the perfect call ...

september, 1992.

today is my 42nd birthday. my wife and i are spending a leisurely indian summer day preparing for a family birthday party tonight. right now we're at the grocery store, in the parking lot, loading groceries into the department's staff car. it's not that unusual that i would have a staff car on my day off. i occasionally go on calls when i'm not dispatched for qa purposes, or to assist with the overhead on the bigger incidents.

it's hard to believe that fall and winter will soon be here. today is warm and sunny -- shorts and t-shirt weather -- and i notice, with just the hint of a slight smile, that there are plenty of ladies taking advantage of today's sun.

as i'm closing the trunk after loading the last bag of groceries my pager shrieks to life: "car/pedestrian accident, subject down, not moving, unconscious, breathing not verified." the address given by dispatch is about midway between me and our outlying station. we slide into our seats, buckle up, i hit the emergency lights and siren, and put myself in route.

it's an easy drive, not too far off the highway. traffic is light. we're making good time. i call dispatch and ask for an update. i'm given the same information as before, but this time she adds that our patient is a 10-year-old boy. i have dispatch put airlift on standby and make sure that in addition to the engine, rescue, and ambulance that was originally dispatched, a medic unit is also responding. disptach assures me they are and that we also have an additional engine responding.

my gut is starting to churn. this could be a difficult call for everybody.

i arrive ahead of the engine and ambulance, driving past the incident and parking just behind the vehicle and patient to block the road and give the crew a safe working area. this is a dangerous piece of road with a long downward hill and a blind corner above that. the ambulance and engine are coming from the opposite direction. i tell the ambulance to pull past the incident and decide to have the engine block both lanes of travel behind us. there will be a lot of work to do here and we'll need all the road to do it.

as i drive slowly past the incident i see that the car has significant front end damage and that the driver is still in the car, holding onto the steering wheel with both her hands. she looks young and very scared. i tell her i'll have somebody taking care of her as soon as we determine the needs of the boy. our primary patient, the 10-year-old, is lying mostly beneath the rear bumper, legs sticking out, not moving.

i give a quick short report to dispatch and request that they fly airlift to our location. they should be here in under 20 minutes.

the ambulance crew arrives with their equipment, slides the boy carefully but quickly out from beneath the car onto a backboard and determines that he has a pulse and is breathing. the engine crew has blocked the road behind us, set up flares to warn oncoming traffic, and is now also with us.

the trauma exam reveals that the boy has significant head and facial injuries, lacerations, avulsions, abrasions, bruising, and a possible fractured arm. he beings to regain consciousness, but also becomes combative -- not necessarily a good indicator. a witness tells us the boy was hit, thrown over the car, somehow caught on the rear bumper, and dragged approximately 50 feet. from the mechanism we all suspect he has significant internal injuries as well.

the incoming engine company notifies me that they are about a mile out and asks for an assignment. i tell them to find a place for airlift to land and give them the job of command of the landing zone. it's their job to find a safe and suitable landing area, establish communications with the helicopter pilot, and then report weather and landing zone situations. today is extremely clear, there will be no weather issues, but we are in a fairly heavily wooded area and most likely they will end up using somebody's yard or field for the landing zone.

the emt's on the ambulance are doing an extremely good job, as are the emt's from the first engine. we train hard at keeping our skills intact. and the taxpayer's have given us good equipment to work with. this is teamwork and there is little need for discussion or direction as to what needs to be done. our patient is on a backboard, with full cervical spine precautions taken. his wounds are exposed and treated. i can hear the siren from the medic unit arriving and i give them a quick short report as they pull up to the scene.

i step back and survey the incident. we now have plenty of hands on scene and work is going well. i assign an emt to take care of the driver. a landing zone has been established and i hear the airlift pilot talking with the landing zone engine company officer. the medics are dropping a tube in the boy's trachea to keep him breathing and prepare him for the flight to harborview, our state's trauma center.

as i turn i notice my wife talking with a woman in the driveway behind us. she's pale, shaking, and sobbing. this is obviously the boy's mother. shit! i should have seen her earlier and taken care of her too. i know how frightened she must be. emergency medicine is not pretty. she should have been told what we found and what we were doing. i promise myself i will do a better job next time.

