The Paramedic Process

Another Haiti photo.  I'm not sure if the scale was discarded of not, but it stood alone in the hospital street, seemingly neglected.

I've done eight straight nights on a 911 ambulance, and have spent a little time reflecting on my paramedic sprint.  I don't remember their faces, and less so their names, but I remember their ailments.  65-year old man, hypoglycemia and profoundly diaphoretic; 56-year old man, severe asthma attack that I fixed in three minutes flat; 67-year old man with new onset a-fib that I diagnosed by feeling his radial pulse; a twenty something man that I knew was lying to me about drug use just by looking at his dilated pupils.  After each run I would review the call in my head looking for mistakes, and there were plenty. I'd see a new medication that I had to look up, a symptom that I didn't catch, a blip on a 12-lead that was significant. Everything got looked up after the fact on my iPhone full of medical applications, mentally filed away for the next time that I see it.  I was intent on each run making me a better medic.  Being a paramedic is a process, I'm, seeing that now.

Seeing

  Also from Haiti.  A woman walks along the street carrying her child closely to her.  The little feet sticking our from the blanket make me sad in a way.

In the very early hours of the morning I sat parked in an ambulance at a truck stop and starred into the window of the late-night restaurant.  I had little else to look at aside from my watch, counting the hours until I got off from work and could go home to my own bed. 

Through the window I watched a very heavy-set African American woman, dressed in the cheap, red uniform, push a broom across the floor. If I were any place else I wouldn't have given it a second thought, but here I was a captive audience and couldn't help reflect on what I was witnessing.  Dozens of questions flashed through my mind as I watched the thirty-something woman go about her manual tasks.  Was this where she envisioned fifteen years ago that her life would end up?  What does she dream of, aspire to, or has she resigned her life to where she is now? I couldn't help myself and tried to recreate her life in my mind, I wanted to project myself into her reality.  What were her disappointments, her victories?  What motivates her?  Where, if at all, would she go back and change her life.  Above all, was she happy? The questions kept coming and coming as I watched her through the grimy window.

I suppose my lesson was that everyone has a story, a life, a past, and a present.  I for one am guilty of going through my days at times oblivious to those around me.  I see people but I truly do not "see' them; the man crossing the street with his young son or the woman pushing the broom late at night.  I suppose in many ways this is why I like 911 so much.  For a brief moment in time it's just me in the back of the ambulance with another person, a chance to get to know someone on a deeper more compassionate level, other than just simply seeing them.     

Not A Good Night For Humanity

 A photo from Haiti. A daughter watches over her father while waiting outside of the hospital "Emergency Room" tent in the heat of the day.

A 911 call came to us last night, respond to a convenience store only a few blocks from where my EMT partner and I were sitting.  Within moments as we arrive to find four squad cars rocketing in and out of the parking lot, one of the officers is eagerly motioning for us to come inside and attend to the patient.  I remember thinking that these guys are amp-ed up, this level of activity is normally reserved for gunshots.

An older Asian woman sits slumped on a stool with an obvious laceration under her eye.  She's in quite a bit emotional and or physical pain.  The story goes that a man came into the store, got himself a large cup of hot coffee and threw it onto the attendant's face.  He then viciously punched her in the eye, grabbed the money out of the open drawer and fled through the front door. 

As my EMT treated the lady I couldn't help but be moved by the degree of violence and inhumanity that had just taken place.  Why would anyone do this and moreover, what was going through their mind?  A question that I've wrestled with lately is, does everyone in the world consider themselves "deep-down a good person", conversely are there people that simply know that they are at-root evil and devoid of humanity and kindness?  How can someone commit such a barbaric act and still view themselves as a "good person"?  Sadly,  I realized my answer last night.

Transitions

IV bottles hang from a tree branch.  Below, an adolescent boy lays dieing on a make-shift cot.  I couldn't bring myself to shoot the the boy.

