David: DNR

Fri, 17 Jan 2003 07:32:43 GMT

GSW in the ED - Part Two (Part One is here.) When things go well in a trauma, it's like a ballet. People move effortlessly around each other, needs are anticipated and things are done exactly when they're supposed to be, nobody gets in anyone else's way and the patient gets great care. When things don't go well, it's a mess. Maybe the surgical resident is scared shitless and is trying to compensate by yelling, or maybe he's just stupid. Maybe one of the nurses is in the ozone, letting IV fluids run out, bumping into others or trying to do what someone else is already doing. Maybe the patient is thrashing around, cursing, fighting, trying to get up and leave and precious time gets wasted tying him down to the bed. When those things happen, it becomes a fight to get things done. It's a cascade of effects: IV's are missed, x-rays have to be retaken, procedures take twice as long or twice as many times as they are supposed to, there's no admission bed available or the Cat scanner is down or the OR's not ready. Anything and everything. And you've just got to work through it as best as you can, because the person on the cart, the guest-of-honor, doesn't care about the excuses. Things are going well this time. between EMS and police, MDs and RNs, other staff and the patient himself, there 20 people more or less involved: looking, feeling, touching, listening, reacting, anticipating. "Who shot you, K?" "I don' know, man!" Damn! This hurts like a mother! "C'mon, K! What happened?" "Shit, me and this other dude was walkin' down the street, just mindin' our own bidness, when this dude came up and shot me for no reason!" "Who was it?" "I don't know, man! Somebody I never saw before. Thought I was somebody else, pro'ly" Ah, if it were only that easy. Some nights it seems that the only people getting shot or stabbed are those who are simply minding their own "bidness". In KM's case, however, the police mentioned that his business involved trying to steal someone else's car. KM's not looking so good, though.He's had two liters of fluid in from his IV and his pressure is better, but his breathing is barely acceptable. He has all the symptoms of a collapsed lung with blood where the lung ought to be, and the bullet hole to prove it. There's not much to decide - he's bought a chest tube. "Give him 5 milligrams of morphine, please. Let's get set up." The thoracotomy tray is open. It has all the equipment needed to cut a hole in K's chest and insert a tube the size of an index finger. The tube is connected to a container that collects whatever blood comes out and keeps the lung expanded. I've already connected the container to suction and placed all the connecting tubing where it needs to be. The senior surgical resident guides his junior. Numbing medication is injected into the skin along the right side, about six inches under the armpit. Using a scalpel, an incision is made and then the opening is widened by stretching the tissue and muscle. Guiding the hemostats over the rib, pressure is applied until the tube pops through the lining of the lung, the pleura. This is painful for K, much more so than the actual shooting. As the resident enters the lung space the is a rush of air outward. The chest tube is hooked up to suction and sutured in place. Almost immediately, blood flows through the chest tube into the collection bag, nearly half a pint. The results are promising. K's blood pressure is better, his pulse drops slightly (a good sign) and his breathing is a little easier. He's a long way from well, though. One of the laws of trauma care is that you can never trust the path of a knife or bullet. Things may look straightforward, but a bullet can break up and the pieces head off in different directions, hitting the heart or the bowel or liver, for example. Blood has been ordered, X-ray is here with a portable machine to check his chest. We are already starting to filter his blood from the chest tube and give it back to him in his IV. Vital signs are checked constantly and his pressure is improving. His oxygen level is good. He is still responsive. Once it is determined that he has no other injuries, it's time for staff to start filtering out. With things stabilized, Sharon goes back outside, EMS has restocked the rig and are ready for the next call, Surgical Intensive Care (SICU) has been notified that they're getting an admission, the surgical senior has instructed his junior on what to do next. It's a matter of crossing the t's and getting him upstairs to the SICU. He'll be watched through the night to make sure the bleeding has stopped and the lung stays expanded. KM will do well. No major arteries were hit, his lung will re-expand and he will go home in a week or two. This was a good trauma because the outcome was good. Sometimes the traumas rate a "good" because it was interesting, even if the outcome was bad. Mostly a good trauma is one that doesn't happen to me. So this is what it's like. Nestled in between the noise, confusion and blood is a routine and a protocol that varies only in the details. KM was a good composite patient. Another one might have just as easily fought and bit and spit and threatened to kill us all. Another may have been dead on arrival, or shortly after, or made it to the OR before dying. It's time to clean up and get ready for the next one, because there is always a next one.

