Mama mad

03ambThis was the key phrase that averted a minor catastrophe and put the best end to that was playing out to be one of those “you’ll never believe this” mini-dramas at two in the morning last fall, around a tree, in downtown Ouray, Colorado. My bride and I had been peacefully asleep when one of Ouray PD’s finest special-called me.

When fully-staffed, there are only 17 full time law enforcement officers in Ouray County; divided between the County Sheriff, the Ouray City Police Department, the Ridgway Marshal’s Office and the enforcement rangers for the Ridgway State Park. That’s not a heck of a lot of law enforcement for 542 square miles. The agencies back each other up but you can be on your own for a while until help arrives.

I wasn’t special-called because officer Biggs, of course nicknamed “Smalls” needed, to quote the movie ‘The Princess Bride,’ “the Brute Squad”. Nope, she wanted me there to pick up the pieces when she tasered this one particular drunken bubba’s butt.

To set the stage, in the City of Ouray, population 973, we had been having periodic problems with marauding bruins coming into town and going dumpster diving. To compound the problem, somehow the bears seemed to know that this would be a particularly long and cold winter for them. How they knew we would end up receiving 178% of normal snowfall science has yet to figure out. Anyway, throughout the month of October we were having even more than the usual number of marauding bear “visits”.

It just so happened on this particular evening that three Texas elk hunters, down on their hunting luck, were drowning their sorrows at the Silver Eagle Saloon when one of them spotted a bear crossing Main Street.

Like any fine somewhat inebriated self respecting Texan would do, they ran out and gave chase to said bear.

Frankly, if the bear had hauled off and decked them, it would have served them right but then the bear would have had to been put down by the Colorado Dept. of Wildlife. So our smarter-than-average bruin turned and high tailed it towards the hillside.

The problem was that he had just finished gorging himself of the contents of several trash cans so he was lumbering a little slower than usual. In turn, our highly motivated but judgmentally-challenged Texans, who were whooping and hollering, were gaining ground. Not to mention generating numerous calls, at least for us, to 911 for disturbing the peace at almost two in the morning.

When Officer Biggs caught up with the group, they had chased the bear up a tree. But that was not the worst of it. Not by a long shot.

The boldest or drunkest of the group had climbed up the tree after the bear because, and I quote, he was going to “Whack it in the butt!”.

You can’t make stuff like this up.

So why was I special-called? Well the telephone conversation went something like this…”This is Norm.” I have long had the ability to sound like I’m wide awake when awakened from a sound sleep by radio traffic or a phone call, even while the brain is still rebooting up.

“Norm, I need you right now.” Officer Biggs informed me in a tone of voice that spoke volumes.

“Ahhh, Nicole… Why?”

“I’m finally going to get to tase someone and I want you here when he falls out of the tree.”

“Pardon me?”

Over the top of voices shouting in the background and Nicole telling someone to get down now, right now and she wasn’t fooling, she went on to tell me, “I’m the only one from my academy class who hasn’t tasered anyone yet, but that is about to end tonight so get down here now.”

More shouting in the background and other noises I couldn’t quite identify and Nicole ordering someone down again. “Look, just get here.” And she hung up.

As I struggled out of bed, disturbing our cat who let me know that she was annoyed, my bride asked what the call was about. I told her I wasn’t quite sure but it sounded like Nicole was about to taser someone.

Vicki called it right as she rolled back over, “Probably some drunken Texan. This time let the police take him down.”

OK, you can take the medic out of the city, but some of those muscle memory instincts don’t always stay behind. There had been a couple of calls over the past three years where I had “adjudicated” a situation and then realized that law enforcement was there and it was in their job description to do so, not mine.
So properly and appropriately chastised I finished dressing and drove the short mile and half to Nicole’s location.

There was Nicole on one side of a swaying 45-foot pine tree and two fellows on the other hollerin’ up to their buddy about 20-feet or so up in the tree who was still insisting that he just wanted to “Whack it in the butt!”.

The Ouray County Sheriff’s deputy was responding to back her up but he was way up in the north end of the county and still about 10 minutes out.

Nicole had her taser out and little blue flashes of electricity were arcing between the dry stun electrodes as she gave several warning cracks on it to let everyone know she was serious.

