Be well. Practice big medicine.

Tough enough

It has been a long winter up here in the mountains of southwestern Colorado. 158% of normal snowfall and it’s still coming with another 12-16 inches predicted for tomorrow. I was talking to one of my neighbors this afternoon and he mentioned that he was ready for this winter to end. That he was about out of tough.

We talked some more but his words kept echoing in my mind. Sort of like when you hear an insipid song and can’t get the lyrics out of your head for the rest of the day. Which got me to thinking, just what is my definition of tough?

Over the years one hears numerous trite clichés for toughness. You know, “Cowboy up!” “When the going gets tough, the tough get going.” “Soldier on”, “Quit your crying and put your big girl panties on!” I actually overheard one of my volunteers say this to a whining patient last year and if it wasn’t for the fact that it was both true and my volunteer was also a woman, I might have had to act on that last one.
Some other clichés we’ve all heard include “Don’t be a wuss” and “Don’t be a puss.”

Digressing here for a minute on this last one. Puss, short for pussy which actually has nothing to do with either a feline or a part of a woman’s anatomy. According to one of my former partners and longtime friend, Russ Zimmerman, a high-speed, low-drag medic of the old school variety who also has a fascination with words and word origins, Pussy is slang for Pusillanimous. Which means to be faint-hearted, cowardly or afraid.

But one of the most recent terms I’ve heard that while I can appreciate the sentiment behind it, rubs me the wrong way is “Man up.” Used in a sentence like, “C’mon and man up!”.

The reason for my annoyance, aside from the shear sexism of it, is the toughest person I’ve known or worked with, indeed my definition of tough is a former partner of mine, Liz Crawford.

Set the way back machine for 1981. I was a newish paramedic employed by the City of St. Louis EMS. St. Louis was one of the oldest municipal ambulance services in the US. Created shortly after the end of the Civil War. St. Louis was a tough city by anyone’s definition. Heck, back then each police station, with one exception, had an ambulance assigned to it.

This was both because of the central locations in the various neighborhoods of the city, but also because back then, St. Louis PD had the culture of being pretty darn stick heavy. Dirty Harry would have been just an average member of the St. Louis PD.

On the negative side, St. Louis EMS was listed as one of the three worst municipal ambulance services in the US in a 1979 article in the now defunct EMT Journal. That same year the St. Louis EMS administration made the decision to make all the ambulance crews salt and pepper, so to speak.

Heck, I learned one of the main reasons I was hired on in January of 1980 was that I had done my paramedic training in Detroit so administration figured that I was one white medic that they would not have a problem placing in the north side of St. Louis. Which was true.

Racially St. Louis was a bit behind the times. In the fall of 1980 the courts were just getting around to ordering bussing to balance the racial make ups of the public schools. And while they were some mixed working class neighborhoods, there were still plenty of all black and all white neighborhoods as well.

So into this violent and racially charged mix, I began my civil service career as a paramedic. Heck my 4th night on the job I was in quarters at the 6th District Police Station with my partner Ace Boyd, an older EMT in his 50s who was trying to show me the ropes and explain how things really worked. Ace had been working for the city as an ambulance driver since the early 1960’s, back when they ran one man ambulances and shared a lot of great stories about the system but I would be digressing again if I repeated them here.

Anyway, Ace was just telling about how he would drive the ambulance up to City Hospital Number One and ring the bell mounted on the ambulance one time if he needed a wheel chair and twice if he needed a hospital gurney for his patient when we heard a shotgun blast go off close by.

Make that inside the police station. A psych patient, or OBS as they were known in the local vernacular, had ripped a shotgun out of the rack of an unlocked police car and gone inside and shot the desk sergeant. The only other officer in the station was the lieutenant who fired at the fleeing perp with his service revolver.

The perp ran across the street into a cemetery while we were being dragged into the station to treat the sergeant. As he took his last agonal breaths, sirens were coming from everywhere. I intubated him, and he was my first ever field tube, and then began CPR on a chest that was mush from the blast while a major gunfight ensued. In the meantime Ace ran out and got the ambulance gurney and a backboard.

We worked the dying sergeant up a little more. Enough time to sink an external jugular IV, secure both it and the tube and then we loaded him into our ambulance for a wild ride to Fermin Desloge Hospital at up to 80 mph through city streets with a flying squadron of a police escorts clearing the route for us. All the time with me doing CPR in the back pausing only long enough to ventilate or push the occasional drug. It wasn’t pretty.

This was a “Humpty Dumpty” resus. All the king’s horses and all the king’s medics could not revive this man and he was pronounced dead shortly after our arrival at the hospital.

