion was standing in the living room next to him in her sleeping clothes and probably had awakened to find him dead in the bean bag chair. She told us she had come from the bedroom to ask him when he was coming to bed. She was the only other person in the trailer, so she had to have been the one to find him and then call.

As I approached to get a closer look, it appeared he had just pierced the vein and was trying to release the tourniquet with his teeth. At the same time, he was probably starting to inject whatever he was injecting. One end of the handkerchief tourniquet was hanging straight down and lying on his chest below his chin. This must have been the end he bit to loosen it. The other end was still under his arm and hanging down along the outside of it.

The tail under his chin and on his chest looked like it had fallen from his mouth to where it now lay. His right hand was resting in his lap, palm up. It must have fallen from the syringe as he was doing his injection. I thought this because the syringe was not empty, and the plunger was not in all the way.

He had vomited, and there was a lot of it. It had flowed out of his mouth over his chin down to where it somewhat covered the tail of the tourniquet on his chest. No vomit was sprayed out to any other place in the room, so his vomiting must have been a slow process instead of being forceful. It appeared it had just slowly oozed out of his mouth.

The crotch area of his pants was wet. Frequently in death, the bladder muscles relax. Actually, all the muscles relax and allow the contents to escape. I felt his wrist artery in the non-syringe arm and the jugular vein on the right side of his neck. There was no pulse, and there were no spontaneous respirations. He was stiff, cold to the touch, and his face, arms, and fingertips were very blue. This man was dead and had been for a long time.

My partner placed the white sheet over the man and the entire bean bag chair, and the police said the coroner was on his way. All I had done was to state he was dead. It had to be said officially.

We returned to the ambulance and began our drive back to Reno. We were again far out of our response area and needed to return as soon as possible. We still had three and a half hours left on our shift, and there was plenty of time for more dispatches. We arrived at our quarters at about five am and had two-and-a-half hours of uninterrupted sleep. At about 7:45 am, the oncoming crew arrived to take over. Finally, our shift from hell was over.

During the previous twenty-four hours, we had experienced thirteen dispatches consisting of nine deaths, one “save,” two extremely critical patients who went on to survive, and one dispatch canceled en route. I was ready to go home. I had to be back the next morning to do it again.

As it turned out, my entire day off consisted of eating breakfast, playing with my cat, and doing laundry. About 10:00 am, I went to bed and slept until 6:30 am the next morning, about twenty and a half hours. I didn’t even wake up to pee.

This shift had ended, but I knew there would be more like this one. I knew there would be more suffering and horror and death. When I awoke the next morning, I took my bath and shaved. While shaving, I looked myself in the eyes and said out loud, “I wonder who will die today.” I was a damaged Paramedic.


Paramedic Memories

A Paramedic I was, and it’s a Paramedic I am,
About that, nothing can change.
It was a way of life, a series of events,
Which even old age cannot rearrange.

So many memories, so many thoughts,
Still carried night and day.
Resolution has never happened,
How much longer will they stay?

They haunt me always,
No matter where I roam.
They won't let me be,
They’ve found a permanent home.

There are days I’m sad and nights I cry,
It seems just yesterday I was there.
Suicides, heart attacks, car wrecks and OD’s,
And SIDS babies new and fair.

I shut down to avoid involvement,
As I entered tragedy and horror ad-lib.
My life was in an avoidance mode,
As all my feelings I hid.

For years and years, this was my way,
Not thinking of what was to come.
I hid my feelings in drugs and alcohol,
Living a life undone.

For decades I “self-medicated,”
To make those memories stay away.
Even Recovery left them untouched,
Because they're all still here today.

So I’m writing them down to get them out, out, out,
It’s late, but I really must try,
Maybe I’ll find some peace, peace, peace,
God willing before I die.

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