She gave one last command for the fellow to come down now. Right now or she was going to fry his butt!

It was then that one of the buddies let out with the telling phrase.

“You better come down now Cody, she really means it and she’s more than pissed. She’s Mama Mad.”

Apparently the term “Mama Mad” caused some preconditioned survival neurons to kick-in and take over. All of a sudden our belligerent tree climber turned docile as a boy scout, climbed down and stood in front of Nicole, all five foot four of her. With his head hung down and in a soft voice totally different from his early hollerin’ he apologized.

“Sorry ma’am. I guess I got carried away.”

Nicole said a few more things. All three of the now humble and chagrined Texans stood towering over her with their heads hung down and mumbling a chorus of “Yes ma’ams” and “No Ma’ams.”. Nicole ended up taking a field report and let him off with a warning.

Our young tree climber and his buddies promised to never, ever, ever chase a bear again or otherwise make rowdy in town and walked back to their motel.

Nicole turned to me and instead of saying thanks, said “Damn! I’m still the only one from my academy class that hasn’t tased anyone yet.”

I said something about better luck next time and got back into my buggy and headed back home. On the way home I started playing the little mini-drama back in my head. The obvious turning pint had been the phrase “Mama Mad”.

I got to thinking about the power of those words.

Obviously this has to be a conditioned response. My dad had a phrase that he would use, “You better” fill in the blank, “or heads will roll and tears will flow like rivers.” When my brother and I would hear this we knew there was only one correct response and everything else would result in pain or worse.

This wasn’t an immediate response the first time we heard those words. We had learned over the years, the meaning behind them. Good judgment is what you get for surviving bad judgment. Yours or someone else’s.

But our mother, she had various levels of, shall we say, force escalation.

Everything from reasoning, motivating, to indirect action. She taught my brother and I to start making our own beds by short sheeting them when I was 12. We quickly figured out it was easier to just make the bed then have to get up at night and remake it right just so we could sleep. And she strategically timed this behavioral modification during the winter months so there was no faking it by sleeping between the top sheet and the bedspread or blanket.

But when those didn’t work, or we had just plain ticked her off most royally or had otherwise pushed her past her limit, well then, the game was on. And Mama Mad was just not a good time for bonding.

Not that I ever got a whoopin’ I hadn’t earned, with one exception, it was just that when mom got to that point, even if my brother JD or I held perfectly still, it was only a 50/50 chance that the swat, shot with the wooden spoon or swing of the belt would actually land on our butts. I understood ‘Mama Mad’ all to well. Having pushed her to that a time or two growing up.

And speaking of games, how many of you remember the 1992 movie A League Of Their Own’? My friend Kenny Darenzo’s mom was one of the women who played in the women’s professional baseball league during World War Two. She had one heck of a throwing arm.

One day Dick Sterne and I were playing at Kenny’s, I think we were 11 or 12. Anyway, Kenny’s older brother Bill had done something to tick their mom off. I mean really cheese her off. She was unpacking groceries while we were playing in the den. Kenny happened to look up and spot his brother walking down the driveway about the same time his mother did.

Kenny took one look at her as she was making for the front door, threw open the window and yelled “Run Bill. She’s got a potato!”

Bill turned around and started beating feet but he wasn’t quick enough. She caught him at almost a hundred feet away right between the shoulder blades, bringing him down in a cloud of dust. She then turned and glared at Kenny.

Dick and I were frozen in place like deer-in-the-headlights but Kenny had no illusions on what was coming next. He took off for his bedroom as quick as he could as Mrs. Darenzo pulled off her sneaker let it fly. Kenny had already rounded the corner and was two steps from his door, but like a Cruise Missile, that sneaker tracked him around the corner and caught him in the back of the knees, bringing him down with a crash.

She fixed us with a look that said “Problem?!”

“Uh, no ma’am. I think we’ll just be going home now.”

“Good idea.”

As I grew up and left home to follow the medic trail. I encountered numerous examples across the races and religions in various parts of the country that reinforced the old adage, “If Mama Ain’t Happy, Ain’t Nobody Happy”.