Thu, 16 Jan 2003 03:42:32 GMT

Here's Chapter Three in my daughter's story "Kissing Satan Goodnight." ( Chapter One is here. Chapter Two is here) Chapter Three (Welcome To Coldville) Coleville - named for Laurence H. Cole, a skilled inventor with nothing much to show for his talent - is like many other small towns: dusty, friendly, isolated, and formal. The old New England rocking chairs call it being "proper", their philosophy being to keep out of other's affairs and the boat will remain calm and blissfully unrocked. The town's namesake was little known among the more famous inventors and professors of his day and those that came after. His name is easily forgotten in that line of work, especially considering that no one knew of any particularly groundbreaking things that he'd done. His lack of recognition was picked over like a scab whenever the subject of local history arose, and most of those skilled in science sneered at the odd ideas that Cole so avidly pursued. With an almost defiant air, the town erected a hideous statue of their neglected hero outside the town hall, a requisite banner to any town of that size and disposition. "Ayuh, he'll get what he deserves, you'll see," the townsfolk swore. "Then this place'll be famous! All the good ones were ignored till after they died." Then the speaker would tap the side of his nose knowledgeably and tip a wink to whatever grocer or barber or bartender he'd been harping to. The fact that it had been one hundred and ninety - nine years since Cole's mysterious death in 1804 does not seem to bother the people of the town. He was their genius, their golden boy - and quite possibly the only one they would have. It is a hot morning, stunningly hot for May, a somewhat unwelcome preview of what their oncoming Maine summer would have up its sleeve. The new leaves hang thirsty from their spidery branches, seeming to pant with the breath of the dry sun. Cars roll by as if tired with the world, puffing out exhaust lazily, the mouths of their windows gaping wide to suck in the breeze. Only the tourists use air conditioning when the mercury is below ninety. The town over the past few days has seemed to be waiting, holding its breath for some oncoming unknown. The feeling has now broken along with the heat, but few seem to notice the connection. Justin Starret pushes play and the small but clean café is filled with the lighthearted rock of Elvis. He spins the volume button on the black, ketchup-spattered stereo left over from a time when flattops and shoulder pads were the height of cool, letting the King fill in the morning groove. The doorknob to the supply closet emits a tiny squeak as he yanks the door open, revealing a tissue box-sized room with the hygienic necessities of any locally owned establishment: a bucket, a mop, a half-spilled box of Roach-Away, and a broom, which Justin grabs, shuffling backward as he sings along. "I'm proud to say that she's my buttahhcup, I'm in love -" he plants his feet and cocks a hip in time. "- I'm all shook up..." He dances through the kitchen, twirling the broom and occasionally using it, finishing up the chores he'd secretly neglected last night when he'd closed up. The café is called Zalio's, a tiny and well-run local place with a fifties charm and blue and white checkered floors. The minute stream of tourists that trickles into Coleville for a peaceful summer getaway rarely notices Zalio's, but it attracts a fair current of locals, as the café has been there for too many years to count. The aging Yankees, some of which are reported to be older than God, have memories that can stretch back to the Byzantine empire, but on the point of when Zalio's opened, they all seem to be fuzzy. Wonders are dismissed, however, in favor of the magnificent cheeseburgers. The mirthful tinkle of the bell is drowned out by Elvis's guitar and the door opens without attracting attention. "Jesus Justin, willya turn it down? The dead are gonna wake up and be pissed." Justin spins around to catch the bemused smile of Rieger Swick, the owner of Zalio's. He is a tall, well built man with white hair and beard, barely visible paunch and eyes that always seem to sparkle with a Santa Claus charm. By all rules of logic, Rieger Swick should be at least ninety years old now, the memories of Coleville[base ']s old men holding scenes of milkshakes and apple pie at Zalio's since they were but tadpoles, but he looked no older than sixty and he always carried an impression of great energy and wisdom. "Sorry Mister Swick," Justin says, reaching for the volume knob and taking the music down