my wife doesn't really know what i do either, or what emergency medicine and firefighting is all about. this is the first time she has been on a bad call with me. but she's been doing a great job with mom.

i introduce myself to mom and tell her that her son has some very serious injuries and that the best place for him will be at harborview hospital. we will be flying him there in a helicopter. before we finish the conversation we feel the beating of the helicopter's blades and then see the helicopter hovering overhead. they land about a half mile from us and the medic unit leaves to meet up with them to transfer the patient to the flight nurses for the trip to seattle.

mom tells me that her son asked if they could bake cookies together. she told him that first he needed to check the mail then they could bake. our witness told me that as the boy stepped away from the mailbox to cross the road, he looked in his direction but not the other, and started to run across the road, with the mail in his hand, back to the house. he never saw the car coming down the hill. and it was too late for the young driver to react and stop in time to avoid hitting the boy.

i asked mom if she was able to get someone to drive her to harborview -- she was too shook up to drive herself. she told me her husband was at the husky game and there was no way to get to the hospital. my wife suggested we drive her there. and so we do.

on the way to the hospital she tells me a lot about her son, how he's doing in school, sports, his brother, and again about baking cookies. she's crying quietly, and i search for comforting words -- few are found. i stay in touch with dispatch and advise them of our trip to harborview and that dad is at husky stadium and ask if they can find a way to contact him so that he can meet us at the hospital.

traffic is light on i-5, and we make it to harborview in good time. thankfully so, i've run out of words.

as we walk into the emergency department, dad is there! dispatch was able to call the stadium and have him paged. i cannot imagine how horrible it must be to hear your name over the stadium speakers, asking you to come immediately to the office for important news. you know it can't be good news -- they wouldn't page you because you just won the lottery.

their son spends little time in the emergency department getting an exam, blood draws, x-rays, and scans before being sent to the operating room. harborview is quick and efficient. there are more docs, nurses and techs working on him here than we had on-scene. a doc comes out of the er and tells them what injuries they found, what they've done, what they are going to do, and what they expect to happen. i listen in. i feel good about his outcome. we leave quietly, allowing mom and dad their needed moments together.

in the months that follow the boy makes good, but slow, progress. it takes a long time to heal that many wounds. mom and him stop by the station occasionally to say hello and thank us for what we did. months later he is still in a wheelchair, but his neuro and motor function are returning to normal and soon he'll be up and walking on his own. i think that there will always be slight defecits from the accident, but nothing traumatic enough to slow him down.

in the years that follow i lose touch with him and his parents, but i think often about how perfectly everything went that day for him. we had a witness that called 911 immediately and gave a good report and a valid address. the fire department was on-scene quickly and gave great basic life support care, followed by the medics with advanced life support. after a quick transport by airlift to harborview, he saw some of the best doctors available. and after his treatment at the hospital he received expert physical therapy. and love from his parents and family.

perfect. that is how it is supposed to work.

january, 2001.

i'm on shift today as battalion chief. it's just after midnight. we're bolted from our sleep by our pagers. one-car motor vehicle accident. vehicle on its top. utility pole sheared. occupant trapped, unconscious and not responding. the address is just a half mile from our outlying station. i know the crew will be there quickly, going to work and giving me a good short report.

i'm on the road, asking dispatch for an update. they don't have any more information than that given earlier. i have them put airlift on standby.

the rescue and ambulance from the outlying station arrive and give their short report: pickup on its top, pole sheared abut 4 feet from the ground. major damage to pickup. driver of vehicle pinned beneath pickup. no pulse, no respirations. major trauma to driver.

i arrive and establish command, giving directions to the incoming units before stepping out of the command car. when i open the door to get out it hits me -- the feeling of death in the air.

it's like the taste of a bad penney. chewing on aluminum. staring into the sun. biting odors. it fills my senses -- smell, taste, feel. i don't know where it comes from or how long i've had this horrible super power. but i know i'm not alone -- many others in the emergency services have the same feeling.

for a moment i'm stunned. my adrenal gland goes into hyperdrive. i can feel my pulse and breathing quicken and my brain goes prehistoric, telling my body to flight or fight. i concentrate on the tasks at hand and bring myself to action.

i have the ambulance crew re-check for a pulse. there is none. and by the injuries i can see i know there will be no attempted resuscitation of our patient. he is doa -- dead on arrival.