Coming home from a deployment is often difficult, especially when you wake-up in some desperate third world country and find yourself going to sleep that night in your own bed at home.  The shock of abruptly moving between the two environments is often dramatic and catches many people by surprise. Aside from your dusty luggage you arrive home still emotionally invested in your previous environment.  For me, I find myself being a bit quiet, withdrawn, hyper-sensitive to sights and smells, and with an overwhelming sense of being "off-balance". 

I often counsel people that I work with to spend a night in a place that is in many respects half-way between the two; a place where they can decompress, have a world-class shower, a solid meal, and slowly turn the lights back up.  Only slightly in jest, a good bottle of wine is also a great help.

Triage Notes

Now a common sight on the Haitian streets.

Not all emergencies are created equal.  The triage area of the Haitian hospital I've been working at is a busy and often ugly place.  An elderly lady is vomiting frank blood into a clear plastic bag, a man has large pieces of his face missing and is bleeding badly onto a filthy rag.  Next to them an agitated twenty-something man sits clutching a slightly angulated little finger… I know it was angulated because I looked REALLY closely.  Mr. Hurt Pinky is motioning for me to treat his finger, his eyes beam impatience and frustration that he is not being promptly taken care of.  "Why am I not at the head of the line?" I don't speak Creole so I point to the lady with the bag-o-blood in her feeble fingers and raise my hands in the international "are you serious?" gesture.  He backs down… for a few minutes.  This is "triage"… isn't that a French word, similar to Creole, that means bags of blood and missing faces come before hurt pinkies?

Not The Sole Providence Of The Strong

 A mother holds her child in one of the hospital's pediatric tents

Again, last night I worked in the hospital's emergency room, my task was to suture lacerations as they came in; I was certainly not at a loss for work.  I trolled the triage area looking for anyone with a bloody dressing; a quick examination and I would usher them into my little work area within the tent.

Sitting on the pew-like benches was a tiny girl atop her father's lap.  She held a stained piece of cloth over her forehead with her own hand.  She couldn't have been more than 5-years old.  As I took a gentle look I silently prayed that I would be able to stick a Band-Aid on it and send her happily on her way.  This was not the case, she had a 4 cm "lac" to her forehead that was going to require a few interrupted sutures.  I cringed at the thought of having to cause this innocent little girl further pain in her life. 

I took them both back into the tent and laid her down on a worn cot so that I could get a better look using my headlamp, often the only light source that we have at night.  She was stoic, unafraid, staring at me with a look of curiosity, almost daring me to assault her bravery.  I wanted to sit a bit with her before I had to inject her with a syringe of lidocaine which is often the most painful part of the procedure.  We smiled at one another, she played with my light, and I patted her on the head.  The interpreter explained to her that it was going to sting a bit, but try to remain still.

She closed her eyes as the steel needle sunk into the gaping wound,  not so much as a wince.  Her face remained calm and passive almost as if she were asleep.  Her bravery penetrated me, this 5-year old girl, in the face of something that would make me cringe, laid there determined to be brave. 

It took only a few minutes to place the three sutures, but not even so much as a whimper.  In the end I touched her forehead and told her "finished"; her eyes fluttered open… a smile from me to her. Little fingers reached up to explore the new dressing.  Her father thanked me and he scooped her up in her arms and disappeared down the dark street.  Bravery is not the sole providence of the strong.

Moments For The Soul

A bit of commotion in the ICU tent early in the evening as some of the American staff were scurrying around.  A young boy, maybe ten or eleven, had taken a 10-foot fall onto the ground; upon further investigation it became a 50-foot fall.  In the center of maelstrom were two Americans, an ex-football player now trauma surgeon and an anesthesiologist; both were desperately attempting to obtain needed laboratory results in order to get the boy into emergency surgery.

An ancient hand-litter was found abandoned in the corner;  the surgeon and I hurriedly carried the boy through the obstacle course of patients, beds, tents, and doorways into the operating room. Along side the litter the boy's father struggled to keep up; his calloused hand resting on the tiny chest. A panicked voice in the dark muttered, "son, son, son" over and over again trying desperately to communicate with his little boy.

