Going, going, going.........

This is the infamous MAHOPS patch I wrote about earlier.
Let's review, counter-clockwise from top left:
Emerson -- gone
Holyoke Hospital -- gone
Lawrence General Hospital -- Active
Greater Lowell (aka Saints) -- Active
Milford 2181 -- gone
Caritas Norwood -- gone
Southshore Hospital -- gone
UMassMemorial -- Active

That's five out of eight hospital-based ALS units out of business since 2005, when this patch was created.

I could have included the Natick-based MetroWest Medical Center unit that was shut down just prior to this patch's conception, or UMass's ALS-2 out of Marlboro Hospital, which closed in 2000 or 2001 (I forget). If we REALLY wanted to round out the roster of shuttered non-transport, hospital-based services we could include the likes of St. Lukes in New Bedford and NSP-1 out of Lahey Clinic in Burlington.

I'm tempted to include the paramedic unit out of the Jordan Hospital in Plymouth, but I think that would just be piling on as, from my understanding, that was a partnership between the hospital and AMR.

Is EMS A Failed Experiment?

I got the word last night.

Another nail has been driven into the coffin carrying the remains of what were once some of the best EMS systems in the country.

Emerson Hospital will discard its non-transporting ALS service next month, ending over three decades of service to its 14-town region spread along Route 2 and centered on the town of Concord.

A private ambulance company will buy the service from Emerson and has pledged to keep things the way they are, right down to the uniforms and offering employment to the service’s current paramedics. Though it will no longer run the service, Emerson Hospital will still provide the district’s medical oversight.

Of course, such employment will come at a significant pay cut for Emerson’s soon-to-be-former paramedic staff, especially considering this private has a lousy pay scale for the area ($16 per hour base, with 25 cents per year of experience) and doesn’t appear to offer differentials for working nights and weekends.

I also think the pledges to maintain the status quo were a means to placate nervous customers (ie, the towns once served by Emerson, the hospital itself) and won’t last.

And so another hospital-based paramedic service bites the dust, this time the oldest in Massachusetts.

Where once there were over a dozen in the late-1990s, there now stand just three – Lawrence General Hospital in Lawrence, Saints Memorial Medical Center in Lowell, and UMassMemorial in Worcester.

Three hospitals in the entire state committed to caring for the people in their catchment areas but outside the walls of the building. Before I say anything else, I think I need to laud in the highest way possible these three hospitals for keeping faith with the idea that prehospital medicine is important, and has a rightful place at the table of the medical professions. There is going to be some criticism in these paragraphs of hospital commitment to prehospital medicine. Saints, Lawrence and UMass have proven themselves the stalwart exceptions, and I wish them all decades of continued success and service.

Some of the hospital-based services that shut down previously have since re-started as transfer-only services, but these bear little resemblance to the non-transporting regional 911 paramedic units they replaced.

Throughout the years the argument has raged over whether EMS should fall under public health or public safety.

Those supporting EMS under the umbrella of the fire service champion it as another facet of the “all-hazards” approach to public safety, where the local fire brigade does everything from putting out the fire in your kitchen to inspecting your new boiler to treating your chest pain.

Advocates of the public health model say that the “M” in EMS stands for “Medical,” and that the proper delivery method for EMS should rightly fall under the auspices of the medical experts.

Which sounds good in theory, but in practice most public health entities from whom paramedics have sought employment – ie, the hospitals – have ultimately decided the cost far outweighed the benefit of providing Emergency Medical Services via a single-role, medically-oriented delivery model.

In other words, hospitals have proven they only have an appetite for running paramedic services if someone else pays for dessert.

Critics point out, correctly in a lot of cases, I believe, that fire departments often only want EMS as a way to bolster their numbers, a backdoor means to securing employment for the most firefighters possible and reinforcing personnel rosters in an era of declining fires, an imploding world economy and an exponentially increasing utilization of EMS.

Deep Throat told Woodward and Bernstein to “follow the money,” and I think anyone who follows the money in public safety realizes that EMS, unlike Police or Fire services, generates revenue.

Whether it generates revenue in excess of expenses is another conversation altogether and depends mainly on your customer base. Decaying former mill cities will have fewer customers with high-end private insurance or HMO coverage than the ‘burbs, plain and simple. It might be math, but it ain’t rocket science.

