If You Can, You Must
When is too much, too much?
Listen to the author read you the story: audio
A five am 911 call means: woke up dead or super sick. Whatever lays ahead, this morning offers the frigid beauty of a Vermont morning. Peeing, prepping before rushing into deep cold, I admire the monster-sized full moon approaching the horizon. I am again awed by the sparkling cascade of clear-sky snow that floats on days like these.
“Dispatch, 14RC1 acknowledging call for Trowbridge. En route shortly.” No, you cannot go from sound, warm, lovely sleep into a -5 degree dawn. At this age, I need the obvious bio stop and time to layer on socks and long underwear below proper warm clothes.
My phone buzzes with a message from Regina: “Pick me up. I’ll be at end of my drive on the road.”
I text back: “3 min and I’ll be in truck.”
Regina leaps up and in. Together now, we speed-ish down her hill and away from acres and acres of hayfields buried in feet of snow. My emergency lights reveal every crystal of ice that dances over the road and in the woods that close in around us. The snowbanks on the left and right stand taller than the hood of my truck.
I think—aloud, I guess—“The boys will wing that back today.” As if that is an obvious and stupid observation. With a clear, cold day between weekend storms, I envision the town road crew plowing with the wing extensions set high. They will trim the snowbanks down while spraying the top half deeper into the woods. Snowbank maintenance. Given we work, drive, and respond over rural Vermont 3-rod roads, when snow tumbles back onto the road, the pathway narrows as if the snow wishes to reclaim it all.
I slam on the breaks.
Regina exclaims (shrieks): “What the fuck?”
“Was that a flying reindeer? Are we in a Santa Claus movie?”
Now fully stopped, I get out of the truck. I hear Regina open, then shut, her door. I circle the truck sunwise and she circles the other way. We meet and continue. The routine reminds me of silliness from high school when we would evacuate a car at a red light, run circles, dance like fools, then jump back in before the light turned green and horns cussed at us for being kids.
My heart has immediately accelerated to 120 beats per minute. My eyes dilate. In fact, my entire sympathetic nervous system reinforces that we nearly collided with a flying (or leaping) deer. Climbing into the warming truck, we babble like civilian humans who saw something that threatened to kill. The deer made it over the truck and landed on the opposing bank. We both witnessed the track marks. He was gone. No blood, no fur, nothing but hoof prints on plow-packed snow.
As we drive towards the emergency, we both breathe to control the massive hit of adrenaline we loaded into our bloodstream. We are professional paramedics. We are cool and calm. We stride onto a scene with a plan and authority that tends to soothe others at emergencies. If we show up wired and sparking with fear, then we will (and have) infected everyone else at the scene.
We are not allowed to be afraid. That admitted, let me confirm that every one of us has blown our cool. Somehow, someday, some setting, we have each keyed the mic with some variant of “oh shit, send me everything.” Because on that day, we are too small, too weak, too overwhelmed to fully assess and report what is in front of us. The 200-car pile-up in an ice fog on the interstate where the first car has mom holding the decapitated head of her husband while the infant in the back falls silent while you fail to understand that this is only the first car you looked at. Or that day when I said “priapism” over the radio because I saw a lad curling into a decorticate posture and an erection often associated with strangulation, hanging, or massive neuro-trauma. The right and professional words evaporate as you key the mic. You can’t be cool while squeaking sterile medical terms into a radio.
You’re first. You’re trained. Breathe, see the facts as they are, invent some stupid plan, then communicate your needs calmly and smoothly over the radio. It doesn’t always happen, does it? Sometime in every rescuer’s career, you want your radio to have an “oh shit” knob.
Hitting a flying deer on a brilliantly dark January morning feels like “oh shit” to the body. But it isn’t. No damage to truck or deer or humans. And yet, a few more miles to travel, hoping now not to meet a town plow coming north on this same road. We breathe. We both actively engage in calming.
I flip the radio knob to the town frequency: “Hey guys, RC1. We’re flyin’ south.”
“Alex, we heard you go out. All clear. We’re still in the barn. Call us if you need help.”
“Thanks, Pete.” They will plow a driveway for us, unstick the ambulance, or make whatever magic we need in the snow.
As one might expect, the best I could do was push Regina and all of our kit out onto the drive while I backed a hundred meters to the road. I parked my running truck with lights telling all who came next which drive and dropping the hint to not come up it. The drive is too narrow for traffic.