Whether in the poor or working class neighborhoods of St. Louis or the blue collar neighborhoods of Ypsitucky. That’s actually Ypsilanti, Michigan. So many southerners, especially from Kentucky had migrated north to work at the GM Hydramatic Plant in Ypsilanti that in the 70’s it had earned that nickname by us emergency responders.

From there to the multicultural neighborhoods of south San Jose to the streets of San Francisco, one thing was constant. In most families, single parent or both, gay or straight, the mother, or the person in the mother role, was the driving force for the family the vast majority of the time.

On more occasions than I can accurately recount I managed to talk my partner and I out of trouble or calmed down an explosive scene by identifying the alpha female and working with them. Once she was with the program, the rest of the family generally calmed down. Or at least stopped venting on us.

This wasn’t always possible though. One call in particular stands out. It was a late spring night 22 years ago. 1986. My partner and I had been dispatched to an assault in a low-income apartment parking lot. It was one of those East San Jose surrealistic calls that sort of defied logic.

For one, the Santa Clara Valley had been developed so quickly in the 60’s & 70’s that there were miles and miles of low and middle income housing in what had only a decade or so before been fruit orchards. Each developer, in turn was able to assign street names to their developments. This resulted in some really interesting themed names for various neighborhoods.

One neighborhood would have wine related themes. Chardonnay Way, Cabaret Lane, etc.. Another was named after various agricultural products.

Cantaloupe Drive, Melon Street. And for some poor married couples, Honey Dew Lane. (The husbands out there will all get this one.)

Anyway, this low income apartment complex was located in a neighborhood where all the streets were named after Disney characters. So we were responding to the intersection of Bambi Lane and Cinderella Court for the assault.

We arrived with a two-man fire unit and two police cars to find a big 16 year old Samoan kid laying unconscious in the parking lot. He had obviously been in a fight and come in second. We c-spined him, backboard, c-collar, sandbags and tape. A nasal pharyngeal airway and high flow oxygen via a non-rebreather mask completed the ensemble.

We had just lifted him onto the gurney and were just about to raise it up to roll it over to the ambulance when we heard a commotion coming towards us. We turned to observe a large Samoan woman running towards us being trailed by what we later learned were her other sons, daughters, nieces and nephews. She was just about my height and size and we were two of the smaller members of the group that arrived.

She threw herself across our patient who turned out be her son and started crying.

I was just about to step forward and reassure her that he would be all right when she started shouting “I told you not to hang out with those boys!” And started punching and slapping her unconscious son.

The oxygen mask and then the c-collar went flying in different directions as she continued to chastise and otherwise vent her frustrations to her unconscious son. I started to step in to intervene when I felt a large hand on my shoulder.

One of her older sons leaned down and said in a low and actually very kind voice. “Don’t. When she gets like this it’s best not to get in the way.”

She was Mama Mad. While I was contemplating his words she finished meting out punishment, cried on our patient’s chest for another minute or so and then told him that she loved him and would see him at the hospital.

We hustled our patient to the ambulance before she had a chance to change her mind and repackaged the kid enroute. Documentation? It began with ‘the patient was the victim of several assaults’ and then went on to describe his injuries, treatments and response to those.

Getting back to the present, as I returned home and made my way back upstairs to annoy our cat yet again because I made her move out of my spot in bed, I bet that patient from 1986 understood what “Mama Mad” was and idly wondered what our tree climbing Texan had done to learn what it meant as well.

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.

Heroin flashbacks

TAOS5I pushed Narcan the other day. The first time in over four years.

Some of you may be thinking “So what.” or “Big deal.” Or even the more derisive “Big Whoop.”.

However, having provided EMS for the southern half of Santa Clara County and the City of San Francisco for over two decades where we used Narcan, almost by the gallon, this was a familiar flashback.

Heck we gave it so many times back then that as an EMS system, we had gotten into the habit of “hot shotting” it. Bypassing the formality of establishing an IV and just injecting it directly into the patient’s veins.

And for those of you who may be cringing at this, we were not a system out of control. Just efficient and expedient. Or so we liked to say. However we drew the line there. Unlike our brother & sister medics across the bay who developed the habit of giving Narcan sublingually by injecting it through the bottom of the patient’s jaw.