i cancel airlift and the medic unit and have the incoming fire engine block the road well away from the scene. i want to keep everybody away that doesn't need to be here. this is not a pretty sight. the police will be arriving soon and will want information to begin their investigation.

looking around i see a car-load of kids standing by the road near the overturned pickup. i walk over to them and ask what they know. they tell me the pickup was passing them, lost control, and rolled into the ditch, striking and severing the pole, throwing the driver from the pickup and trapping him beneath it.

they know who he is and tell me his name.

for a moment i can't breath. my eyes blur. i'm unsteady and want to sit down. i don't want to be here -- but i do want to be here.

this is the same boy who was hit by the car after getting his mail in 1992. the one we airlifted out. who, with his mother, visited us at the station to thank us and show us his recovery progress. our perfect call.

i steady myself against the ambulance and have the crew check for a pulse again. i so want there to be one. but i know there won't. there can't be. not with those injuries.

i survey the scene again, making sure we're doing everything we possibly can. i see a car stopping near the scene. it's his mom and dad. one of the kids drove to their house and told them about the accident. they live nearby. i don't want them here. nobody should see this.

they park where they can see the pickup but can't see their son lying beneath it. i run through the mess of people, vehicles, and debris on the road and meet them as they are getting out of their car. i remember how poorly i handled the call years ago and how i promised it would not happen again. they look worried -- no, it's not worry, it's terror. "what is happening?" they ask. but i think i know that they know exactly what is happening.

i explain to them what we found and what we are doing, but that it doesn't look good. he has no pulse and he isn't breathing. and we can't get him out from under the pickup quickly. i have to tell them the truth. lying wouldn't do anybody any good. they ask if we've done everything -- if we could check him just one more time. i send a firefighter to check his pulse again. but we know what the answer will be. they hear the firefighter's reply as he radio's back to me.

i ask them to go back home. to wait. i will be there just as soon as possible. and i will bring our chaplain to help with phone calls and arrangements. there is nothing they can do here. there is nothing we can do here.

code 4

code 4: firefighter radio slang for cpr in progress.

it's outdated slang. and the only ones who still use it are the old dinosaurs, like me, or the newer firefighters who like to carry on the tradition and heritage. i also still tell dispatch to "start me a card" when we have walk-in aid calls at the station. i know that dispatch has not been using time-stamp cards for almost 20 years now, using instead computer-driven dispatch systems that automatically record times and addresses from the moment the 911 call is received to the time a vehicle is back in service ready to respond to the next call.

but it's muscle memory in my brain. all of the dispatchers know what i mean and respond back "received, cpr in progress."

it's just after 4 a.m., 0409 hours by the time on my pager. the lights in my room come on and the station alarm is sounding, or at least they should be, telling us that somebody is having a bad day and expecting us to make it better. for some reason the lights and alarm aren't on -- which is unusual -- usually the system works. but my pager is making enough racket to wake me.

"female, unconscious, not breathing." we'll empty the station on this call.

within moments we're all up and heading to our rigs. i have a two-man engine company, a two-man aid unit, a three-man medic unit (including our rookie), and me on the battalion car, at our station. i also have another station east of town with three personnel ready to respond if we need the manpower.

the call is close to the station and we arrive in just a few minutes and find police doing a pretty good job of cpr in the bedroom. i think we have a great relationship with our police department. they help us out a lot and i hope they feel we return the favor when it's needed.

overall, the call doesn't look good. the patient is mid-50's, somewhat overweight, and obviously has an underlying medical history. fifty-year-olds don't just suddenly collapse and quit breathing. but we go to work. doing our best. always expecting a good outcome.

we move the furniture around to give us some working room. there's never enough room or enough light. the medic gets the monitor hooked up and his meds out while the emts get an airway in place so that they can breath for the patient and then start compressions. the cops move out of our way. asystole -- no heart beat.

the patient has poor veins, so after a few attempts at the arm, an iv is started in the patient's leg using an io gun. this line will feed directly into the inner space of the patient's bone -- where the blood cells are made. the medic gets a good line, and it flows freely. this is where the meds will be injected.