But these critics unjustly let hospitals off the hook.

Some in EMS pillory as morally bankrupt fire departments who want EMS as a way to keep their people gainfully employed, and yet don’t bat an eyelash at hospitals who unceremoniously drop their ALS programs as a way to slash the payroll and balance the budget by breaking the backs of some of their lowest paid employees, employees who, it needs to be said, also bear patient-care responsibilities that much higher-paid health workers, like nurses, could only dream of in their worst nightmares.

In the end the closures of the hospital-based paramedic programs at Emerson, Milford, Holyoke hospitals and MetroWest Medical Center in Natick, as but a few examples, served no higher purpose than the saving of a few bucks.

Even UMassMemorial in Worcester, which is to be commended for its commitment to providing 911 to Worcester and Shrewsbury, had its limits. Earlier this decade UMass shut down its non-transporting ALS unit out of Marlboro Hospital for cost concerns.

The claim, often touted in these hospital-based service closings, that a declining call volume due to fire department upgrade to the ALS level is responsible for hospitals shutting down their paramedic units has clearly proven over time to be a red herring, meant to distract us from the fact that hospitals in Massachusetts do not believe in EMS as a core public health mission vital enough to be supported in the one way support is registered in 21st century America – money.

Were it otherwise my MAHOPS patch (a wonderfully and pitiably anachronistic acronym for the Massachusetts Association of Hospital Operated Paramedic Services – it is worn on the right shoulder of my soon-to-be defunct Emerson Hospital Paramedics uniform and was designed by a former longtime Emerson medic who had to quit and become a municipal bus driver in order to get the same benefits and retirement plan as local police, fire and DPW workers) would not be adorned with the names of a half-dozen hospital-based paramedic services shut down over the last decade even while recording robust call volumes.

So the question I find myself asking, in light of the fact that the medical profession here in Massachusetts has by and large turned its back on prehospital medicine, is this:

Is EMS a failed experiment?

What does it mean if the only people who truly want you do so mainly because it helps them fight fires, and that the medical professionals who should want you don’t think you’re worth the money?

If so few doctors, the high priests of medicine themselves, have railed against the closing of the hospital-based paramedic services (although it should be noted that the doctors who have tried to stop the madness have fought with great passion and conviction – and to them I would say that we know who you are, and we are proud to have worked for you), what does that say about our place in the medical cosmos?

Not much, I’m afraid.

Part of that, of course, might have something to do with the relative age of our profession. The first cops were probably the biggest guys in the prehistoric post-Ice Age caves, who tens of thousands of years ago used clubs to keep order. The first recorded firefighters were loosely organized under Emperor Trajan during the Roman Empire. I, however, am 40-years-old, yet still older than my profession.

We’re new to everyone.

But are some people in the medical profession beginning to have doubts about EMS, or even the necessity of paramedics?

I think so. It doesn’t take a Burmese scout to track the scent.

Numerous studies have appeared in journals in recent years documenting paramedic shortcomings in everything from intubation to STEMI recognition to the overall morbidity and mortality of every living human over the last 30 years. There are too many of us, the studies say, we’re not particularly good at what we do, and the evidence doesn’t seem to suggest we make much of a difference.

Adding insult to injury, the powers-that-be in Massachusetts want to give EMT-Basics the ability to place invasive, advanced airways in patients despite the fact that the curriculum for EMT certification is so watered down that we can’t get them to bring Stair Chairs or do blood pressures on calls on their own initiative.

Such suggestions smack of the low regard paramedics have garnered in some corners of the medical establishment, that someone with 110 hours of training is pretty much interchangeable with someone who’s had 2,000.

It reminds me of the stand taken by the Massachusetts Board of Registration in Nursing several years ago in a white paper that said, in its view, paramedics were no more capable than a certified nurse’s aide and had no place working in hospitals at all.

Of course, those of us who actually do this job for a living and are not sitting in a university office somewhere with a graphing program and an Excel spreadsheet, know that these conclusions are ludicrous, because our eyes and ears tell us so every day in the real world, with actual patients who have more substance than mere data points on some PhD's graph.

