Saturday, December 18, 2010

Zen and the Art of Tying Knots

I was only four months into EMT school the first time I was attacked by a patient.

Looking back on it, EMT school was really just a warm-up for the fourteen-month-long paramedic course, the place where pre-hospital care advances from mere first aid to actual medicine. But at the time, as someone uninitiated into the world of public safety, it seemed to me an entree into a very strange and exciting world. We were taught to recognize imminent life-threats like strokes and heart attacks and given a crash course in anatomy and physiology. We learned CPR, the Heimlich, how to immobilize patients with possible spinal fractures, and how to apply tourniquets and pressure dressings.

In fact, after hour upon hour of practicing skills and studying books, we could, in those early months, recognize and respond to any number of critical long as the victims were mannequins.

That’s an odd disclaimer to place upon a group about to enter the world with the purpose of saving or at least preserving human life but none of us had yet laid eyes on a single living patient. The longer class went on and the closer we got to finishing and heading out into the real world to treat real people, the more this began to weigh on my mind. The word trauma was absolutely terrifying and conjured up images of flashing lights and motorists dying on the side of a highway. Yes, I knew the buzzwords and the techniques but I had no idea if I’d be able to translate that information into the practical skills that actually save lives.

All that changed one day when our instructor walked into the classroom and rather cavalierly informed us that before finishing the course and being released to take the National Registry Exam – passing which allows you to work as an EMT anywhere in America – we had to ride on an actual ambulance. And see actual patients.

This was as thrilling as it was nerve-wracking. Our instructor had arranged for us to ride with Grady EMS, the 911 provider for the City of Atlanta. Grady EMS is part of Grady Hospital, one of the largest public hospitals in the southeast and a place known the world over for having first-rate trauma care. A reputation, of course, that was earned the hard way.

Grady Memorial Hospital looms large in Atlanta’s consciousness. It is a place of horror stories and ghost stories, of lawless halls seen only by the poor, the crazy and the critically ill. My first view of it came in the dark of a November morning as I awaited the start of a 4am third ride. The giant lighted cross atop the 16-story building glowed red in the dark sky, and steam from a pair of smoke stacks slowly rolled out like a blanket of fog, softening the orange glow of the street lights.

The original hospital still stands, as do a handful of other nineteenth century buildings and between the fog from the steam plant and the crumbling, century-old buildings, a large moon in the otherwise empty sky, the whole thing resembled to my wide eyes a scene from Jack the Ripper’s London. Somewhere in the distance a lonely siren wailed.

The knowledge that at any second, without warning, you will be called upon to deal with an emergency creates an anxiety which, if you stick with this long enough, is eventually reduced to a low-grade form of nervous anticipation. But in the beginning, for me, the thought was all-consuming. Waiting for the crew I’d been assigned to, I paced back and forth, wondering what I’d see, what I’d be asked to do and how I’d respond. Once they arrived things began to move very quickly and before I knew it, before I was ready, I was sitting in the back of an ambulance rumbling through the heart of a sleeping city.

All ambulances carry the same smell, a dizzying cocktail of disinfectant, plastic and diesel fuel tempered by the menagerie of scents leaking in from the outside world. But there’s something else, a smell you can’t quite put your finger on and, in truth, doesn’t even exist. It comes not from any physical source but from the knowledge that people have sweated, bled and died in there. This knowledge that so much has happened in so small a space will immediately dispel the notion that those who die in violent or sudden circumstances forever haunt the site of their demise. An ambulance, at its most spacious, is a ten-square-foot rolling memorial to the suddenly and tragically dead. How many have slipped away in any one of them is simply unknowable and yet not one story exists of lonely and angry specters rattling chains or whispering threats to frightened paramedics.

That said, the crew I was assigned to that day were specters in their own right and had Charles Dickens been there he may well have called them the ghosts of EMS Past. The job has changed a good deal over the years and Pike and Wooten came up in the brawling Wild West days when Atlanta was the murder capital and surviving the daily parade of shootings and stabbings required a hard-bitten and ruthless approach. Pike was a wiry, rangy guy with a thick goatee straight out of the Civil War who chain-smoked cigarettes, pounded coffee from a beat-up silver thermos and had the manic energy of a guy who never slept. Wooten was silent and bitter, his thickness a testament to the poor diet so common among public safety workers. While Wooten sat silently in the passenger’s seat, Pike drove like a madman, talking without stop, without prompting. “This whole area, everything you see,” he said, waving his arm indiscriminately at everything we passed, “fucking shit hole. I hope they raze it all.”

The shithole he was referring to was an area known locally as The Bluff – five square miles of drug houses, flop houses, abandoned buildings co-opted by the homeless, drugs, violence, desperation and the constant woop-woop of sirens. The Bluff is Atlanta’s answer to Compton, to Chicago’s Southside and to the Heartland’s countless and nameless meth-riddled trailer parks. It is where all of Atlanta’s heroin is sold and most of its crack is consumed. People here live in aging projects or derelict bungalows and, Pike said, when they weren’t getting into trouble they were calling 911.