to a less assailing level. "Ah well," says Rieger, going to the back in search of coffee. "If it can't be good it may as well be loud." "Hey!" Justin stops sweeping. "Mister Swick, this is the King, how can you say -" Rieger Swick chuckles, patting the air in a defensive motion. "Don't get your panties in a bind, son," he says. "I was only kidding." With a soft "hmph" Justin returns to sweeping. He should have known better than to jump on the defensive. Since he was sixteen he'd been working at Zalio's and getting to know Rieger Swick. Justin was at once calmed by his open personality, his blunt and casual wit, and his endless well of wisdom. He'd watched his boss load Elvis records into the old jukebox and even sometimes heard the same playing softly in the back room as Rieger counted out the drawer. Justin is nineteen now and over the years he's come to appreciate the quirks and complexities of his boss's nature. "Has Frank called about his order yet?" Rieger asks, poking through the cabinets above the rundown percolator. "And where is our real coffee?" "No, he didn't call yet," says Justin, sharing his employer's exasperation as Frank has been ordering groceries from Zalio's for years and calls every Monday to confirm his order. With larger city businesses this might be necessary, but with a place as tiny as Rieger Swick's, the employees have long since memorized Frank's grocery list. "He's nothing if not thorough," Rieger Swick has said of Frank. "We'll give him a couple more minutes out of etiquette," Rieger calls out of the cabinet, his precise, round voice nailing the "t's" with effortless grace. "But then if you could take his order over, I'd appreciate it." "Ayup." Though he never mentioned it, Frank's knees had been bad since the war and Rieger Swick, in his omnipotence, had insisted that Frank's groceries be brought to him every Monday. "What the hell and the hootenanny...?" Rieger pulls out a crumpled coffee bean pack from the cabinet. "Decaf? Get it outta here!" He tosses the pack over his shoulder and it lands with a thunk in the trash can. "Does Frank usually call this early?" Justin asks, trying to persuade a stubborn bit of fluff to extricate itself from a corner. "Seven o'clock, on the nose," Rieger murmurs, pulling out another packet. "Pumpkin Spice?" "Don't even bother," says Justin. "Left over from last Fall and it tastes like cardboard anyway." "Where's our regular regular, we tear through the stuff every day but when I look for it..." Leaving his little pile of dirt and dust, Justin leans the broom against the counter and comes around the window to the kitchen where his employer is kneeling on a stool with his entire upper body hidden in the cabinet. "Here let me," Justin says. "What are you looking for?" "Something black," says Rieger, moving aside for Justin and settling into a stool by the grill. "Like ink. Better yet, like sludge." "This is a change for you," Justin raises an eyebrow, pulling a coffee bag from behind the percolator. "What's up?" Rieger Swick has never been a coffee man. He will drink the occasional cup, but never seems to be in great need of it like the twitchy morning regulars, and usually settles for a cool diet Pepsi, two ice cubes. Having nearly been killed in the fight to quit smoking many years back, which he did with a self disgust that he was not eager to experience again, he'd set his mind against any kind of addiction. Seeing the way some of his customers scrambled for their morning jump start, he'd erased any desire to start the habit. "Couldn't find a piece of rest last night," Rieger says. "Bad dreams... and it seemed like everything was crawling, scratching at my walls and my windows. Then I'd really listen and there would be nothing. And I mean nothing, boy, no noise at all," he shakes his head slowly. "That's not a healthy sound, silence. Noise means life." "That's odd, I slept okay. Maybe you're just getting to that age," Justin flashes a grin as he starts the coffee machine, filling the room with the gentle sound of hot water running. "Hm," Rieger nods, ignoring the crack. "Well, Frank's late calling, you'd best get going. If he calls while you're out, I'll tell him you're on your way." "You'll be cool to open on your own? I mean, if a lot of people come in..." "Marilyn should be on her way soon. Go ahead, his bag's in the back." "Okay boss." Justin nabs the bag and says goodbye to Rieger Swick with the promise to be back soon, then leaves the café and his pile of dirt on the floor to get into his car and set off for Frank Lauden's house. (Copyright Kit Fox, 2003)