There are people walking this Earth who would be dead had my various partners and I not arrived in our ambulance and done a few things correctly, things that took experienced paramedics working in concert with the committed physicians who trained and watched over us. There aren’t as many of these former patients as I’d like, but they’re out there, and I know their loved ones would have an opinion or two about whether paramedics make a difference, and what price competent ALS is worth to the general public.

The truth is that many of these studies (and, perhaps predictably, most often the most damning examples), though given the veneer of hard science, are really just sociological ruminations, promulgated under the guise of science, made at the behest of certain “investigators” who simply want the imprimatur of publication in a scientific journal to advance their own agendas, even when those agendas are often in direct contradiction to the reality on the streets.

I find it laughable to read these serious-minded “studies” that come to such broad conclusions based on a heterogeneous mess of self-reported data and guesswork, assigning cause-and-effect via intuitive leaps in reasoning so confounded by flaws in logic that they would never pass muster in a laboratory, where real science using objective data to come to repeatable conclusions is performed.

But the state of "scientific" research in EMS leads me to the conclusion that EMS itself, at least here, where I live and ply my trade, is verging on a failed experiment:

Hospitals don’t want to pay for us. Most doctors don’t want to work with us. Most nurses don’t respect us.

But I have hope, and it’s that word “most” that gives me hope.

I know there are physicians out there who have given immense chunks of their professional and personal lives trying to advance prehospital medicine, often working even harder than my paramedic colleagues and probably to the detriment of their own careers. I often wonder how much different this field would be if some of my paramedic friends gave as much of themselves to advance our profession as some of the physicians we’re privileged enough to work with and for?

And I know plenty of nurses who give paramedics their due, who realize we’re an important part of that chain of care that begins by the bedside and continues in the hospital. And to be fair, paramedics don’t always do themselves any favors by the way we interact with nurses. Some of my best mentors have been, and continue to be, nurses. But we’re not going to get any where with the nursing profession as a whole until we hold ourselves to their standards, which is why I think the minimum entry to being a paramedic should be at least a two-year Associate’s Degree program. Again, a conversation for another time.

So for the time being I personally don’t think EMS is a failed experiment, but we’re in trouble.
I think the model is changing, and I think we need to embrace the change. That’s the only way we’ll have a voice in whatever’s coming down the pike to replace what’s already been done.

For EMS, we’re at the end of the beginning. The question is, now what?

Hospitals don’t want us. Fire departments, private ambulance companies and third-services do. I think we need to find a way to keep the “M” in EMS, even if the medical establishment couldn’t care less, and practice the best MEDICINE possible, no matter what the patch on our shoulder says.