“And for no damn reason at all,” Pike said, stomping on the gas and tearing open the air with a long, loud burst of siren. “Wake up, motherfuckers!”

My father-in-law spent a year of his life in Vietnam, an experience that has affected him deeply and about which he is generally tight-lipped. There are some topics, however, he is willing to discuss, one of them being the futile efforts of the 1960s-era Army to prepare its conscripts for jungle warfare. For instance, he loves to tell you how he trained with an M-14, never even laying hands on an M-16 – the weapon with which he was expected to win a war – until after he was already in Southeast Asia. And he’ll laugh as he describes the WWII-style combat tactics taught to him by his drill instructors, men who’d never seen a jungle and who never once addressed the unique difficulties and strategies of jungle warfare. Any skills he’d eventually acquire for keeping himself and his friends alive would come from the war-weary nineteen-year-old kids who’d gotten there a week or two before him.

EMS training is nowhere near so inadequate but the very nature of practicing medicine in streets or bathrooms or living rooms or elevators or construction sites, renders obsolete many of the rigid procedures drilled into our heads during school.

That first morning, while Wooten napped in the ambulance, Pike chain-smoked cigarettes and rattled off a list of techniques learned in school that were not only poorly-suited for the streets but could, in some cases, get me or my partner hurt. As he spoke, flicking ashes and pacing back and forth, I felt like Charlie Sheen in Platoon – a crumpled and useless FNG watching Willem Defoe dig through my backpack and discard all the items I didn’t need and which would only slow me down.

“Backboarding,” he said, referring to the practice of strapping patients with suspected spinal injuries to a long, hard board. “Do it like they show you, straps running crosswise over their body? Fuckers’ll slide right out.”

“Slide out?”

“What happens when you got them strapped like that and you try carrying them down stairs?”

“They slide out?”

“They fucking slide out.” A heavy drag, a long, languorous exhale. “Run those straps between their legs and crisscross them over their chest. Fuckers aren’t going anywhere.”

On and on it went, my head spinning as I tried to collect and organize all of the advice into its appropriate mental folder.

“When it comes to fighting patients you—”

“Wait, what?”


“Fighting? You said fighting?”

He laughed. “You think all these fuckers are glad to see you? That they’re gonna hop on out to the ambulance for a quiet ride to the hospital? Think again. Four, maybe five times a year I end up in full-on brawls.”

I asked what would cause someone who, presumably, had called for my help in the first place to attack me upon arrival. Pike shook his head as though I was almost too dumb to help then ticked off a list that included seizure patients, drug overdoses, violent psychs, drunks, head injuries, pissed off family members and those who, for no good reason, were simply pissed off at the world and to whom I represented a great place to start exacting revenge. It was all how I approached them, Pike said, the way I asserted my authority – a tricky blend of rigidity and leniency – where I drew the line and what I did the moment they crossed it that would determine the direction these calls would take. “Handle it properly and you’ll be fine. Fuck it up and you’re in for a long afternoon.” He grabbed a pack of patient restraints and asked if I knew the proper way to restrain a patient. I shook my head and just as he was opening the pack we caught our first call.

“We’ll deal with that later,” he said, tossing the restraints back on the shelf.

People often wonder how it is that we deal with the sight of critically injured patients, how we are able to move beyond the grotesque and set our minds to the task before us. The answer I give is that it’s one thing to see someone hit by a car and have to watch, helplessly, as they bleed on the sidewalk. It’s another thing altogether to show up in an ambulance with the equipment, experience and knowledge to get that person help. There is also a time-space thing at work, where empty-handed witnesses have nothing to do but focus on the horrific details. We, by contrast, can occupy our minds with the long list of tasks that need tending to prior to our arrival at the hospital. Typically it isn’t until the whole thing’s over and the patient is in the hospital and out of our care that we even begin to consider what had just happened. The result of this is that things move much more quickly for us and twenty minutes pass by like two, while for the bystander each second ticks loud in their head, time moving excruciatingly slow.

These factors combine into a defense mechanism of sorts and allow us to finish a call and head straight for lunch. On that first morning, as I watched from the close and inescapable confines of an ambulance, my inexperience put me in the unique position of being both frightened observer and busy rescuer. It also made me utterly useless. There are countless reasons why work in an ambulance, no matter how critical the patient, is almost always a two-person job, not least of which being there simply isn’t room for a third person. Toss in that extra body and you get in each other’s way and, more importantly, on one another’s nerves. Attach, then, to this third wheel a complete ignorance of what he should be doing and you see why most medics hate third riders. I’m not sure Wooten even knew I was alive but Pike’s willingness to deal with me certainly began to fade as the day wore on.