“Dispatch, 14RC1 establishing Trowbridge command. Inform the ambulance that my truck marks the drive. Tell them the drive is plowed, but no turn around. They should back up. It is flat, straight, and clear.”
See, that is appropriate and professional communication.
I shuffle up the drive, listening to the snow squeak beneath each footfall. The lights of the house and my headlamp illuminate the falling snow. It is like being in an old-time cartoon, stars dancing around the head of an injured duck or coyote. The snow sparkles and flutters.
At the door, I get the standard urgent greeting: “Hey, my mother is in the downstairs bedroom. She’s having a stroke. Your partner is already in there.”
Every action must communicate: calm, control, confidence. I offer hope. “Strokes are not like they were when we were kids. There are fantastic treatments that often work.” I don’t need to worry about Regina. We, two, didn’t need a plan. I continue, “When did you last see her looking and acting normally?”
“Maybe last night.”
“Well, what time did you go to bed or last see her?”
“I dunno, nine, I guess,” answers the son.
As we say in the business, “Time is brain, meaning the faster we assess and move, the better the outcome for your mother will be. Can we sit for a sec? I need her name, date of birth, physician’s name, and all of her meds. Also, I need to write down her medical history.”
I use my voice to slow the pace down. My pen and index cards are poised to capture information that will round out Regina’s assessment and aid the hospital in locating records and planning their actions following our stroke alert.
With the front and back of my card filled, a fresh photo of the advanced directives that rested under a magnet on the side of the fridge, I slip into Mom’s bedroom. I touch Regina on the shoulder.
“Urinary Tract Infection,” she says softly.
I shrug.
“Problem is, this stupid stroke chart assumes symptoms fall on one side or the other. She’s pretty gorked.”
“Ambulance is en route. We’ve got time.” I see what she sees. Every rookie and most EMT-basics would not hesitate to identify this as a stroke and push the big red button called “Stroke Alert.” A stroke alert, made to the hospital via phone or relayed via dispatch, pushes the hospital into high gear. The guiding principle is that it is better to make the stroke alert than to be wrong. But Regina and I have decades of experience and thousands of hours of additional training.
“Wanna call medical control?” Give some overnight doc the data and take the decision from the hands of two medics in a small bedroom forty-five to sixty minutes from the nearest community hospital.
What happens when you call in a stroke alert to a community hospital? They may tell you that their CT machine is down or… or… In short, the hospital may tell you to go elsewhere. If the ambulance starts rolling, they may have to turn around to head west or head south. Because options don’t exist.
Regina dials the hospital from the home phone. She asks for medical control. In her hand, she holds a PDF version of the Vermont stroke protocol open. She identifies herself and asks for the doctor’s name, which comes across as Ted.
“Ted”—Regina looks at me, indicating that I am to write more notes—“What is your credential level? Are you a doc?”
“PA? Ok. I have an 86-year-old female exhibiting stroke-like symptoms. But I believe that she is deep in a UTI.”
Regina’s frustration flashes at me.
“Of course, I did a FAST assessment and checked her blood glucose and that is why I am calling. Her symptoms are bilaterial. She’s aphasic and not following commands well. Both arms drift. Her face doesn’t have a lot of tone, but appears symmetrical.”
“I understand that a paramedic can’t look into a brain. She scores a 5 on the FAST-ED.”
“Fine, then. Trowbridge command is calling in a stroke alert for…” She reads from my notecard, providing our patient’s name, date of birth, and key medical history.
“Ted, if we tell the ambulance to divert to Dartmouth, we will add at least ninety minutes, if not two hours, before this patient rolls through anyone’s door. Is this the best option?”
Regina holds her middle finger towards the phone for my benefit.
“Thank you, Ted.” She hangs up and looks at me.
“I’ll call Mass. I am NOT calling Dartmouth. The docs at Dartmouth will tell me to get an assessment locally.” She calls the next emergency department. Frankly, this ED is either the same distance or closer than our primary ED. “Hey, I’m a medic in Trowbridge, Vermont. Can you guys handle a stroke alert? Is the CT working? Got an MRI? Is your neuro telemed link working? All the things?”