Fri, 10 Jan 2003 14:28:33 GMT

(This is one I've wanted to recycle for awhile, another true story.) God's Messenger, arms and legs restrained by leather, shouted and chanted his song of Divine Displeasure from his Emergency Department bed. "God's mad wit' you! "God's mad wit' you! "You made God sad, You made God cry, You broke God's heart. "God's mad wit' you! There was no reasoning with him (or Him, apparently). No room for error. No possibilitiy that God was merely aggravated, or peeved. In the world where he lived, the Messenger had but one purpose - to warn any and all that we were evil and going to Hell because God was mad. He said it without malice, even sounding a little sad as he pronounced my eternal damnation. He also denied the allegations of his family; that he hadn't taken his medication for the last three days. "God's mad wit' you! God's mad wit' you! God's mad wit' you! (the bridge) It's not me sayin' it. It's God sayin' it. It's not me sayin' it. It's God sayin' it. You hurt God's feelings. You didn't feed me. (repeat chorus) God's mad wit' you! God's mad wit' you!" . . .for twenty minutes, until the medication kicked in - like a rap/blues/hymn, the sweat pouring off him like a preacher confronted by a jealous husband, his bottle-bottom glasses tight to his head. "I was preaching to the crack dealers," he said between verses. "I coulda got killed, but God said 'don't worry.'" and finally the Haldol/Ativan cocktail reached the neurons that were so badly misfiring and he began to slow down. "They gonna take me to fourth floor?" (you bet!) He been here before, knew that some of his wires were crossed. And he knew he was safe. But he had to tell me again, just in case I hadn't heard. "God's mad wit' you . . ."

Sun, 29 Dec 2002 17:08:43 GMT

I didn't feel like writing anything and discovered this delightful surprise: the beginning of a story written by my younger daughter. She's 17 and turning into a better writer than I am. So here's Chapter One of "Kissing Satan Goodnight" by Kit Fox . . . The devil spoke to Ruth last night. Just try to shut him up. It seems every time her head sinks into the soft cotton of her pillow she catches a trace of that spice and brimstone or hears the gentle, exotic clunk of the woodchimes in her room that he's fond of playing with. The sun hits the bottom of the hill outside her window and there he is, perched like an anxious cat at the foot of her bed. He never wakes her on his own, just stares until she gets the message and snaps away from her foggy mist of drifting, peaceful dreams. "Oh hey Ruth," he'll say as if not having realized that she'd been sleeping there (as if she ever sleeps anywhere else). "Feel like having a chat?" "Mmph," she'll say, squashing the pillow over her face. She doesn't know why she'd expected Satan to be from the bayou (the idea having appeared in childhood and stuck, despite the popular belief of a huge, powerful voice with no trace of an accent) but he'd surprised her with a crisp, cool Canterbury twist. It was compelling at first, if only for the listening value (she's always seen voices as giving everything away about a person) not to mention the strange excitement involved with talking to Satan, but the novelty wore off quickly. ". . . and it's not as though I was being an angel either, but he could at least have shown that he respected me as a person . . . it just feels like no one listens anymore." "Mmsure," she'll murmur, barely awake. "Whatever, Satan." "And my mother called again today." She would find concept of Satan[base ']s mother compelling were it not four in the morning. "Hm. Zat so." "She's fixed on this whole marriage thing..." Sometimes she will be startled awake by the sounds of a crash or rattling cookware in her scrap of a kitchen. She'll grab the thick baseball bat that she keeps leaned by her bed, crouching down with her bare feet sinking into my fluffy white carpet. Stepping as quietly as she can across the plane of her tenth floor apartment, she'll poke her head into the kitchen and see him looking helplessly down at a shattered puzzle of porcelain or blue glass, having broken one of her mugs while trying to make hot chocolate. "Sorry," he'll say as she patiently cleans up the mess. "What's with the Louisville Slugger, dear?" He'll reach above her to pull another cup from the cabinet. "Oh nothing..." Ruth will sigh as she and Satan wage a silent battle over which of them will make the hot chocolate (it[base ']s no good trying to drink his -- it's always too hot). Thinking about it, she supposes she prefers these nighttime visits rather than being surprised at work during the day. Her perfectly happy and boring desk job at Colin & Krupka Accounting is comforting, filled with stable numbers -- one of the few things in life that won't change behind her back. The thought of her mild job being disrupted by the spectral visit of the Supreme Demon is chilling and she can't imagine how she would explain things if her boss walked in on her having a conversation with Satan. But why Ruth? She hadn't even believed in the existence of a devil from her teenage years on. The idea of malignant spirits, vengeful ghosts who infest themselves in human culture had made sense on some creepy, mystical level. However, any actual belief in a Hell, in a ruler of all that is hateful and unkind, seemed like nonsense, like superstition that had stuck for too long. Old habits die hard, not to mention belief structures -- she'd even read a book on the brain science and biology of belief, that these things are genetically imprinted in human psyche. Yet there he was, in full grin and goatee, usually clad in red pajamas. The question of why the devil spends his time with her is puzzling. Though she doesn't hold the disposition of a librarian, she hasn't led a particularly wild life. There are no outstanding black spots on her record -- the only one that comes to mind happened in her junior year of college, a time when no one can be expected to do the right thing. At a weekend party, the kind of dimly lit, crowded house event with loud music and lots of drinking, she'd tried smoking pot, lured by the easy, mellow attitude of her stoner friends and the oddly compelling smell of the herb -- nauseous sweet, like insect killer. When the joint was passed into her shaking hands and she drew in a breath, the noxious smoke filled her pores like sick Jello. Despite her instructions to hold the smoke in she coughed, expelling the brown-smelling smoke from her lungs. Her eyes and chest burned. She clambered to her feet with a choked apology and ran out of the room to her own where she immediately stripped, throwing her clothes into the wash. She spent the rest of the night in her pajamas, furiously brushing her teeth. Since then she's been more or less a good girl. She'd expected the devil to bring it up, tease her about it if nothing more, but he seemed more interested in trivial things like sex and her parents and how much hell rocks... your basic pillow talk. In honesty, she barely listens anymore when he starts in with his nonsensical diatribes. Half the time she'll be assembling a grocery list or trying to count her heartbeats or fall asleep. Patiently, Ruth has listened to tirades on all the usual: God, sin, hate, damnation, the playoff game last night (he's a Yankee's fan... it figures), even his grandmum's banana bread recipe. Three years she had been the unwilling companion of the ruler of Hell, and she'd sought far and wide for a way to be rid of him. (copyright Kit Fox, 2002)