The perpetrator suffered a similar fate with over a dozen gunshot wounds and two sets of tire tracks across his torso.

And as for me, I had definitely jumped into the deep end of urban EMS. It was sink or swim and as the ALS part of a one medic, one EMT unit, I had to either swim or drown. So swim I did. Not always gracefully or with style.

But we always made it while giving the best possible care we could for our patients. Although in retrospect, while I have to acknowledge that I learned my craft at some of their expense, it was never malicious.
What management hadn’t counted on was that along with becoming a competent medic, I also both read the rule book and had a low tolerance for bad management and unequal application of the rules.

The reward for being right and catching them out on a work rule violation, again, was to be moved arbitrarily during the next sign-up period to a day watch on Medic 8 with EMT Liz Crawford.

Liz was a few years older than me and had quite the reputation. She was known as the Black Widow among the paramedics, who were mostly white males, because she had a habit of eating male partners alive. She was also known by various other monikers such as “Dynamite Liz” because she was known to have an explosive temper. And by some shallow types as “Liz-a-bitch”.

But in talking to my previous partners, all black, I learned that she was a good EMT who cared about her patients. Strongly. I figured that was all I really needed to form a good working team.

So our first couple watches together were interesting. And I’m not using the word in that east coast, New England way. You know. When you can’t think of anything nice to say, you say it was, “interesting.”

Getting back to the first few shifts with Liz and myself as partners.

Well, think pack mentality. Two alphas approach, circle, sniff and check each other out. The fact that I cared that the ambulance should be adequately stocked and after calls restocked, but didn’t dump the entire responsibility onto her played into my favor. After checking each other out on calls we found we had a fairly similar approach to patient care and fortunately, I didn’t try to boss her around or attempt to play para-god with her.

I also believe that the fact that I had a strong EMT background. Six years before going to medic school and then taking my first job out of school with a private ambulance service that had the 911 contract for Washtenaw County, MI that was about to go ALS but hadn’t yet. At the time, as a paramedic all I could do above BLS was hook the patient up to a heart monitor, a LifePak 4, and once they went into cardiac arrest, insert an EOA. What this screwed-up system, that never did go ALS and ultimately went out of business did teach me was that the basics worked. With a paramedic education and the assistance of just a couple of tools, I relearned that BLS before ALS except in a very few circumstances, worked most of the time.

So consequently, by the time Liz and I were partnered up, I had developed the reputation as not being one of those paramedics that had forgotten where he had come from and didn’t try to treat every problem by wanting to establish an IV or hook the patient up to the heart monitor.

But what sealed the deal for us was that certain elements of management liked to screw with Liz just to watch her get angry. Our fourth watch together Liz had relaxed enough around me to vent about the latest mind screwing, phrased differently at the time, she was receiving from a certain EMS supervisor and deputy chief.

A few minutes into this I learned that she had filed a written complaint and it had been ignored, again. I mentioned to her that according to the rules, that management had three business days to answer a complaint and if they did not, then the employee had the right to resubmit the complaint to the next level of authority along with a comment that the original complaint had not been acted on within the specified timeline.

At first she just looked at me like I was on drugs. But after we returned to quarters and I showed her the section in our employee manual, and then went on to point out that the bosses had to answer to their bosses as well and they could get in trouble for ignoring her, she shook her head and walked away.

I figured that was the last of it. When I returned from our three days off Liz had a big smile on her face and was waving both an acknowledgment of her complaint and a written apology from the same supervisor and deputy chief for not acting on her complaint in a timely manner.

The same portion of management that thought they were teaching both of us a lesson by putting us together suddenly were starting to have second thoughts.

In the mean time Liz and I, while opposites in many ways, became a tight crew and grew to be pretty good friends. We banged the calls out and would even jump other crews’ calls. By God! We were getting paid for 10 hours of work per shift and nothing made the watch go by faster than banging out the calls. Especially the good ones. And in 1981 St. Louis had beat out Miami for murder capitol USA so there were plenty of hot calls.

(Miami, frustrated that we had snatched their 1979 & 1980 titles away from them, reclaimed the title in 1982. I would like to think that it was in part because we had a better EMS then they did and more of our victims survived the event then did theirs. But that is probably just fanciful thinking.)

I also learned first hand that Liz was tough. I mean pure mad dog mean and tough. There was no backing down with that EMT. We would roll up on a call and someone would start screwing with us. Usually by attempting to play the race card on me.