the emts are doing a good job of cpr. compressions are a lot of work and i make sure that the personnel rotate out before tiring. thankfully we have a lot of people on this call. i send somebody out for additional oxygen bottles and also call dispatch to request a chaplain to our scene. the medic drops a tube down the patient's throat to make breathing for the patient, with our bag-valve-mask, easier and more efficient. we are ventilating the patient with 100% oxygen, giving her the best chance of survival.

the person who called 911 is not giving us as much medical information about our patient as we would hope. we're not sure of her previous medical history and have no idea what prescribed meds she may be taking. this is not unusual. often family members and friends are too grief-stricken to talk with us, or simply just don't know. if only everybody wrote this information down (like the vial-of-life program), and put it where we could find it -- the refrigerator is where we always look -- valuable time would be saved.

finally a chaplain arrives and i feel much better. our chaplains are trained in caring for the family members and always seem to be able to get the info we need for patient care.

now the team is working like the proverbial well-oiled machine and the medical magic is starting to happen. but after a few rounds of meds things aren't looking all that good. the patient is not responding as hoped. we just can't seem to get a heart rhythm going and the medic is considering calling medical control at the hospital and asking for guidance. after another round of meds and a change to a fresh bottle of oxygen he makes the call to the on-line medical control doc.

it's been a long call. we've been on-scene now for 30+ minutes, which is the norm for a cpr call. we're starting to run low on meds. we're starting to wear out. we carry the same meds in our medic unit that the hospital uses during cardiac arrests -- epi, atropine, bicarb, and more. if this incident had occurred in the hospital the timing and application of meds and procedures would be the same.

the medic is on the phone with the doc discussing the call. we stop cpr again to check for a heartbeat -- what? we've got a rhythm on the monitor. not a life-sustaining rhythm, but one that we can work with. the medic tells the doc "looks like i got work to do" and hangs up. our pace quickens and our mood brightens. the patient is still not breathing on her own so we continue to use our bag-valve-mask and oxygen.

as the medic goes to work the heart rhythm gets stronger and better. we load her up on the stretcher and get her into the ambulance. i assign personnel to accompany the medic in the back of the ambulance for compressions, ventilations, and charting. once again i'm glad we have enough well-trained people on the call. the rig speeds away with lights and siren for the 15 minute ride to the hospital. she continues to improve on the way in.

it's an hour later and the crew pulls back into the station. the medic still has to complete his paperwork and enter the call into the computer. our patient is still critical, but has been admitted to the hospital for further treatment and observation. we discuss the call and talk about what went right and what we could have done better. all in all, we're pretty satisfied with how it went and how she's doing.

my dad died of a heart attack eight years ago. he lived in another town. i know many of the firefighter/emts and medics who worked his call. the scenario was similar, but unfortunately with a different outcome. i was in seattle when he collapsed and mom called 911. during the incident i received a call from the captain of the crew, a friend of mine, that was working his code. as i was driving to mom and dad's house he explained everything to me that was happening. i could actually see what was taking place. i knew they were doing everything that could be done. and i knew what the outcome would be. and also that they would feel bad, for me and themselves, for not being able to bring dad back to life.

since dad's death, every time i go on a cpr call i can see my dad lying there with the crew working on him. and it makes me want to work that much harder and push the crew that much harder too. it's not a sad thing, it's just a vision, a reminder of what you expect of us and how hard we train and work to make it happen. sometimes the magic works, sometimes it's just smoke and mirrors.

one of the things i've realized, after 25 years of doing this, is that we -- or maybe just me -- see way too many dead people. and it can make us indifferent, hardened, soft, emotional, a bit nutty, and combinations of all of these and more. it's kinda like a multiple-choice question with the correct answer being "d - all of the above." but my hope is that it gives us the respect for life -- in those around us and in ourselves -- that we deserve. and it reminds me that life is not forever. that i need to make the most of it.

and that i need to remind those around me of that too.

gracias por sus rezos

i'm home safe.

another successful mission to guatemala.

another life-changing experience.

on february 11th, just before midnight, i boarded a continental 737 for my destination of el paraiso, guatemala. included on board the plane were 20+ others in our mission group -- doctors, nurses, dentists, nutritionists, pastors, techs, assistants, people looking to help. some, like the doctors and dentists, have specialized training. others, like me, a pa (plain-assed) firefighter, just want to help in some way.