Mon, 23 Dec 2002 13:56:19 GMT

A WORLD OF (trouble) In 1969 the war and the country raged. From the vantage point of a new century, it's easy to forget the passion, fear and anger of the times. The year before had seen the assassination of Bobby Kennedy and Martin Luther King and the police riots at the Democratic National Convention in Chicago. The war in Viet Nam was in full burn and the body count had become a staple of the evening news broadcasts. In 1969, there was the emergence of massive protests in the streets of major cities and a shift in public opinion about the war. Young men had two choices: college or the military. Those who were able went to college. The rest either enlisted or waited for the letter from the draft board. I had been in college for two quarters after high school, but had no goals, no plans beyond a vague notion of wanting to be a photographer. I dropped out of college. That made me fresh meat for the draft. A distant cousin and no one I liked, worked for the local draft board and let slip that my name was about to come up. Getting drafted meant the Army and the Army meant Viet Nam. So I joined the Navy. I will never forget the morning I left. At 6 a.m., my father drove me to meet the Greyhound bus that would take me to the induction center. He dropped me off and said goodbye. It was one of those rare times I saw him cry. I didn't feel so great myself. There was a group of ten who sat with the commuters on the trip to Cleveland. We got to the Federal Building and began our first lesson in military life: hurry up and wait. It was more than a cliche; it was a standard of behavior. We filled out papers, joked nervously and were finally taken into a room where we stood for induction. After pledging to defend our country, we split up according to our destinations. There were a dozen of us heading for Navy boot camp in Great Lakes, Illinois. It was in Chicago, however, that the real trouble began. We got off the plane and were led through hallways to a restroom so we could take a group break. Everything was done in a group and one of us (not me) was appointed "leader" for the time. I was excited to be in Chicago, even if it was only O'Hare airport. I gratefully stood at the urinal, took care of business and turned around to find - no one! At least, no one I recognized. I ran out the door, looked right, left, and discovered I was alone! O'Hare was the nation's busiest airport and, to this Ohio boy's view, gargantuan. I ran down halls, turned corners and tried not to panic. I never found the rest of my group. I did, however, find the Military Assistance Desk and gratefully approached the uniformed man at the counter. "I, uh, got lost" "Yeah? Who are you?" His was not a friendly voice. "Fox," I said. "Fox? Boy - you're A-W-O-L!" Fortunately I had already gone to the bathroom or I might have embarassed myself further. Absent Without Leave and it was barely my first day. "Are you a deserter, Fox?" He seemed to hope I'd answer in the affirmative so he could begin taking me apart in front of the desk and any onlookers he could summon. "No, sir!" I knew the lingo. "I had to go to the bathroom and when I looked around, everybody was gone." "You had to go to the bathroom, huh?" He said this as if to remind me that mama's boys went to the bathroom and real men held it. I wisely said nothing. "Sit down on that bench. There's another bus coming at ten." I sat down. On that bench. I sat for the next three hours as other recruits gathered. The last bus of the night finally arrived and we boarded, carrying our meager belongings and a deep sense of foreboding. The bus driver grinned as he turned to greet us and he said the words we would be hearing again and again that fall. "Gentlemen - you're in a world of shit." Our journey into the world of the military was beginning and there was nothing to do but go forward into the dark of a northern Illinois night.