I never had to say a word. Liz would be up in their face. And size didn’t matter, Liz was 5′ 7″ and rail thin but, well as that old cliché goes, “It’s not the size of the dog in the fight…”

Before I could even say a word she would be cutting the line of racist drivel off. It usually went something like, “Look you called for a paramedic, well Mr. Rookah is a paramedic. If you are or whoever you called for is doing so well that you can run your jaws about his color rather than have him look at your friend, then your friend can’t be all that sick!”

That’s putting it politely. It was usually a whole lot more colorful and intense.

By now the hapless individual, usually a male, would be backing up and trying to figure out how they were going to get themselves out of this problem. She would be staring them down and I would step in and say something like, “why don’t you show me where your mother is” or “why don’t you get your wife’s medications for me” or some such line.

These poor guys were usually in such a state of shock that they would mumble something like she’s over here and all thoughts of race went out the window. Which was a good thing. Because if I didn’t step in, about half the time, the hapless male who had started things would try to recover his dignity and the game would be on.

And it would pretty much always end the same way. Eventually he would get around to saying something along the lines of “You can’t say that to me. I’m a man!”

I could be doing CPR and when I would hear those words I would leap up because I had another life to save. I would insert myself between the two of them and redirect the guy on to some task because if I didn’t, the next words out of Liz’s mouth would be, “Just because you got that between your legs don’t make you no man!”

And then the fight would be on. And Liz would win and I would have a second, now wining patient to deal with and paperwork to fill out. I never got directly involved in these conflicts. There was no need to. I just covered Liz’s back and stood down anyone else who attempted to jump in, which was infrequent and occasionally got it on with the rare fool who tried. As a crew we never picked a fight. But we never, ever came in second either.

We had a good working relationship with the coppers in our station. The way the system in St. Louis worked back then, we almost never ran with the fire department, unless it was for a fire or a vehicle accident. If we had a cardiac arrest we ran a two person code until a second ambulance arrived to assist with the code and transport. If we needed a lift assist, our district police officers would respond to help us out.

As I mentioned, we had a great working relationship with our police officers. Both on the street and in the station. Where we would frequently be called upon for a curbside consult on some injury or medical condition that one of them or a family member might be having.
Hopefully I have set the stage for the call where Liz went from being a tough partner in the good way to becoming my definition of tough.

It was a sunny late March weekday morning and we were dispatched to an apartment building to evaluate an elderly woman on an unknown medical. We were met at the door by one of our police officers who had just gotten off the night watch.

His mother was a widow and he usually called her each night and again in the morning when he got off before going to bed. He hadn’t been able to reach her all night and when she didn’t pick up the phone this morning he went over to check on her. And then called us.

Liz and I followed the officer into the very neat apartment to find a woman in her 70’s laying on the floor, staring at us but unable to speak or respond to us. It was only 08:45 but her electric clock, which was unplugged and laying on the floor next to her read 9:17.

Just then she had a grand mal seizure. Liz and I rolled her into the recovery position and placed her on a high flow oxygen with a non-rebreather mask. The officer remained calm and told us his mother did not have a seizure history and the only medications she was taking was for high blood pressure.

The seizure quickly ended and she almost immediately returned to staring at us like she understood what was going on but could not respond or move. Her vitals were elevated and her BP was sky high. There was no doubt in either Liz’s or my minds that this woman was having a stroke and it had started over 11 hours ago.

The officer and I sit-picked his mom and carried her into the front room of the apartment. In the meantime Liz grabbed the jump bag and ran out to the ambulance and single-handedly unloaded our Ferno two-man gurney, dragged it through the snow, up the seven front steps and in to us.

The three of us loaded the woman onto the gurney, who was starting to have another seizure, and made our way out to the ambulance.
Some of you may be wondering why we didn’t start and IV and break the seizures with a dose or two of Valium. The answer is as simple as it was stupid. We didn’t have any.

We carried it when I had been hired in January of 1980. But in 1981 it had been pulled from all of the units. Not because we didn’t know how to use it or there were inventory control problems with it in the field. No.

It seems that five units of Valium went missing out of the drug locker in the EMS supervisor’s office. Management’s solution. Remove Valium from our drug inventory.

So we were back to the ABCDs for taking care of this patient. And unfortunately the D did not stand for Diazepam, but rather diesel.

We were at the back doors of the ambulance. We had just lowered the gurney down to the ground and were about to pick it up when our patient went into her third seizure. Liz and I picked the gurney up and had just gotten the front wheels up onto the ambulance deck when disaster struck. I felt the gurney start to pull back on me as I was pushing it in and out of the corner of my left eye I saw Liz’s right knee buckle and bend backwards in way that it was not designed to do so.