But I am digressing.

Last week’s run was a simple call really. We responded to the only trailer court, actually the house trailers, single and double-wides, are spread out over a ridge side. But when your jurisdiction is a glacial valley high up in the San Juan Mountains, that counts as a trailer court.

Getting back to the call, our intrepid local visiting nurse was checking up on one of her charges, a broken down cowboy and former champion team roper, a healer, who is only a few months older than me, when she noticed something was amiss. Actually Altered Mental Status.

Seems our cowboy had a medical history somewhat akin to that children’s song, “I know an old lady who swallowed a fly”. He had a degenerative back disorder that in turn led to immobility, which in turn led to the development of multiple bed/pressure sores and hot spots.

One of which had been recently debrided almost down to the bone and he had a suction pump on over the wound site.

In turn he was prescribed a Fentanyl patch for pain control and after the debridement, also placed on Oxycontin, among other things. This is a Reader’s Digest version of this man’s med history but enough to set the stage.

So it seems that our cowboy was in significant pain and this particular morning he took not one but two of his Oxycontins. AKA, Hillbilly Heroin.

The prescription drug that conservative right wing radio commentator Rush Limbaugh became hooked on. Along with hundreds, if not thousands of North Americans north and south of the 48th parallel over the years.

Our patient was one we had seen numerous times over the past three years for a variety of problems. AMS secondary to alcohol to a fit of depression where he shot up his trailer court and held off emergency responders for several hours before being talked down and allowing us to transport him to the hospital. He was always initially angry on first contact but once we were able to talk our way through the anger, he was actually quite a charming and affable fellow.

This time he was in a recliner, snoring respirations of two to four with a room air sat of 61 percent and rouseable to moderate physical stimuli. Once roused he was lucid for 20-30 seconds but if left unstimulated, drifted back down to unconsciousness.

At my suggestion, my volunteer checked our patient’s pupils, one of the most frequently overlooked or fudged patient assessment signs, and, you guessed it, they were pin point. My EMTs thought I was genius.

Yeah, right!

Truth is that I am just an old medic who has the benefit of working 20 years in the San Francisco Bay area, the heroin capitol of the US. I, like all of my bay area medic brethren and sistren have assessed and treated more opiate overdoses, straight up or in combination with other substances than you can shake a stick at.

As our volunteer EMTs and driver placed our cowboy on high-flow oxygen, which brought his oxygen sats up into the 90s, fantastic when your elevation is between seven and eight thousand feet, dozens of my former patients flashed before my eyes.

Like the time I was a new medic and was trying to figure out why my female AMS patient with pin point pupils had a huge wad of ice shoved down the crotch of her panty hose. Or the multiple times we had been called for the unknown medical eval in a hallway of an SRO apartment building only to find one, two and sometimes more patients, all in respiratory arrest and AMS.

It would turn out the patients had been in a “shooting gallery” and received a stronger dose of Heroin than they were used to. The fine operators of the gallery would dump the unfortunate user in the hallway or out on the sidewalk and call 911.

Probably the best war story about this type of call occurred to a brother San Francisco Dept. of Public Health Paramedic, Mike Tregassor, aka Tregasourous, back in the early 80’s.

Back then, after three in the morning, the City of SF would go down to five ambulances until the day units would start coming inservice at 05:30.

It was a busy night and all the other units were tied up on runs. Sound familiar?

Anyway, Mike’s unit was dispatched to an apartment code two for a medical eval. Mike and his partner arrived and received no answer when they buzzed the apartment number at the door. Dispatch was unable to get anyone to answer the callback number.

Being resourceful medics, they went down every apartment number on the door panel until they were finally able to rouse one of the other building occupants to let them in. They trudged upstairs to discover the apartment door partially open.

Pushing the door open after no one responded to their knocking, they discovered that they had not one, but five patients scattered about the apartment. All unconscious and not breathing or grossly hypo-ventilating.

A shooting gallery that had the misfortune to be using a new shipment of Heroin that was stronger than the local junkies were used to.

My partner and I were just unloading an assault victim at San Francisco General Hospital when we heard Mike come across the air stating he had five H-ODs and needed at least two additional ambulances.