Thu, 19 Dec 2002 05:04:26 GMT

Saw LOTR - The Two Towers tonight. It is, in every sense of the word, spectacular. But I have to go against the grain and say that it lacked the emotional connection of the first part of the trilogy. It is the middle portion of a very dark story. The characters have mostly been established, the few new characters are serious and sober lads and lassies and death and doom seems to be on everyone's mind. Pluses: Gollem is not a mere CGI creation, but a real character with body language, emotions and complexity that rivals any human. Gollem is ugly and piteous, funny and cunning. If Frodo is the ego, then Gollem is the id. Sam Gangee becomes the soul of this movie, the subconscious, the motivator that continually keeps Frodo on the right path. Liv Tyler and her perfect complexion have only to be in front of the camera and I am riveted. My daughters feel much the same about Orlando Bloom. The story moves, the battles are thrilling and this is, in short, everything one could hope for in a LOTR movie. Except - the characters are set pieces with little complexity or emotional development. One of the things that make Gollem so appealing is that he has a complex inner life, no matter how twisted it may be, that makes him constantly at odds with himself. And poor dwarf Gimli has been reduced to being the butt of a continual series of jokes about his height or his bravado. The Two Towers is worth seeing as many times as you can. If it lacks the heart of The Fellowship of the Ring, then it makes up for it in bravery and spectacle. This is director Peter Jackson's middle child, growing up in the shadow of the older sibling and sure to be forgotten, or nearly so, when the final episode arrives late next year. This year, however, this middle sibling demands your attention and deserves every minute of it. I can't wait to see it again.

Wed, 18 Dec 2002 13:53:59 GMT

"If this were the last night of the world, what would I do that was different - unless it was champagne with you" - Bruce Cockburn In the 1998 film "Last Night", humankind has had two months to think about what it would do. Now they are down to the last six hours and Don McKellar's film focuses on just a few of the residents of Toronto and how they choose to live until the end. I caught this on the IFC last night and, from the beginning, was hooked. This is not an American film, so the emphasis isn't on explosions and violence. It is obvious that things are falling apart. There are suggestions of violence, burning buildings, overturned cars, roving gangs. This, however, is not a story about apocalypse, but about people: those who gather in groups, bond for an instant, seek solitude or go about their business as usual. McKellar is Patrick, who wants to go out of this world alone on his roof, drinking wine. He tries to Sandra (Sandra Oh from Arli$$) who is trying to get back to her husband where they plan to take their own lives. Unable, the two spend their last hours coming to know each other. "Last Night" is called a "comedy/drama" and there are genuinely funny moments. The end of time is covered on TV as though it were New Year's Eve; people in the streets cheering and dancing. My favorite aside is the newscast's mention of a rock show featuring 6,500 guitarists who always wanted to play, led by Randy Bachman (Bachman-Turner Overdrive) who is teaching them the chords to "Taking Care of Business." "Last Night" is funny, but it's not jokes you're left with, but images of people, individuals, meeting and saying goodbye. McKellar's script doesn't condescend. It is haunting, dark, bittersweet, touching and thoughtful. If this were the last night of the world, what would we do differently?