after a change of planes in houston and a long layover, we landed in guatemala city and easily made our way through customs. all our meds, equipment, and handouts had been packed in large plastic crates and were labeled with their contents. guatemala customs barely took notice of what we were bringing in. i think they are pretty used to having mission groups visiting -- and there are always other groups on our plane heading to different locations.

a bus was waiting for us, along with our guatemala hosts, susy and helmer, and we were on our way to antigua for a day and a half of sightseeing and aclimating to the time and cultural differences.

antigua is a beautiful city. guatemala's ancient capital. it is surrounded by volcanoes, one of which is active. there are numerous schools teaching spanish for the traveler and is the recommended jumping off point for guatemala visitors. guatemala city is large, dirty, and sometimes dangerous. antigua is small, clean, and set up for the tourist trade.

but antigua has changed a lot since i first visited in 2001. gone are the masses of street peddlers and beggars. now the streets are cleaner and the peddlers fewer and more polite -- not harassing you, but still applying just enough pressure to make the bartering fun. but gone too are the students from all over the world. i remember walking down the streets hearing german, dutch, english, japanese, and many languages i didn't recognise, along with the spanish of the citizens. i hope this is only a temporary thing, maybe due to the poor global economy. if you ever get a chance to visit guatemala, antigua is a must-see -- especially during easter week.

i made my self-required visit to frida's, a local hangout for ex-pats and travelers. i have never seen any locals in here, unless they were accompanied by visitors. the food, drinks, and atmosphere are great, and i brought along gary (our mcgiver) and joel (one of the dentists). we were soon accompanied by more of the group. they know just where to find me.

that evening i had dinner with claritza and her family. claritza is my spanish teacher from my 2001 and 2002 visits to antigua. she teaches through a spanish school called probigua and also on-line through skype. i'd give her a plug here but i can't find her business card.

i must digress ... i need to thank those who make my trips possible. first, my wonderful and loving wife, for not only allowing me the time away from home and duties, but also for her encouragement in me searching out new adventures. my employer and fellow chiefs, for rearranging their time to cover my shifts, which gives me the extra time off needed. my family, my two daughters -- both health care professionals -- for their love. and my friends, for your prayers. thank you.

after dinner that night, a good sleep, my last hot shower for a week, and the next day sightseeing and souvenir shopping, we'll be heading to el paraiso on a 10-hour bus ride into the jungle.

the bus ride isn't all that bad. although the roads here are mostly dirt, full of chuckholes, and the drive is long, the countryside is beautiful, and my fellow missionaries (funny, i don't think of myself as a missionary), pass the time talking, sightseeing, and sleeping (along with some vertigo just to keep it exciting). we stop for lunch at a mall (mall? it seems so out of place), and continue on our way, finally arriving in el paraiso late afternoon after changing buses in the town of fray.

our clinic will be set up sunday in the village's nazarene church, after services. we will move the pews around, forming areas for greeting, vitals, nutrition, exams, dental, and pharmacy. it will take us all sunday afternoon. we also unpack all the crates and set up the equipment.

it's sunday morning, sunday school for the kids at 0800 and then full services at 0930. church here is a bit different, especially because it's in quiche, the local language, but also because: the women and children sit together, the men all sit to one side, and kids are allowed to roam freely -- and the men are very passionate during prayers, crying and sobbing.

a translator is supplied so that we can understand what is being said, and he invites us to the front so that we can sing a song and be introduced. cindy, doctor mark's wife, plays the electric piano and we sing along. i know nobody here understands what we are singing, but they probably recognize the tune. it's a good thing i have a booklet with the words in it because i don't know the hymn. i think we sound pretty good and everyone claps for us.

after services we break for lunch. we bring in our own cook, food, and bottled water and we are fed very well all week. meat, potatoes, rice, tortillas, beans, lasagna, cereal (with soy milk), eggs, ham, spam (i love spam), and the regular foods we eat at home. we've brought a propane stove and this time a refrigerator. three squares a day.

setting up the clinic goes pretty smooth -- after we've broken open the cases and figured out where everything is supposed to go. about half the people on this mission are new, but they seem to have a sense of what needs to be done and we all work well together. putting together the pharmacy always takes the longest. we put the meds in alphabetical order -- mostly -- but group items like the pediatric meds, cough suppresants, and lotions.