Dispatch acknowledged his traffic and then informed him that there were no available units and that they were on their own.

My partner and I just looked at each other and then informed the triage nurse that our patient was stable and that we had to go and we beat feet to the ambulance to back Mike up.

Mike in the meantime, I’m sure uttered a word or two of frustration but then became medic brilliant. He and his partner came up with one of those innovative solutions that they just don’t teach you in EMT or paramedic school.

They dragged all the patients to the middle of the apartment and arranged them like spokes on a wagon wheel. Heads towards the center and feet out to the periphery. Mike’s partner got out their only bag-valve-mask device while Mike hooked it up to their portable oxygen. The partner, I wish I could remember his name, then crouched in the center of the patients and ventilated each patient with two breaths before going on to the next patient.

Mike in the meantime ran back down to the ambulance and grabbed all the Narcan on the unit, which was a lot. He returned in time to help his partner disentangle himself from the oxygen supply tubing and continue to ventilate each patient in turn.

Mike then hot-shotted each patient with Narcan in whatever vein was most prominent. Whether it was the traditional anticubital, AC, or the less conventional external jugular. Every patient received 2-4 mg of Narcan.
Mike later stated that if he had needed to do CPR on all the patients, the way they had them arranged, he could have just literally jumped from chest to chest around the circle. Fortunately, this wasn’t required.

The Narcan got all of the patients breathing again on their own. Two of them even woke all the way up. When my partner and I arrived we were greeted by the elevator door opening and Mike dragging a still unconscious, but now breathing patient by his collar and the two other patients who were now awake sort of assisting two other semiconscious patients.

We supplied some additional Narcan and helped transport all of these very fortunate folks to the hospital.

Ten years and dozens of Heroin overdose calls later, I was working the night watch with Vicki, my bride of now almost 24 years and sister medic.

In addition we had a ride along that evening. Lance Wright, an Auckland, New Zealand paramedic and friend, who was visiting the Bay area and was spending part of his vacation riding with us.

It just so happened that a new shipment of Heroin had hit San Francisco that weekend and we were dealing with H-OD after H-OD the previous two nights. The hits just kept on coming.

I happened to be driving that evening and Vicki was attending, when we received a call for an AMS, possible H-OD in the 4th floor hallway of a Chinatown walkup apartment building.

We arrived ahead of the fire department but there were several police cars on scene. And of course the elevator was out of service. As we took to the stairs we heard a woman screaming and looked up to see a police officer’s head pop over the banister and tell us the patient was not breathing. The head disappeared and then reappeared a second later with the statement.

“Oh my God! I can’t believe my partner is giving him mouth to mouth!”

This had to be bad if the cops were doing a lip lock on a patient. So we chugged our way up 4 flights of stairs to find one officer with a screaming woman, she turned out to be the patient’s wife, and a large unconscious male laying in the hallway outside of their apartment.

Lance lets out one of those cheery Commonwealth statements along the lines of “Oh goody, I’ve never seen Narcan given before.”

We quickly explained as we started bagging (ventilating) the patient that we weren’t going to give it right away. That the reason opiate overdose patients had the reputation of coming up combative after Narcan administration was not that we had ruined their high. It was hypoxia.

Opiates work by slowing everything down including the patient’s respiratory drive. Opiate OD’s die not because the drug kills them directly. Those patients who are found dead with a needle still in their arm, were not killed by the opiate, but rather what the drug had been cut with. Like Strychnine or something else equally unhealthy.

Deaths due to the opiates occur because the patient’s metabolism and specifically respiratory drive have been slowed down to the point where they just forget to take their next breath. This is why your classic opiate overdose is AMS, weak, thready pulse, pinpoint pupils and either apneic or hypo-ventilating.

So we ventilated our patient with 100% oxygen. In the meantime we introduced Lance, who was wearing his New Zealand Ambulance Officer’s uniform — and as a station commander/senior paramedic had an impressive set of pips on his epaulettes. Our coppers were fascinated with him and proceeded to show him the patient’s works set and other evidence to look for. It was all quite interesting and educational for Lance who asked a number of astute questions.