The First But Not The Last

There are some things on this job that will never become routine.
Or, more specifically, there are things about this job that, should they become routine, ought to signal to you that it's time for a career change.
You can't check your humanity at the door the day you get your EMT ticket in the mail.
It's Ok for certain things to get to you. Hell, it's probably necessary. After all, what would it mean if there was nothing on this job that could tap into those parts of ourselves that contain empathy, sympathy and compassion?
What if we no longer had a well inside us that contained those things?
It would mean we had become less than human, automatons able to recite drug doses and perform various medical procedures but without that spark -- divine or otherwise -- that differentiates us from monkeys, who are also able to perform simple procedures.
In short, it's Ok to admit that some things bother us. It is in fact necessary to admit this.
That was the point I tried to make to the distraught EMT in the charting room.
We'd just worked together on what was her first cardiac arrest, a sentinel event for anyone new to EMS but made especially so because our patient was 2-months-old.
After we dropped our patient off with the code team I restocked the truck and went to the charting room looking for my partner, ostensibly to see if he needed help writing up the call, but really just to spend a minute or two with a medic I respect tremendously, commisserating about the sadness of it all before shaking it off and getting ready for the next call.
This is a strategy I've used to great success throughout my career.
The room was empty except for the EMT, who stood in the corner weeping. She was a little embarrassed to be discovered, but didn't stop.
I asked her if it was her first pedi code, and she told me it was her first code, period.
I assured her that she had performed admirably and professionally, and that there was nothing she or any of us could have done to bring that baby back; that we all acted as aggressively as we could, but that the baby had been down long before we got there.
I know the "research" about debriefing after rough calls is sketchy, and that there is a school of thought out there that says critical incident stress debriefing -- an automatic process that kicks in in many EMS systems after intense calls -- actually causes more harm than good by continuously re-opening psychic wounds among responders and not allowing time for healing.
I'm not sure what I think.
I've never taken part in a CISD session.
I don't say that as a critique of people who have, but I've never had a problem admitting to a partner after a bad call that there were aspects of the call that bothered me.
More often than not my partner has felt the same way.
And having those feelings out in the open, I so far have always been able to move on.
There are many former partners of mine out there who deserve thanks for the fact that I am not burdened by the occasionally horrific and often sad things to which I've been a witness.
I don't know if my little conversation with the EMT in the hospital charting room helped or not.
I know her partner, who I didn't speak to, ended up going home after the call, while this EMT did not.
I saw her again on a call, later that night.
A 35-year-old woman had walked into traffic on a busy street and been hit by a car.
The street lights were out and the woman lay in a crumpled heap in the middle of the road, her left leg mangled.
We worked by the reflected glow of emergency strobe lights off the wet pavement and the weak light of a half-dozen Mag Lights held by a surrounding phalanx of police and fire personnel.
I completed my assessment and was working on securing the patient to a long board when I noticed that EMT again in the circle of people caring for the woman, this time holding traction on the patient's head.
We completed c-spining the patient, loaded her into the ambulance and took off for the hospital.
I was in the back with the EMT but we didn't really speak, occupied as we were with caring for our injured patient.
But I couldn't help but think that the fact that she was even here with me in the back, doing her job, taking care of the sick and injured, was a good sign.
Her empathy didn't die with that poor baby.
It lived on, in the simple belief that she still had work to do and there was a worthwhile reason to be here, working in the back of a cramped ambulance roaming the streets of this beleagured mill city.
There is a name for such a thing.
We call it "hope."

Congrats Mistah Mayor!

Lost amid all the media hubbub over Joe O'Brien's election as Mayor of Worcester this week is the fact that before he was a rising star in the Massachusetts political firmament, he was (and remains) a gifted and universally liked and respected Paramedic.
I've had the pleasure of knowing Joe since 1994, when I got my first job in local EMS as an EMT at the Worcester division of MedTrans, where Joe was working as a Paramedic.
(As a side note, MedTrans is a now-defunct service that found itself without a chair when the music stopped in its parent company's attempts to buy AMR; it was finally folded into the latter's brand when corporate overseer Laidlaw decided AMR carried more weight nationally).
From the very beginning you knew there was something different about Joe.
While all Paramedics are convinced we have the answers to any problem in society, few of us actually become active participants in things like local politics.
Joe was one of the exceptions, probably THE most exceptional of the exceptions.
He didn't simply have an opinion, he was involved and he knew the issues inside and out, far beyond the surface knowledge the rest of us gleaned from the newspapers.
Joe was the first one I ever heard -- in the media or anywhere -- mention the name Deval Patrick as a legitimate candidate for higher office, telling me over breakfast one morning during a shift together that he thought Patrick stood a real chance at winning the race for Massachusetts governor should he decide to run.
Anyone who's ever met Joe knows what I mean when I say that he received a triple-helping of that quintessentially Irish ability to make everyone he meets feel like a long-lost friend, and is especially well-known in local EMS circles for bestowing nicknames.
Joe probably called a hundred people "Superdude" or "Super Salad Shooter" in the course of a day, but when he called YOU that name you felt like he really only meant it for you.
He's a phenomenal clinician, as good as any medic I've ever seen in a jam. He is on that very short list of medics I would trust without question to care for my children.
As much as I've always liked Joe, my admiration for him increased exponentially when he and his wife bought a house in Main South, back at a time when that really meant taking a gamble with your own personal safety AND despite the fact that he could have lived just about anywhere.
But Joe always loved Worcester, and truly believed in the goodness of its residents no matter the neighborhood.
I'd be lying if I said I always agreed with Joe politically.
But as I get older I realize more and more that we've made a huge mistake as a nation by picking our leaders dogmatically, when what really matters is character.
So maybe I don't agree with Joe on every issue, in the end it matters not.
The thing I know about Joe O'Brien is that he is a man of incredible integrity and character and intelligence, and Worcester residents couldn't have chosen a better person to lead their city.
Congrats Mistah Mayor.