For my part, I was mesmerized. We picked up a child with a fever, dropped off a woman with abdominal pain and bandaged a man who’d been sliced open by his girlfriend during a domestic dispute. Twice. The first time we dropped him off at Grady he stayed long enough for them to stitch half of his wound before leaving. Naturally, he headed straight home and resumed beating his girlfriend. The second time he was transported by the police and as I bandaged his still-bleeding arm, his girlfriend poked her head out of the back window of a police car and pledged her undying love for all to hear.

The day continued like this, calls going out in projects and high-rises and on the litter-strewn shoulder of I-85 until mid-afternoon, when we finally got some downtime. There are no breaks in EMS, no lunch hours or nap times and when it’s busy there’s scarcely a spare moment to use the bathroom. So you eat what you can when you can. That afternoon we ate greasy chicken from a fast food restaurant whose health rating couldn’t have been higher than 80 and then immediately fell into a stupor. The cool morning air had finally warmed up and we all became sleepy and content and as I sat alone in the back of the parked ambulance I drifted off to sleep. I was floating somewhere in that half-dream, half-awake state where the real-life sounds around you become part of your dream when the ambulance suddenly started moving.

“We got a call,” Pike yelled.

I hadn’t yet shaken off the fog of grease when the ambulance jerked to a halt and, for the first time that day, I heard Wooten’s voice.

“Holy fucking shit.”

There are strange things that happen in the world and one of them happened that afternoon. A man none of us had ever seen before and would never see again had spent the previous night binging on an interesting cocktail of drugs known as a speedball. A speedball is a mixture of cocaine and heroin – one drug to cut the trail for you, another to send you down it. Heroin being what it is, calms while the cocaine fuels.

The problem is that the heroin has a shorter lifespan than cocaine and so, out of nowhere, BAM! Your smooth and mellow, yet inspiringly vivid, high suddenly becomes all sweat and frustration and grinding teeth. Generally speaking, heavy users don’t deal well with this transition. Our patient certainly fell into this category and, after his buzz turned sour, he spent the afternoon homicidally racing his car through the streets before running down a ravine and crashing into a tree.

He’d hopped out before our arrival and so we found him, confused and combative, running around the street. The sight of a big, sweaty, drugged out lunatic running through traffic wasn’t what caused Wooten to finally speak, however. For a medic who’d been on the street for a decade, that alone would’ve been somewhat routine. What stood out immediately as cause for, if not concern then at least his first verbal reaction of the day, was that the man had broken both of his legs below the knees. Badly. Your lower legs are made of two bones. The larger of the two, the tibia, is essentially what holds you up below the knee. The fibula is smaller, runs parallel to the tibia and is what you feel when you reach down and grab what’s referred to as the shin bone. It’s not all that uncommon for these bones to break but it is uncommon for those thus inflicted to walk, let alone run. Our patient, strung out on the souring effects of a speedball binge, didn’t seem to notice his legs were broken. Hence the running.

And it was this running, or rather the resulting injuries, that caused Wooten to shout. When the man had gotten out of the car, the broken bone ends immediately poked through the skin so that now, with each step, the upper and lower sections were jutting out in a grotesque sort of crisscross pattern. I stood next to Pike and Wooten in front of the ambulance – heart-pounding, pupils dilated – partially horrified, partially hypnotized and totally unsure of what to do. Wooten swore under his breath. Pike spat in the street. A passing car honked. And then it was on.

Pike hopped up in the ambulance and grabbed our box of narcotics and a syringe. As I watched, he drew up five milligrams of versed and another five milligrams of haldol, a potent mixture of sedatives that rarely misses its mark. With me following close behind, they slowly approached our patient in much the same way a zookeeper might approach an unruly bear. When the guy saw us coming he turned and ran back into traffic and the world was instantly drowned in a flood of squealing rubber and blaring car horns. With nowhere to go, he turned back toward us. For an instant we froze. In that tiny space of time, certainly less than a second, he sized us up like a cornered bull and decided we presented the path of least resistance. Pike and Wooten quickly recognized what was happening. I was a little slow in arriving to the party.

They both jumped out of the way. Not me. I stood frozen as the patient – wild eyes, hulking mass, broken and scissoring leg bones – charged me. I’d like to say it all happened in slow motion but it didn’t. It happened so fast I never reacted. Steps before the guy plowed me over, Wooten, much more agile than his rumpled largesse suggested, appeared out of nowhere and knocked him down. Pike piled on top. I stood watching as the three of them rolled around until Pike screamed out in pain, wailed the guy with a wild elbow and yelled, “Grab the needle!” Somehow in the tussle he’d dropped the sedative and it was now out of his reach. This, finally, snapped me out of my daze and I grabbed the syringe, popped off the top and, with Pike’s direction, jabbed it into the man’s ass.