“Nice, cool. Ok, I am calling in a stroke alert for an 86-year-old female. I honestly think she got a rippin’ UTI, but she ticks the boxes for a stroke. Also, I should add, she has that odor. Her symptoms are symmetrical and a bit sour smelling, if you get me.”
She listens. Then prattles off the history and demographic data as the ambulance’s backup alarm creeps closer.
It takes a few years to understand that, sometimes, a “stroke” can be treated with a course of antibiotics because the stroke isn’t a stroke.
We’re back in my truck as dawn starts showing, an hour before the sun will appear through the trees of our forest.
“You did fine.”
“I’m tryin’ tell a guy a thing and he’s not listening.”
“Shitty, huh?” I am not a great sympathetic listener, often too quick with solutions and advice.
“I’ve been thinking I am done.”
“Done, done? Like, not renewing? Like, giving up your license?” I ask.
“I think so,” she says with all the earnesty she can muster. “I work full time and been doing this for two decades. Then some runt tells me I haven’t run enough codes, or landed enough intubations, and I need remedial training in addition to all the other crap. Christ, I love dogs, but now I need to be fully trained and credentialed for treating police canines: IVs, intubations, meds. Only for Mass. Vermont not so much. Keeping my license in Mass and Vermont requires separate training and separate credentialling but they are both part of the national registry.”
“It feels like 100 hours of training per year.”
“Yeah, something like that. Oh, your Mass refresher missed this Vermont module, or God forbid I take a Vermont paramedic refresher and submit that in Mass. It was supposed to all be easier. Nope, I have to add one class in Mass because the modules don’t line up. Vermont doesn’t have Nero’s law mandating veterinary emergency care for dogs.”
“Your gran was a nurse, right?”
“Yeah, and she raised us.”
Regina pauses.
“What it really comes down to is I don’t want to manage the next big call. I don’t know that I need another dead kid, a teen suicide, to be my last call. Can’t I just quit on my terms? I am sixty-four years old. Am I doing this at seventy? Am I recerting so I can work until I am, what, sixty-six, or sixty-eight?”
“Pull the plug,” I offer, feeling much the same.
“But I am still doin’ good out there. I like being on a medic transfer truck. Tons of meds and pumps. I work my ass off. Then some f’n buck decides today is the day for a megacode refresher, and no matter what you do, he needs you to fail. He keeps changing parameters and yells elevating the emotional pressure. He feels he needs to add realism. Yet for a decade of doing codes, we whisper and use our eyes to coordinate. Why do I need that? Get through the human resusitation station, then queue up and wait for the dog station. I am so sick of it.”
She pauses. “It goes back to the old phrase: ‘if you can, then you must.’”
“Sure,” I answer. “That was the rule here. If you were between sixteen and eighty and able bodied and male, then you must be a member of the town militia. It isn’t the case anymore. That ethos died. It is better to drive an expensive car and bully first responders for being in your way.”
Silence.
“Just let it go. I am going let it go soon, too. It can be someone else’s turn. And if there is no one else, then someone younger, more energetic, and less pissed off can solve that problem. I’ve done tried.”
I say: “Regina, my friend, I think it is perfectly fine to acknowledge that not everyday has to involve a shot of adrenaline that comes with a life-or-death encounter.”
“Dispatch, Trowbridge Command terminated.” I say into radio’s mic with perfect professionalism. I wonder how many more times I can wake to the emergency tones then rush through dressing and peeing. How many more times do any of us have? From sleep to crisis in a millisecond. Then some young human buck decides that EMS training must resemble screaming, high-tension, combat operations. Or some deer buck decides that leaping from one snowbank to another over a red pickup truck makes good sense. Cortisol, the stress hormone, floods when the tones go off alerting us to a 911 medical call. Cortisol hits again after not hitting the deer. No doubt for Regina, another hit came when the PA at the local hospital ordered the patient to go direct, via road, to the trauma center in New Hampshire. At some point, done is done. Right?
It is ok to walk away, isn’t it?
She’ll miss it. I’ll miss her. At one moment, you are the one with the tools, and skills, and experience to make stuff better. You’re the hero. You save lives. You’re the person people want to see walking through the door. That’s a nice feeling.
“I don’t know.” She says as she gradually accepts that this maybe it.
I.M. Aiken is a Vermont-based novelist exploring the impact public service takes on us.
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