Flying Frequently

I'm sitting in the kitchen of a Frequent Flier and wondering what to say.
My main job is for a suburban service now. We're slower, but the patients tend to be sicker because they take their medicine, visit their doctors, take better care of themselves and thus, when they finally need 911, it tends to be because they are very sick.
This patient is the exception.
There is nothing remotely sick about him, at least not physically.
In my last job at a busy urban 911 system, Frequent Fliers were as common as streetlights.
They were an accepted part of the landscape. Only when they decompensated and became real players -- say, calling once or twice a day, every day, for a month or more at a time -- did they warrant comment.
But when they do get under your skin, well, there's NOTHING worse in EMS.
Some guys can handle taking the same Frequent Fliers shift after shift without a problem.
For others, it's sometimes enough to make them contemplate leaving the field entirely.
I'm usually in the former camp, but often in the latter -- much more so lately.
So now I'm in the kitchen of a guy who's called for nine nights in a row, each time complaining that his uclers are bleeding.
But he always has a twist to his main hemorrhagical complaint -- the ulcers are acting up AND a local gang has caused a rash on his forearm, or the ulcers are acting up AND the federal government has him under surveillance.
He's been rotating among the three nearest hospitals because each has identified him for what he is almost immediately.
Typically he's discharged and on his way home within a couple hours, depending on how much time and personnel the overworked EDs have to devote to a patient who darkens their door daily with a slew of bogus and bizarre complaints.
Tonight he is asking to go to a hospital 20 miles away. On a rainy Friday night. In a town with a single ambulance.
I have to measure my words.
These are not good times for telling it like is in EMS.
It's best if you don't think too much, don't worry about the system or allocation of limited resources or wasting public money on public nuisances.
The best thing for my career is to just forget the abuse this particular patient is heaping on the system, forget the tens of thousands of taxpayer dollars wasted on the meaningless carousel of transports, ED evaluations and ambulance rides back home this patient has created in order to exorcise his personal demons, and ESPECIALLY to not consider for a moment the possible patients we won't get to help while we are performing yet another fruitless transport -- the father of four who suddenly goes into cardiac arrest, or the 72-year-old CHFer woken from sleep by the suffocating presence of lungs filling with fluid.
Thankfully this nightmare scenario hasn't happened. But it's only a matter of time, I think.
But telling him so won't do any good and may in fact cause me significant grief.
So as much as I'd like to tell this patient exactly what I think of what he's doing, instead I smile.
We can't go to that hospital 20-miles away, I say. We are, though, more than happy to bring to the hospital of your choice in The Big City, about 5-miles away.
He is appeased, and within minutes we're on our way to the hospital once again, both of us certain in the knowledge that this won't be the last time this particular patient will make this particular trip in this particular ambulance.

In The Land of the Blind, The One-Eyed Man Is King

Think the health care reform debate is complicated?
Think the people making the policy that will result most likely in a government takeover of about 20 percent of the US economy give a flying fart about EMS?
I understand when laymen have trouble figuring out all the ramifications.
What does it mean when the "experts," people with PhDs who do nothing but ruminate daily on the health care reform debate, admit that they haven't thought even for a moment about health care reform's potential impacts on EMS?
And yet, this is exactly the case.
Last week I read a 10-page supplement to the Columbia Journalism Review written by a think-tank that philosophically stands squarely behind President Obama on health care reform.
The think tank advertises itself as "A private foundation working toward a high-performance health system."
When I read this group's piece I thought maybe I had found that touchstone, a group that made it's argument lucidly, plainly and convincingly.
Maybe, finally, I had found a way into the debate that made sense, could give me a reason to get behind reform.
But one nagging thought remained.
Nowhere in this 10-pager was there mention of EMS.
Nothing about how ambulance services would be re-paid for services rendered to Medicare/Medicaid patients despite the fact that almost every proposal for health care reform calls for Draconian cuts to the costs of Medicare/Medicaid.
How, I wondered, would EMS survive deep cuts to Medicare/Medicaid reimbursements if services to those folks were already burdensome financially at the current level of funding?
So I emailed the director of the think tank that wrote the piece and asked if she had any information on the subject.
She wrote back rapidly with the candid admission that she had no idea.
To her credit, this director spent part of her Friday night tracking down the contact information of people who might be able to answer my question, even though it was clear that I'm not a person of any particular importance and was asking the question mainly out of personal curiosity.
But it also points to the fact that EMS is NOT a part of this debate, and my fear is that when the entire US health system is overhauled and re-done, the EMS system could find itself with more demands and no way to meet them.