In the meantime, after two to three minutes of ventilating our patient, all the while accompanied by the rhythmic screams of his wife in the background, Vicki started hot-shotting Narcan directly into our patient’s right anticubital vein. We gave all 8 mgs we had in our response bag. Spaced out one after the other waiting for the patient to recover in-between each injection.

Five minutes later our patient is still unconscious but at least is making some respiratory effort on his own. Man, this was some strong stuff.
Being the driver on this call, I was the one who had to trot back down four flights of stairs to retrieve more Narcan from the ambulance. On my way down I passed the fire crew arriving on scene and trudging up to the stairs.

After grabbing three more Narcans, I headed back into the apartment building and up the stairs. As I ascended, I noticed something was different but I couldn’t figure out what. As I arrived on the 4th floor, doing that hypoxia breathing through clenched teeth, I handed the three Narcan preloads to my bride.

She handed one back and pointed behind me. That is when I figured out what was different. It was quiet.

Well except for the firefighter holding on to the upraised arm of our formally screaming wife who was now unconscious and in a crouched position.

She would have been passed out on the floor except for our firefighter holding her up by the wrist and shaking it saying “Lady. Hey lady. Wake up.”

I walked over and hot-shotted her and fortunately she woke up with only 2 mg of Narcan. It was one of those surrealistic moments where she went from unconsciousness to looking up at me and stating, “I just had a baby.”

Seems our couple had just had their seventh child, the other six already having been taken away over the years by social services, and were celebrating their latest child by sharing a fix. It was just a lot stronger than they were used to.

Both were taken care of by a total of 14 mg of Narcan between the two of them and pleasantly walked down to the ambulance for a ride back to the hospital.

Lance, in the meantime, was ecstatic, in that quiet British Commonwealth style.

“Do you realize I’ve seen more Narcan pushed on this call then I’ve done in my entire career? Usually we just replace it because it has expired or the vial has broken. Thank you.”

Yeah, like we scheduled this call just for him. But then again, we were somewhat blasé because this was typical for us but new for him. It was just another one of dozens of H-OD calls we had and would run during our almost 20 years with the city. The same basic theme but with varying subplots.

Like trying to coach a paramedic intern on the value of ventilating first.

Or put more simply, BLS before ALS. Yes, we know young Jedi medic that you have the silver bullet of Narcan. But let’s treat the patient’s hypoxia first and then see about administering it.

This has proved to be invaluable wisdom for multiple reasons. Like for those poly-drug users who use Cocaine or meth but hate the post-high crash so they snowball or speedball. Inject a combination of cocaine or meth and heroin. The stimulant for the desired rush and the heroin to ease the post high crash.

The problem, sometimes the heroin was too strong and they would OD. Our only clue was the patient’s vital signs. Unconscious, apneic with pinpoint pupils but instead of a weak thready pulse, they would have a booming, bounding pulse and normal to high blood pressure.

These were the patients we would really ventilate well and then rather than blast the entire amp of Narcan in, would tease it in in small doses. Just enough to wake them up, but not enough to wipe out the chemical governor actions of the heroin, leaving us with a straight meth or cocaine patient bouncing off of the walls and ceiling.

Our airway adjunct device of choice for these kinds of calls was always the nasal pharyngeal airway. It accomplished the job and was well tolerated by the patients as they awoke. Frequently pulling out the NPA and staring at it with a puzzled look. More than a time or two a smart ass SF medic or firefighter would made the comment, “Hell of booger dude.”

We drilled this concept into one of our paramedic intern’s head. We were running on his second or third H-OD call early in his internship. Again I was driving and Vicki was attending.

We arrived on scene and fire was already there and ventilating our female patient with their BVM.

Her boyfriend was quite amped up and talking away a mile a minute.

His pupils were dilated big as saucers so I could tell his drug of choice was speed or some other stimulant. Being the good support medic, I culled him out of the scene and took him out into the hallway on the pretext of getting a good patient history on his girlfriend.

Over my shoulder I could see Vicki coaching our intern on getting the NPA ready. Selecting the right size, lubing it up with a water soluble lube and then he had fire stop ventilating the patient.

The boyfriend was proving to be high maintenance so he had most of my attention but I overhead our intern say, “Oh shit. Just keep ventilating her.”

