______________________
Steve Kavalin
Gunslinger
I was a gunslinger, ten feet tall and bullet proof. As the Sheriff of Trauma Town, F-L-A, nobody died on my watch. Nobody. Period. Cocky and arrogant weren’t large enough words to describe the way I felt.
I had paid my dues for three long years slinging stretchers as an EMT/ambulance jockey until I could finish paramedic school and gather enough merit badges to break into the big leagues as a county paramedic. It was the bigs all right. Cool squad trucks, department-issued everything, from raincoats to boots. We wore badges, and at that phase of my development, I needed them. With an ego bigger than a house, my walk grew from a wet-behind-the-ears stagger to a cool-as-ice swagger. I was so cool I let my oversized arrogant ego write checks my new skill set sometimes had a difficult time cashing.
I was all about the drama of trauma. What I was missing in wholesale was an entire population of patients that did not quite fit the categories of medical emergency or trauma. A large group that I could have better served had I just gotten out of my own damn way. What follows is an account of one such population and how I “grew up” taking care of these citizens. Back then my behavior was all about self-promotion and preservation; now it is based on understanding of the human condition and the evolution of my own humanity. But, back then I was just trying to hang on. Oh, and look cool while doing it.
I worked for a big department and it seemed I was almost always in the busiest zones of the big department. In the beginning it was all fun and games (remember I was the Sheriff of Trauma Town). It just kept coming and coming, night after night: shootings, stabbings, car wrecks, all the violent and generally not nice things that people think to do to each other. I was there; I was all over it. The more blood the better, the busier the better. Trauma is drama and I would find my face in the paper or “my” call on the evening news.
Shazam! I was a star, or so I thought. After a whole day of running all the “great” calls, we would settle into the evening, first wrapping up the drunks and then the drunk drivers. After the last drunk driver was backboarded, the early morning cardiac calls began. You could count on at least one rich old man who had partied a little too hard with the cocaine princesses the night before. Those scenes were always interesting. A rescue crew (my partner and me), a cop or two, a few firemen, and an ambulance crew all piled into the bedroom in some million dollar mansion with a breathtaking view of the intracoastal waterway off Moneybags Boulevard. A sixty-something, divorced swinger dude with a bad comb-over, cool (as in, cold to the touch), pale and diaphoretic, sitting on the edge of the bed professing this was the first time he had done coke and only because she wanted him to. The “she” was the 20-something (he was praying as the cops looked for her ID) lying unconscious and naked on the bed next to him.
As we cared for him, someone covered her up and gave her a little shake and shout, usually calling her Annie in the process, just to make sure we did not have two patients on our hands. Those calls were recreational. We started IVs, gave oxygen, morphine sulfate and a few sublingual nitros as we transported Mr. Money-no-brains to the hospital with a promise not to mention his well-known name over the air when we called in the report. The medcom radio was a big orange box just like on T.V, and this was way pre-HIPPA before patient information became sacrosanct. These calls were always a fun little way to wrap up the shift.
After a short time on the job I realized there must have been an entire chapter missing from my paramedic textbook. I came out of school well versed in the 15 module D.O.T. curriculum and had passed every skill station and written exam, but nowhere in my lessons (I know, I went back through my notes) did I find anything that covered the next call scenario.
With predictable regularity, we ran a call about 1 or 2 AM that usually went something like this: we would have been asleep for about an hour, just long enough for my partner and I to mistakenly believe we might get a few good hours of deep sleep. The plectron would sound to announce an unknown illness or injury at 123 Poorman’s Street. We fired up our stuff, found our way to the address, tossed 60 pounds of lifesaving equipment across our backs and shoulders, and made our way along cracked sidewalks and through dimly lit hallways to Apt 2B.
The door usually opened after the knock and we announced ourselves. “Paramedics, Paramedics!” so everyone knew we were not cops. Sounding like a cop at 2 AM in this neighborhood had the likelihood of getting you shot. After entering, we usually found a solitary person sitting in the near darkness with most of the light spilling into the room from the opened door. My partner and I would hunt down the light switches, scan the room for potential threats, and start our assessment.
“What’s wrong tonight?” I would ask.
“My ______ (fill in the blank: head, hand, feet, hip, spleen, knee, toes, feelings) hurt.”
“How long have you been having the ______ pain?”
“About 15 years.”
Here I tried to sound therapeutic instead of angry. “Well what about the pain is different tonight?”
“Nothing, it’s the same.”
Now I’m angry but professional. “Well, I’ll tell you what. I’m not going to tie up my ambulance taking you to the hospital. This is not an emergency. You can have a friend take you to the clinic in the morning or you can take a cab to the hospital, but I am not sending you in an ambulance.”
With that, I would tell everyone to leave, with a parting shot to the citizen that 911 is for emergencies only.
There. Now I was available for the next shooting and so was my ambulance. You can predict what usually happened next. We would get back to our station, bed down and be asleep for 45 minutes and sure enough, the same call would come in. I launched into my speech about cabs and clinics and 911 being for emergencies (being simultaneously angry and professional).
I would have been blue in the face if my blood pressure were not so high. But I was the Sheriff and I was going to maintain order. At least until the call came in again, same place an hour later, with the same result. I still had not figured this whole thing out.
There was a subtle dance going on, only I could not hear the music. This is when a one-way ego and youthful arrogance will kill you. I beat my head against the wall for a few years until it dawned on me. The solution was right in front of my eyes all the time: send them to the hospital on the first call. Genius! That way I only had to run the call one time. The patient had his needs met immediately and I was available for the next real emergency. This met with a few grumblings from the ambulance crew but when I explained to them that it would allow us maybe to sleep the rest of the night, they eventually came around to my way of thinking. In fact, some had gotten so good that if they beat me to the call they would have the patient loaded prior to our arrival. I would assess the patient, making sure there was nothing else going on, and wham bam Bob’s your uncle we were done. It really was a beautiful thing, akin to the Zen Archer chestnut of “One Arrow, One Life.” Mine was “One Call, One Ride.”
What had I been missing? Why did this type of call take me off my game? The frustration I had was with myself at having taken so long to figure things out. It was just one patient in no apparent distress and not requiring any of my advanced life support skills. What I failed to see was that when a 75-year-old guy calls at 2 AM and can only tell you his hip has hurt for 15 years, the hip is not the problem. He is scared, lonely, alone or something else. He is crying or dialing out loud for help. This person needed high care, not high tech, in the form a ride to a clean, well-lighted place, for whatever reason.
Unfortunately, my youthful ignorance and ego caused me to miss the cry for help. I did not see it because it lacked crowds and cameras and was not covered with blood. This human drama unfolded on the small stage as the patient reached out for compassion, sympathy and help, and all I did was quote the damn rulebook: 911 is for emergencies only! I missed it, blew it big time.
Not all of our care comes from a textbook and a drug box. The world is not black and white but a whole lot of gray. Life unfolds in small moments, sometimes at 2 AM, and trauma and drama were the exceptions, not the rule.
What we as paramedics must come to understand is that everyone has his own definition of an emergency based on his ability to cope with sudden and unexpected situations. When we are first taught to interview a patient, our concern and focus is on the symptoms the patient conveys, but the bigger lesson here is that omission is as important as declaration. As paramedics it is our job to listen to both what is spoken and what is not.
In the years that have followed, I have done my best to teach these lessons in the classroom. I tell my students to do their best and not to make the same mistakes I did. I hope they listened.
“If you want others to be happy, practice compassion. If you want to be happy, practice compassion.” The Fourteenth Dalai Lama