My son's G-tube fell out this week.

He was at soccer practice.

I was at work, but my wife said he nonchalantly handed her the "tubie," as we called it, its anchor balloon deflated by a lengthwise tear.

"Here," he said. "This fell out."

One of the other players' grandmother is an ICU RN, and she was kind enough to clean and dress the site.

The whole event wasn't the emergency it might otherwise have been.

The g-tube had outlasted its usefulness, Brendan hadn't had a feeding from the tube in months and we were planning this week to ask for its removal.

Fate took care of things, and after a brief inspection by a doctor revealed no problems, the GI clinic at Children's Hospital in Boston signed off on our request to get on with life and close this particular chapter.

We're happy for practical reasons.

The tubie, as far as I'm concerned, was just another route of infection.

It was a constant source of worry, and caused my son a good amount of pain when hit by soccer balls, baseballs and errant limbs while wrestling with his brother.

But it was more than that.

Now 7, Brendan was starting to feel self-conscious about the device.

Most importantly, though, it's another in a progression of mileposts that puts some distance between the now and the then, not that long ago, when Brendan was fighting for his life against medulloblastoma, a highly malignant brain tumor.

And it was a good week to create some more of that space.

September, after all, is National Childhood Cancer Awareness Month.

You can read more about it here, at the Web site Curesearch.org, a wonderful resource, and here, on the Web site of the Dana-Farber Cancer Institute, home of the Jimmy Fund and the Stop & Shop Pediatric Brain Tumor Clinic, the people who directed the care that saved his life.

The Disaster Is The Planning

I've railed on this site before about the ridiculous amounts of money poured down the drain since 9/11 in the quest for "preparedness."
A whole industry has sprung up over the last 8 years dedicated to something, although what that something is I'm not completely sure.
Across my own little corner of the public safety universe legions of trailers, stacks of portable radios, pallets of tents, spacesuits, PAPRs, AV-2000s, and enough Tyvek material to encircle the Earth stand ready to protect central Massachusetts from the forces of evil who are conspiring to destroy us.
But meanwhile the people who would presumably use that equipment to keep us safe are being laid off due to budget cuts.
As disaster preparedness money has appeared in such abundance that no one really knows what to spend it on anymore, real-world public health experts are being discarded because the cash to pay for THEM has dried up.
But I have to wonder, in the end, what's going to protect me and my family -- a comprehensive vaccination program and a robust public health department to ensure the population is protected, or a bunch of bureaucratic hacks in color-coordinated polo shirts and khaki trousers "working" from grant to grant without producing anything that will actually save a single life?
I did some work briefly for a local Medical Reserve Corps who's biggest concern was purchasing an ID system for its volunteers, and what color duffle bag to hand out to its workers.
We got Polo shirts AND a fleece vest.
I didn't last long.
It's all very worrisome to me, and now it appears that an MIT doctoral student has published a paper that supports my concern.
In it, MIT PhD candidate Peter Doshi suggests that so-called "pandemic flu" planning has actually made us less ready for a real breakout of a flu epidemic like that one in 1918 that killed 50 to 100 million people worldwide, depending on who's estimate you believe.
It's an interesting read.
I think it's time for a little common sense when it comes to preparing for disasters.
You can't just throw money at the problem -- the people who catch the most cash are rarely the ones who can do a darn thing to help us.

Helping a Helper

I really like this.

Michael Morse, author of my favorite blog, Rescuing Providence, linked to this site.

Besides just being a nice thing to do for someone who clearly deserves it (I can't even begin to describe the respect I have for working Moms and Dads who manage to complete something as daunting as Paramedic school), I think the writer is addressing a real need.

With the world's credit markets still frozen like the Siberian Tundra, school loans are becoming harder and harder to come by.