Tue, 17 Dec 2002 13:26:14 GMT

Back in the day (as my kids like to say), I used to drive an ambulance. I was in a volunteer rescue squad in Southern Maryland, down near the mouth of the Potomac. The local rescue squad was staffed, on a rotating basis, by business people and farmers and housewives. And me - a newly trained Emergency Medical Technician with not enough knowledge to be much more than dangerous. It was nice to help people, occasionally exciting to respond to the scene of an accident or (rarely) a shooting. But the truth of the matter is that just driving the ambulance with lights and sirens going was cooler than anything else I could imagine. I liked driving through the center of town in the middle of the day and hearing the siren echo off the buildings in the town square. I liked driving at night with the red and white lights flashing like a pinball machine. One night we had to respond in a thick, close fog, the lights bouncing off the mist three feet away, surrounding us in a light show. It was the custom for patients who needed to be transferred from the small local hospital to downtown Washington, to be transported by a spare volunteer crew. I got tapped, one day, to drive a patient up to George Washington University Hospital in D.C. The patient was going for routine surgery, but it was getting late in the afternoon, so the referring doctor told us to drive him up "hot", i.e.: with lights and sirens. It was a trip of approximately 60 miles and we headed out. This was a routine drive as we headed north through Loveville and Mechanicsville, took a right in Waldorf, and headed toward DC. Traffic got heavier and we hit the siren a little more often. By the time we got to Landover we were in rush hour. This was not a route I'd taken before and the medic beside me, Neal, was helping to navigate. We passed over the Anacostia bridge, came up South Capitol Street which leads straight to the House end of the Capitol, and proceeded down Pennsylvania Avenue. At 4:30 in the afternoon. I was starting to get a little nervous at this point because traffic was coming thick and fast and nobody seemed very impressed with our emergency. I also didn't really know where I was going. Neal suddenly urged me to take the next street to the right. I was in the outside lane, so I whipped it around and discovered it was a one-way street and not in the direction I was headed. At this point, I figured, what the hell and hit the siren. I don't think I've ever seen a more impressive sight: our nation's capitol in five in the afternoon, two lines of cars peeling away from the center and making way for the crazies in the ambulance. We made it there and back again safely. But I wish I'd have had time to look at the faces of the drivers when they saw us coming.

Fri, 13 Dec 2002 13:14:08 GMT

We are a people in search of light. We light our homes, our cities, our streets. We bring things to light, light up when we're happy, try to become enlightened, treasure candlelight, firelight, lighthouses, and, in the end, go toward the light. We fear the dark. We think of the Dark Ages as a time of ignorance and squalor. Dark tales are unhappy, unnatural, the hiding place of those who would harm us. Criminals hide in dark places, cockroaches scurry from the light, evil things live in the dark under rocks and monsters only come out from under the bed in the dark of night. In the dark, we are left with our senses, our fears and our imagination. Our ancient ancestors knew darkness. When night came, there were no street lights, no flashlights. The fireplace and the torch were all there was. The beast was unseen, waiting beyond the fire's light. Our helplessness against the dark became allegorical. Even today we tell stories of powerful dark forces arrayed against the forces of good. Our fear of the dark, is really a fear of ourselves, a fear of the darker, more passionate impulses and feelings we all have. We close our eyes but we don't cease to be. In the dark we can be our secret selves. So it seems no surprise that Christmas was set at the time of the winter solstice. The days, having gotten progressively shorter, darker, are now starting to reverse their course. There isn't a shred of evidence to suggest that December 25th was the date of Jesus' birth, but it seems an apt time for celebration. All of this is by way of wondering, yet again, what place Christmas has in the mind and spirit of a non-believer. I don't go to church anymore, not even on Christmas Eve. I love the music and the candle light, the contemplative mood. It's just the theology that doesn't ring true for me. The value of Christmas, the value of the season, is to celebrate the light in each of us. Christians, Jews and Muslims have been all too willing to shed each other's blood in the name of "truth". That, alone, makes all the seasonal good will suspect. The hectic, hysterical greed that drives the season in the U.S., makes it difficult to take seriously any claims of holiness. But I drive down the streets and see houses lit up, winking at passersby, welcoming neighbors and strangers alike, lighting our path. The lights on the houses aren't for the owners inside (except for competitive, vain, and probably greedy people), but for those of us outside. Christmas is a time for light. Hanukka is a festival of lights. Ramadan ends when the first light of the crescent moon reappears. We are about light. Stepping away from the commercialism, this ex-Christian finds beauty and spirituality and a sense of peace in the lights of the holiday and in the light that, sometimes, shines from us all. Merry Christmas and Happy Holidays.