Turns out she was one of those folks that had established her individuality by having a septal nose ring and three additional rings on each side of her nostrils for a total of seven.

This turned out to be a good teaching call because without prompting, our intern went back to manual airway control and ventilating the patient up.

When he administered the Narcan, the patient woke up without a problem or a complaint.

In the meantime her boyfriend was becoming increasingly slow and slurred in his speech and when I rechecked his eyes, they were now pinpoint. I gave him 2 mg Narcan IM in the shoulder and we all walked out to the ambulance for the ride to the hospital.

There were many more H-OD calls. Especially around the Christmas Holidays.

As Vicki put it one Christmas Eve night after we had treated our 4th H-OD.

“There must be dozens of mothers across the nation who sent their son or daughter a check and said “here, buy yourself something nice for Christmas”.

But the one Heroin overdose call that truly stands out in my mind, the one I learned the most from, and the one that I was humbled by occurred in 1992.

By 1992 I had been an EMT and later a paramedic for 19 years. I was more than a little jaded by everything that I had been witness to or participated in. And when it came to Heroin overdoses, I was more than a little callous.

Looking back, I was an arrogant schmuck.

(For those of you not familiar with this highly descriptive Yiddish term, it means a prick. As opposed to another great and equally descriptive Yiddish word, Putz, which means a limp dick. Used in a sentence like, “He’s just a putz.” or “Quit putzing around.”)

My view on Heroin overdoses ran along the lines of the theme song from that 70’s TV show, Baretta. “Don’t do the crime if you can’t do the time.” So I didn’t have a whole lot of sympathy or empathy for our H-OD cases. After all, just like the patient who drinks too much, they had chosen to do this to themselves. They rolled the dice and when I would see them, the dice had obviously come up snake eyes. Literally by the looks of their pupils.

Several times over the previous few months, my partner, Mike Whooley and I had responded to the same Tenderloin apartment for a 69 year old female H-OD. She had no veins to speak of and was skin popping the drug. We would ventilate her up and then administer the Narcan IM which would wake her up and immediately push her into withdrawal symptoms.

Pitiful and uncomfortable to witness, let alone experience. But it wasn’t like I was pushing the Heroin on her. After the third or fourth time I had done this, while we were transporting her to the hospital, I asked her why she was doing this.

After all, the tradeoff with age for youth is wisdom over strength and endurance. And God Dammit! She was old enough to know better.

And that was when I was quietly knocked off of my arrogant high horse. She looked over at me on the squad bench and in-between dry heaves said to the effect.

“Sonny, I don’t shoot that crap to get high. I have cancer of the spinal column. Two years ago the pain was so bad that even Laudanum wasn’t touching it and I was in such constant agony that I was considering jumping off of the Golden Gate Bridge.”

I was now feeling about two inches tall as she continued.

“My granddaughter, who had been the bane of my existence up until then came up to me and said, grandma, let me fix you up. And I was so desperate that I let her shoot me up. And you know what? It was the first time in over two years that I had been pain free. So I don’t take this shit to get high.

I just take it to live.”

“And I can’t help it that this stuff isn’t regulated by the Food and Drug Administration so when a new batch hits town every six weeks or so and is not stepped on enough for my usual dose, it knocks me out and you have to be called. So pardon me and get off your high horse.”

I mumbled an embarrassed “Yes ma’am.” And pondered her words for the rest of the transport. And Mike and I did see her several more times over the years. We adjusted the amount of Narcan we gave her IM, just enough to wake her up but not so much to push her into withdrawal.

Our system also did our own dispatching and maintained a frequent flyer book. After I completed the call, I went to dispatch and entered this patient’s pertinent information and history so if anyone else had to respond to her they would go in with their eyes open and avoid my mistake.

And that lesson came back to me with my opiate induced AMS cowboy. I needed to rouse this fellow enough to breath on his own but not wipe out all of his opiate effects and either push him into withdrawal or slightly better, just put him back into a painful agony.

So after we ventilated him up to a 98 percent oxygen sat, I gave him 0.5 mg Narcan IM in his right shoulder. And within a minute he woke up and was not too unduly uncomfortable for our ride to the hospital.

Lesson learned. Mission accomplished.