A friend of mine who runs a Paramedic program told me that the company that once financed the considerable cost of an education at his school notified six members of his last class at the last minute that the money they had counted on would not be coming.

Those six are having to instead wait a few more years to attend school.

I love what's being done here, and I hope some Central Mass Medics readers might be able to help out even a little.

To steal a little more from Morse's last post, here's a link that might explain why this is worth it.

Adios, redux...

I've quit EMS in The Big City.
For real this time.
I've left before, once to go to work as a flight paramedic, the other a firefighter.
Both times I remained per diem.
But not this time.
The heart can't serve two masters, or something like that, so this time I made a complete break, and barring unforseen events I will never again wear the brown uniform that has meant so much to most people who've worn it, myself included.
I am very proud to have worked here.
I think I did a good job.
I think I was a good partner, and a good clinician, but ultimately those judgments are left to the people I worked with.
I only hope they enjoyed working with me as much as I enjoyed working with them.
It wasn't an easy decision to leave, but in the end not as hard as I would have thought.
It wasn't the 20-call shifts, or the every other weekend schedule, or the banged up trucks.
Truth be told, while we complain about those things, the reality is that we wear the craptastic nature of some of our equipment like badges of honor.
Miracles have occurred in the back of beasts of burden like 611, or 68, or even in the crop of ambulances that were on their way out when I arrived, the ones with cabs so small that Gomesy drove with his knees pinned behind his ears and roofs so thin that the metal flapped like tinfoil at highway speeds.
And while five new ambulances are planned for shipment soon, there's a grim pride in tapping numbers like "264,500" into the "mileage" field of our newly-installed Mobile Data Terminals at the start of every shift.
It's kind of like when I was in the Marines and you would meet Huey pilots proud of their ships and the way they could get so much from aircraft abandoned so long ago by larger, more pampered services.
Kind of like that.
Though I'll remain forever pissed off that 2667 doesn't have arm rests...
I didn't leave because of the continuous influx of new technology, some of it balky and overly-delicate and maybe released into the wild a little before being ready for prime time.
Nor did I leave because of that new EMD dispatching system -- designed for a completely different model of EMS delivery than the one we use in The Big City -- that sends first responders careening through the city for urinary tract infections because some card tells the dispatchers to make it so, or that sends us and a fire engine and some police officers, Priority 1, EVERY NIGHT, for the same guy who calls at the same time from the same steet corner complaining of "assmar," when all he really wants is a sandwich and some sleep in a comfy hospital bed.
It was none of those things.
Technology improves.
No EMS system is perfect.
Frequent fliers are a bane everywhere.
It wasn't the lousy press we've gotten lately, notably from Tom Caywood at the Telegram, who's more stenographer than reporter, and who has seen fit to ruin the reputations of six medics since April without ever contacting any of the targets of his "investigations," even once, for comment.
Tom, I don't think you can ethically accuse six people of the horrible things you accused them of, name them publically and prominently on Page 1 of the most-read edition of New England's largest metro daily newspaper outside of Boston, and not have the decency to EVEN ATTEMPT to contact ANY of them.
Not once.
Nothing.
Complete...radio...(and telephone)....silence.....
The medics you've maligned didn't deserve any of what you've brought upon them.
The press is becoming something we all need to fear, I think.
I was once a newspaper reporter.
I still have friends in the business, and the business is dying.
One of the consequences is that newspapers are too busy trying to stay afloat to pay much attention to the stories their reporters are turning in.
And if those reporters decide to forgo fully reporting their stories in order to make a quick hit before splitting town for, say, a weekend blues festival, then that flies in today's media, the innocent be damned.
This is a dangerous time for journalism, and I had a front-row seat to just how bad things are.
But bad press had nothing to do with it, either.
No, the main reason I'm leaving is to spend more time with my family.
It's that simple.
But I find that the simplest things in life are the most important.
I wish the best for my now-former colleagues, and I hope if you're reading this you'll take a moment some day in The Big City, when you see those folks in brown working yet another shift on some of the busiest ambulances in America, to let them know they're appreciated.
Almost no one ever does, but I bet it would go a long way.