To describe the operating room would be it's own post, but suffice it to say the only word that I can find is, "medieval"; only a handful of dim florescent lights, stacks of disorganized supplies, and a few pieces of dysfunctional equipment.  The boy was dying. 

A Haitian surgeon appeared while the boy was being intubated and "put to sleep".  The new arrival could plainly see in the American's eyes that he was "assisting" on this one.   With only a single patent IV line an incision was rapidly made in the little boy's abdomen, fluid erupted from his belly in staggering amounts.  I left, there was nothing more I could do, it was in the hands of the surgeon.

Hours later I learned that the boy had died.  The surgeon, standing by himself in the street's shadows, was clearly alone within his thoughts.  What struck me was the emotional investment on the part of the burly American, a man who likely had faced death and dying countless times in his life. My image of the quintessential 'trauma surgeon', the gods on earth that are the definition of stoic, precise executors of their science/art was immediately burst.  A moment that has become a part of my soul for the remainder of my life.

Rules To Live By

A young Haitian girl stands outside one of the hospital pediatric tents.

There's an art to living on top of people, one which I suspect actually gets taught in naval submarine schools and fire academies.  My existence for this trip to Haiti has been highlighted by the return of communal sleeping conditions to my life, something that I've not experienced since my days in Special Forces. I fear that I've grown accustom to 5-star hotel suites with multiple flat screens and ocean views. Those that know me are laughing right now.

The group that I'm with on this trip is camped out in a small, open room with 15-20 thinly mattress-ed metal frames placed within a foot of one another. My personal space extends from my bunk to 6-inches on every direction; I am the master of my kingdom.

The first and really only rule is to be overly considerate.  Here are some things to think about:

• No unnecessary banging around of things during sleep hours.  Even the slightest rustling of stuff can be annoying to those that are trying to sleep.
• iPods can be heard by neighbors, also typing on keyboards.  Take it elsewhere.
• Be mindful of your neighbor's kingdom… no border excursions however unintentional.
• Keep your things packed and neat. You're not setting up house - it's temporary. 
• Flush the toilet.  Even if there's no water in the tank, that's what the big barrel of water and bucket are for sitting right next to it.  The water goes in the bowl, not the tank. Also, in most third world bathrooms- the paper goes in the trash not the bowl.  Get used to it.
• Learn to love cold water bucket showers. Close your eyes an imagine a tropical waterfall.  It lessens the shock.
• Personal hygiene.  It's not a competition to see how nasty we can all be. Wash yourself, especially your hands as often as you can.
• Pick-up communal spaces, and especially don't leave stuff for others to have to deal with.  Leave it cleaner than you found it. Pack it out baby!!
• Pitch in, pitch in, pitch in.  Someone has to take the trash out and sweep the floors. You know it needs to get done.  Don't ignore it.
• Keep valuables secured.  You never know who will come strolling though your living spaces, and  other cultures look differently upon opportune acquisitions than we do in the west.
• Share electrical outlets.

Watching

I've spent the last several nights working in a Haitian emergency room along side some very talented and caring physicians and nurses.  Last night an unconscious man was brought in by car and carefully laid on a stretcher outside our rain-soaked tent. Dressed in mud-soaked jeans and a worn t-shirt he had simply collapsed while crossing the street. His family brought him to us.  There was no neurologic function, his blood pressure was very high, and his heart rate was slow; all indications that he had burst a blood vessel in his head.  There was nothing that we could do for the man.

The family listened intently as the news was passed through a Creole translator.  They asked if there was some machine that we could put him on, some medication that they could procure that might give him a chance to come back to them. "We're sorry, there is really nothing we can do".  The family went away to get some other clothes so that their father/friend/husband didn't have to die in wet jeans and a soiled t-shirt.

He lay there and I watched.  All night, breath after breath… I watched.  I watched as the man took his last breath, nothing more than a small gasp really.  It stopped raining; I left the tent to get some coffee.