I stopped the backwards movement of the gurney and shoved it in from my side dragging Liz up to the back ambulance door. I looked at Liz half bent over, clutching the door with her left arm to keep from falling over and her knee with her right hand. Her face was a mask of guarded pain.

I quickly made one of those medic decisions reformulating a course of action I thought would take care of both of my patient’s problems. Like I was in charge or something.

“Look Liz, let me get a line started on our patient and then I’m going to put you in the captains chair. Just guard her airway and I’ll have another crew meet us at the hospital.”

Liz looked up and grabbed me by the front of my shirt with her right hand.

She was still hanging onto the ambulance door with her left hand and she fixed me with “that look”. The kind where you suddenly start hearing the song from the final gunfight in the movie “The Good, The Bad and the Ugly” in your head. The kind that made me know that there was only right answer and everything else would be pain or worse.

“That lady needs a paramedic so get your paramedic butt in there and take care of her!” She gave me a shove and then turned to close the doors.

As I got our now postictal patient hooked up to the heart monitor and switched her over to the onboard oxygen I heard Liz clawing her way down the side of the ambulance, dragging herself by the rain gutter along the roof and painfully pulling herself half step by half step to the driver’s door.

I listened as she let out a little cry/grunt of pain as she pulled herself into the driver’s seat, start the unit up and proceed to give us a very smooth code three ride to Barnes Hospital. All the while driving and braking with her left foot.

I got two IVs established and radioed ahead for a crew and a supervisor to meet us at the hospital. That my partner had blown her knee out and that we were code three with a seizing stroke patient.

Liz got us to the hospital where we were met by two crews, followed shortly thereafter by both EMS supervisors, the deputy chief and the chief. Liz consented to let us unload the patient without her help.

After giving a quick hand-off report to the ED staff I left the other crews to move the patient to the hospital gurney, grabbed a wheel chair, because I knew Liz would not tolerate a hospital gurney, and went back out to the ambulance.

I would like to say that Liz started to pull herself out and this time I grabbed her by the front of her uniform with both of my hands and firmly pushed her back into the seat. “You’re not going anywhere until I splint that leg.”

And you know what, she let me.

I bound her good leg to her injured leg and then picked her up in my arms and set her down in the wheel chair. One of the other medics handed her an ice pack which she put on her knee and I wheeled her into the ED and over to a hospital gurney. I picked her and put her on it as gently as possible.

When the grimace cleared from her face she smiled at me and whispered, “Not bad for a white boy.”

But that’s not how it happened. I brought the wheel chair out and went to pick her up from the driver’s seat to place her in the wheel chair.

She pushed me away while saying “Get your hand off of my butt.” It was said with a smile through the pain as she lowered herself out of the ambulance and sat down in the wheel chair.

I wheeled her in to the designated ED cubical and she did consent to let me support her injured knee and leg while she climbed out of the chair and up into the bed.

But the call wasn’t over. By now I had two other EMS crews and the entire EMS administration behind me. I turned around to the bosses and firmly but quietly stated, I was told later, hissed, that Liz was going to be taken care of right here. At Barnes Hospital. That I didn’t care what the rules said, we were not going to transfer her to City Hospital Number One.

Apparently some of Liz’s toughness and reputation had rubbed off on me and both chiefs quickly reassured me that this was exactly what was going to happen. And it did.

Two days post-surgery I brought 3 of Liz’s favorite things up to her. A two-liter bottle of Pepsi and two large bags of bar-b-que potato chips. She was pretty doped up on pain meds but was with it enough to thank me.

But the best was the “IV”. I had emptied a 250 cc bag of D5W and refilled it with a half pint of scotch and spiked it with macro drip tubing. I grabbed a medication label from the nurses station and marked it as such. I made sure all the nurses knew that it was scotch and not to plug the line into her and then hung it up by her bedside with the tubing within her reach.

I pretty much finished my career with the City of St. Louis on Medic 8 and worked with several more good partners but those are stories for other columns. Liz was a long time in returning to the street. We partnered up again for one watch and then went our different ways, me ultimately relocating out to San Francisco in 1985.

During the course of my EMS journey, I have had the good fortune to work on some good units with mostly good to some great partners. Along the way I also had the chance to become a SWAT medic, a structural collapse/USAR technician and medic, a surf rescue swimmer and a cliff rescue type. A lot of opportunities for testosterone and adventures.

But throughout my 34-year-and-still-going career in EMS, Liz Crawford stands out as my platinum standard for tough. Partner tough and loyal. EMS tough and getting the job done. Street tough without crossing the line and becoming a bully.

Thanks Liz.

Leave a comment