As for this blog, I intend to get it going again.
I had refrained from posting over the last few months during the furor of which I spoke earlier.
It just seemed best to keep on the sidelines.
Also, though, a colleague of mine who writes one of the most entertaining area blogs -- Wormtown Medic -- had gotten some grief from management for his unabashedly honest analysis of various local EMS issues.
It was the first period in my life where I caved in to what amounts to prior censorship.
I'm not proud of that fact.
It won't happen again.

And you thought "Rescue 77" was bad...

I'm going to check it out -- I mean, hey, how many shows about EMS are on TV?

Hopefully it won't be as crap-tastic as the last few (remember "Saved?")

No Second Chance At Second Chances

We found him upstairs.
He was wedged in the far corner of the largest room of a huge home at the end of a circuitous driveway in a secluded, wooded neighborhood where million dollar homes dot the rolling hills by the dozen.
If happiness were merely the product of our trappings, than this man should have been delirious with joy.
But in today's economy, happiness is a commodity that can no longer be bought. The market has re-set its value, and some are unprepared for the change.
Our patient was one of those.
In his late 50s and obviously a man who'd enjoyed significant professional success, his wife reported that he'd come home despondent over the loss of his job earlier that day.
After dinner he'd said he was tired and wanted to go to bed early.
Four hours later, when the wife had gone to bed herself, she found him, here in the corner, his mouth full of vomit, his heart not beating, his lungs sitting idle, and several bottles of empty antidepressants lying nearby.
We tried desperately to bring him back, to give him another chance to see a different way out, but nothing worked. He'd been down too long, taken too many of the wrong drugs, and ultimately he was pronounced dead in the emergency department.
I'm hoping that this call was just part of the normal ebb and flow of life that we see on the ambulance, that his death, while tragic, statistically fits what we expect to see from time to time.
People commit suicide in the best of times as well as the worst. Our patient was taking medicine for depression, and for all I know this was not the first time he'd attempted to take his own life.
It's hard, though, not to see him as a casualty of a war on whose front lines we unknowingly sit every day.
No matter where you work, ambulances -- and by extension, emergency departments -- are always dealing with a particular population of people for whom daily life is itself a task.
Think about the chronic drunks and junkies for whom life is one endless chase for the next bottle or the next fix, and who take residence in the backs of our buses so often that we know their names and dates of birth by heart, whose medication list is as known to us as our own, and who can be identified by the time of day and location of the pay phone from which the 911 call is made.
But I worry that my patient represents the early stages of a new wave of casualties who are having to cope with an economy in the worst condition since World War II.
Does my patient represent the start of a wave of people overmatched by the conditions of early 21st century America, or is his death simply a normal part of the process of life for the rest of us?
Time will tell.
I'm an optimist by nature, which of course means I'm conflicted because I don't know that either possibility leaves much about which to be optimistic.
I do know that I wish my patient had been able to see beyond whatever it was that led him to take his own life.
I wish he'd been able to see that tomorrow is always a new day.
Mostly I just wish we'd been better able to give him that second chance ourselves.

Neurosurgeons are people, too.

Anyone looking for a good book would do well to consider "Another Day in the Frontal Lobe" by Katrina Firlik.
Dr. Firlik is a Connecticut-based neurosurgeon with a spare, compelling writing style who gives her readers entre into one of the most challenging and probably least understood (at least amongst the lay public) fields of medicine around.
The book mostly covers the period of Firlik's seven year neurosurgery residency in Pennsylvania, and while there are some war stories, they are brief and always in the service of the deeper introspection and naked honesty she brings to her examination of her chosen profession.
It's this last point, in fact, that I find to be the most interesting facet of the book, that Firlik would admit to some indecision about whether becoming a neurosurgeon was even the right choice in the first place.
It's clear that she has made an uneasy peace with her decision. As compelling as she finds the work, it's obvious that Firlik has interests and passions that extend far beyond medicine, and it seems that she's not entirely happy to, say, defer her wanderlust and love of travel in exchange for frequent call nights and the tyrannical power of the pager.
Firlik is at her best when wrestling with such issues, and she manages to bring flesh and blood to the neurosurgeons, those ethereal creatures most of us are lucky enough never to need.
It's a great book and a relatively short read at 270 pages.
Check it out, you won't be disappointed.