Then I backed up. Pike and Wooten slowly untangled themselves from the patient and watched as the drugs worked their magic. Within seconds the patient, still flat on his back in the middle of the street, was snoring. Pike grabbed the stretcher and the three of us snatched him up and loaded him into the ambulance. Once the doors were closed, Pike and Wooten exchanged a wary glance and laughed. It had been ugly but they’d gotten the job done. Wooten took out a pair of scissors and cut off the man’s pants to get a look at how much damage he’d done to his lower legs while Pike and I set to work on tying restraints.

Tying someone’s hands and feet to a stretcher with soft restraints is as much art as science, with special consideration needed for different patients. If they’re strong, for instance, you want to restrain one arm at their waist and the other above their head, thus separating their major muscle groups and making it that much harder to break out. You also need to be careful about what type of knots you tie.

To this day I know very little about knots other than that the type I tied that day should never be used to tie a patient’s hands. But, as is so often the case with acquired knowledge, this is something I had to learn the hard way.

Back in the ambulance we had the patient’s legs stabilized and bandaged, his vitals checked, IV lines running and – we thought – the restraints securely fashioned, so we started for the hospital. Pike was behind the wheel and Wooten and I sat in the back observing that awkward silence usually reserved for perfect strangers in an elevator. One thing about sedatives is they affect each patient differently and you never know how yours will act until after you’ve sedated him. If, for instance, a patient has been given that particular combination of drugs before he’ll have built up a tolerance and they’ll either last a shorter period or simply sedate him to a lesser extent. Other complicating factors exist, of course, including what else your patient has in his system. Large amounts of certain drugs, cocaine being among them, simply make it hard for sedation to truly set in. And so, after a few minutes on the road, our patient began to stir.

In reality, this isn’t all that uncommon and generally it’s not much of a concern if your patient has been properly restrained which, as I’ve alluded to, ours wasn’t. So I sat on the bench seat and watched this rather herky-jerky reanimation process with a pit in the bottom of my stomach. It was the very same feeling I got as a child while helping my step-father in the garage. He’d be underneath the car when suddenly oil would begin pouring out and in his fury he’d scream for me to hand him something in a voice so garbled by the car and the excitement that I wouldn’t be able to understand him. I’d freeze knowing that at any second, madder than ever, the problem worse than before, he’d poke his head out only to find me standing there empty-handed.

“Uh…he’s coming around,” I said after the patient opened his eyes.

Wooten shrugged. “He’s tied down.”

My hands began to sweat as the patient twitched, then jerked, a wild animal caught in a snare. He turned to me and shook his head in fury, then flopped back, sat up, kicked his legs and blew out a lungful of hot anger. Breathing heavily, he lifted his head and pulled against the restraints. His right hand, the one Pike had tied to the stretcher near the patient’s right ear, didn’t budge but the left hand, the left hand was clearly a problem. Already it was loosening and when he ran his fingers over the shoelace-style knot I’d tied it was clear all he’d have to do is tug on the right strand and it’d unspool. The patient and I locked eyes, both of us coming to the same realization at the same time, and I swear he smiled. Maybe he did, maybe he didn’t, but before I knew it he was untying the knot.

I yelled for Wooten but it was too late. Before either of us could react, the patient had freed his left hand and was reaching for the right. Wooten, again surprising me with his feline quickness, grabbed a sheet and yanked it hard over the patient’s face, if not fully restraining him then at least blinding him. Feeling useless following my knot-tying failure, I jumped up and tried to grab his free arm when a paralyzing pain shot right through me – the patient, half-restrained, partially-sedated, a little bit blind and totally out of his mind – reached up and grabbed my nuts.

It’d be nice to say I reacted firmly. That I endured the pain, swatted away his hand and set to work on regaining control of the situation. That would be nice but the scream I let out – terrified and desperate and too high-pitched to be mine – says otherwise. I don’t remember Pike stopping the ambulance. I don’t remember him getting in the back and properly restraining the patient. I hardly remember the trip to the hospital. What I do remember is a blinding, searing pain and my long, quiet period of huddled convalescence.

At some point we dropped the patient off. At some point we went back out and ran more calls. At some point the day ended and I went home and whatever I told my wife or my classmates of that first day was, in all likelihood, edited for content. Did I claim to be a hero? No. But did I own up to the scream? I doubt it.

Of course, there were other third-rides, more classroom hours. More quizzes and, in December, the national registry exam. I did fine on my rides, took the quizzes and passed the exam. I received my EMT certification in the mail and was prepared to begin my career. But I did all of those things with the knowledge that knots are knots, patients can turn on you and when all hell breaks loose, I’ll get the job done – but I’ll scream like a girl as I do it.