Thu, 12 Dec 2002 12:59:16 GMT

Paul is 61 and scared. His chest feels like someone is sitting on it, he's sick to his stomach, dizzy and can't seem to get enough air. It's 3 a.m. and he knows this is not a good way to wake up. His symptoms are typical, as is his response: "I just thought it would go away." As is frequently the case, his wife made him come in. The impulse for the heartbeat originates in the heart, itself. Beginning at a place inside the right upper chamber, an electrical impulse is generated that, in turn, generates wave upon wave of similar impulses spreading down and out like ripples in a three-dimensional pond. There are standard pathways that cause the upper, smaller chambers of the heart to contract, and then the larger, more powerful lower chambers. For most of us, this happens 60 to 100 times a minute, night and day, awake and asleep, until the day it stops for good. Paul tries to tough it out, to act casual as though "I do this all the time - no big thing.": But his thin smile is less than convincing and his heart, oh by the way, is beating a cool 160 times a minute. At that rate, the ventricles don't have time to fill before they are squeezed again. Output drops, the blood supply to the heart, lungs and brain becomes less than sufficient and panic ensues. Now here's the part that's too cool for school: this is a problem that is easy to fix. Paul gets a quick EKG (heart tracing) to confirm the rhythm, a quick IV and then a very quick bolus of adenosine. Adenosine is a medication that stops the heart and allows its natural pacemaker to reset itself. The medicine is fast acting and doesn't last long - three seconds or less of inactivity is all it takes. When you're the patient, or watching the monitor for the first time, three seconds seems like a lot. Imagine: lub-dub (one- mississippi, two mississippi, three mississippi), lub-dub. Watching the monitor flatline for even that short period of time can be, well, heart-stopping. Then the drug wears off (it always does), the regular beats resume and you've got a patient who looks better and feels better. The blood pressure is back to normal, the chest pain is gone - smiles all around. Paul got transferred to intensive care, to make sure the fast rhythm doesn't restart and to test for any signs of heart attack. This time the smile was genuine as he left the ED. It's nice when a plan comes together.

Mon, 09 Dec 2002 12:54:05 GMT

"I shot the robber! I shot the robber!" "I know - you shot the robber. Now lie still." He was in the E.D. for stitches. The police brought him in. Stan was in his 70's but, for a few brief moments, he felt 20 again. The robber broke into his house, but Stan found his gun and now there was a dead body on his bedroom floor. Stan came from one of the eastern European countries that had been swallowed up by the old Soviet Union. Though he had lived in the United States for nearly 50 years, he still spoke in a broken, Slavic-influenced English. He and his wife lived in a small wood-frame bungalow in what was once a working class neighborhood. They raised two sons who still lived near by, still visited every Sunday. Stan and his wife had been retired for years. They had worked hard for what they had, worked hard to provide a life for themselves and their sons. They knew they were far better off here than they would have been in the old country. They were typical a working-class American success story. "I shot him - I shot the robber." I know. Now will you quit, already?" "I saw him stand over me and I reached under the bed for my gun and I shoot him." Their house was on the border of a changing neighborhood. The old neighbors, friends, had either moved, died, or were hanging on to time - one eye on the clock, the other on the calendar. For years now they had locked their doors, even during the daytime. They grew accustomed to neighborhood break-ins. Stan knew it was his job to be not only the provider, but now, the protector - the last barrier of defense against a newer, more violent world - an America that was as alien to him now as when he first encountered it. He was older, but still vital, still a man. So Stan bought a gun. "I saw him. He hit me in the head, but I got my gun and shot him - then I ran next door and called the police." We sewed up the cut on his forehead and listened again to his story. His sons had talked to the police, then they came to the ED. I left the room. I didn't want to be there when they told him. "I shot the robber." "Yeah, Stan. You shot the robber. Stan was the victim of a break-in. He heard the noise of the intruder and started to raise out of bed. A blow to the head sent him to the floor, unconscious, and the intruder fled. Stan's wife heard the noise, grabbed a flashlight and came to the side of the bed to see if her husband was OK. Stan woke up, saw a form standing over him holding a flashlight. He found his gun, brought it up to the light and fired. I left the room when his sons came in. "I shot the robber," he said to his boys. Then he was quiet.