while everybody is setting up their areas, the locals watch through the windows and doors. pretty soon there's a group of kids in the church and someone has blown up balloons and exam gloves for them to play with. everyone's excited, both us and the villagers, to get the clinic going monday morning. we're finally done around 1900 hours, tired, dirty and ready for dinner.

this is our third year in el paraiso. the first year we had pit toilets and bucket showers from rain water collected in cisterns, taken behind black plastic curtains. before we arrived our second year we were told they had a surprise for us and when we arrived last year we found flush toilets and real showers. the village had devised a method to pump water into overhead cisterns and use gravity and head pressure to supply the water for the toilets and showers. two real toilets with real seats to sit on. two real shower heads (although the water was cold), to stand under. pretty close to heaven! we do have to sleep in tents inside the area of the church that is the school rooms. this part of guatemala has scorpions, tarantulas, malaria mosquitoes, and lots of other big and nasty bugs. we found two scorpions in the sleeping areas, and one in the kitchen. one tarantula was captured in the clinic and are almost always found in the bathrooms.

clinic starts first thing after breakfast monday morning. we're all set to go. this year i'm assigned as half a doc -- i do patient histories and chief complaints, after which i pass them on to doctor mark for physical exams. in the past i worked taking vitals and in pharmacy. it's all fun and hard work too. when taking vitals you get to meet all the patients. pharmacy is taxing in making sure you're filling the right prescription. patient histories and complaints is triage. doctor mark asks me what i think is wrong with the patient and what i would prescribe. by the last day, and with doctor mark's help, i'm getting pretty good at figuring what is wrong with the patient and what they should be prescribed. it's similar to what i do as an emt, but here i get to carry through and diagnose and prescribe, which i don't do as an emt. one year one of the docs had me suture, which was cool.

our patients run in age from babies to the elderly. almost all of the children and adults complain of headaches and muscle pain -- from working all day in the fields in hot weather -- plugged ears and stomach complaints. the babies have fevers, measles, scabies, giardia, and chronic diarrhea. many are constantly tired and i prescribe iron to boost their energy.

i must use an interpreter because of the quiche language. some speak of bit of spanish, and i also speak a bit of spanish. so we're able to practice together. it's fun, but sometimes heartbreaking. i always ask about their diet, what they are eating, and if they have a good appetite. it wasn't until the third day that i realized that what was being interpreted to me as "poor appetite" actually meant that they weren't able to eat because they had no money for food. when i visited guatemala in 2001, with rita, my spanish teacher from shoreline cc (and the best teacher anyone could every have -- thank you rita), it was the first time i was exposed to a third world country and true poverty. here were people living in mud shacks, dirt floors, with thatched roofs. no fresh water. no fresh food. everything they owned, which wasn't much, was within their reach. some had farm land to work. some goats or chickens. everyone bartered and everyone, at times, went hungry. no health care. no education. no security. i've seen poor conditions here at home, but nothing like this. and this is why i return.

between the medical and dental clinics we saw 1010 patients. most with the normal illnesses you and i put up with day to day and simply go to the grocery store and buy over the counter medicine. i can't tell you how many teeth the dentists pulled, but it was a lot. we also saw patients who had strokes and cardiac issues, who probably wouldn't make it until our visit next year; one fractured forearm on a boy from falling during a soccer game; a machete wound on a foot; a hernia; many lymphomas; ob/gyn issues; breathing problems; pretty much a little bit of everything else that comes through a busy er.

i think the best thing we give these people is an education in nutrition and hygiene. maureen and her crew do an excellent job at this. it seems to me that each year the people are a bit less sick than the previous year, which means they are eating a broader diet, washing their hands, and not drinking water unless it's been boiled. it wouldn't do much good to keep coming back year after year without the education.

this post has become way too long, and maybe too boring, so i'll finish here. but i do want to plug two websites. the first is kiva.org. at kiva you can make a difference by donating money for mini-grants to people and groups in third world countries. and when you get boared and need diversion, instead of playing solitaire, go to freerice.com. at freerice you can learn a language, or math, or another topic, and in so doing make donations of rice to feed a hungry world.

thanks for staying until the end.