A stream of conciousness

Guest post by @real_paramedic

Disclaimer:  The words you are about to read are by no means a masterpiece, nor do I even believe them to be any good. They do however describe events exactly as they occurred, barring the fact that names and locations have been omitted. Some of the events described below reference traumatic events and reader discretion is advised. In point of fact, I wouldn’t recommend the reading of these words by anyone. So there.

When I lay awake in bed at night, as I so frequently do, listing my regrets, of which I have many, I always have the same list floating up through the time fog: the first (and last) time I killed a patient by missing an open book pelvic fracture; not getting any sutures or even any form of comfort when I fell out of trees or confidently leapt from rooftops because I placed too much confidence in the aeronautical capabilities of the umbrella as a child; spending too much time at work; not having a relationship with my family; working for an unethical company for a brief, but protracted period of time; watching the entire duration of the ‘Fifty shades of Grey’ film adaptation (perhaps it is just the milieu within which I grew up, but I thought that beating lady folk into submission when they provided you with rather lacklustre and pedestrian sex until they either started liking it or stayed with you as some warped form of Stockholm Syndrome was stock standard behaviour); not treating people I love better; my first round of burnout; destroying every relationship I ever had; my second round of burnout and so the list goes on and on.

The problem was, that of late, I had started regretting becoming a paramedic, a notion that was new to me, in that I found it difficult to contextualise. I suppose if I’m being honest, the regret that surfaced the most … no, wait… Perhaps this is one of those stories that should not start right off the bat with an existential conundrum. Perhaps I should start at the end – the end of my operational career, that is.

Let’s start with the last patient I saw. I was at the base and the phone rang. It was night time and I was stuck in the middle of some deplorably long shift. I answered and was instructed to attend to a paediatric patient that had been severely injured.

As soon as they started reading the vitals out to me, I found myself slamming the handset against the table, until an esteemed colleague removed the device from my hand and reminded me of the duty I had undertaken to fulfill during my shift.

I arrived on scene and found the little-one immobilised, supine, gargling in his own blood.

Another provider on scene said: “He was just so difficult so just waited for you.”

A voice inside my head was saying: “I’d like to de-glove your face and leave you in your own blood and see how difficult you get.” But I just gave them the stock standard reassuring smile.

Mom wanted to be close, so I allowed her to hold his hand. He settled after a dose of intramuscular Ketamine and I started clearing the blood and loose tissue from his mouth.

He had weak pulses and a relatively low mean arterial pressure, so as part of his resuscitation an intraosseus needle was placed in the proximal tibia followed by a 20ml/kg fluid bolus. He soon thereafter received appropriate doses of Ketamine and Rocuronium to facilitate intubation. I asked a colleague who was close-by to pull the looser facial structures aside with forceps in order to facilitate a better view.

Despite his massive facial injuries, I was faced with a Grade 1 Cormack-Lehane view…when it hit me like a ton of bricks.

How many little cords have I seen over the years?

How many small tubes have I passed?

“I’m sick of this shit. I don’t want to do this any longer” I said aloud whilst passing an appropriately sized cuffed endotracheal tube through the little cords. He ventilated well at low pressures with some adjustments in PEEP, but was ultimately presented to the Emergency Department with a good BP, good capnography, in a head-up position, with an elastic dressing holding down our tube.

In terms of meeting the requirements clincially, we were sitting pretty.

“Should we Lodox?” I was asked.

“It’s only the head and face.” Was my reply.

“Let’s just Lodox, you guys always miss something.”

In true form I did – a clavicle fracture.

I handed the patient over and when asked to complete the tracking form, couldn’t remember if it was 2015 or 2016. I didn’t even think to use my phone. All I wanted to do was sleep. I put my head on the counter I was in deep contemplation:

“15/16/16/15/16/15?”

How many sleepless nights and endless days had this gone on for? How can I not even know what year it is? I was too embarrassed to ask, so I sort of drew a 5 that metamorphasised into a 6.

For the life of me, I could not remember the year.

Have you ever smoked a cigarette and after a brief lapse in concentration you look down to see a sideways or upwards curl of ash and you think to yourself: “Surely the wind smoked most of that one?”

Well, the cigarette was the year I’d had, and underneath the snake of ash, I was burning away. I wondered how I got there, but of course my unraveling had already started a few months back.

I woke up a few months ago after an hour-long nap after night shift. At that stage I never slept more than two hours a day, no matter the circumstances – I just couldn’t prevent my brain from keeping me awake. That morning it was as though the first beams of light that hit my eyes immediately filled my brain with a kind of melancholic discomfort and I knew what I had to do.

You see, I was among the small demographic of people that was awake all night assisting others, so what I needed was to attempt to kill myself in the gym, immediately followed by the consumption of a strong drink.

Most people look down on alcoholics, but not most people in my profession – and nor do I, for that matter. Not that I am one, but I can certainly understand the appeal. Alcohol works, for better or worse and it works immediately. So I did just that. I went to gym and after exercising until I vomited, I set my sights on a bar.

I suddenly realized that I lived in a really inappropriate part of town for drinking by myself, so I decided to pack up the car and relocate temporarily to a place where I would be better tolerated.

I was driving through the suburbs when I almost missed a little bar tucked away on a corner. I saw a neon sign flashing “open” through a haze of smoke and immediately pulled my car into a rather acute left turn and braced for the G’s, bringing her to a screeching halt in front of the bar.

On exiting the car, I became excited when I saw smoke slowly drifting out the windows. I often think I was born too late into an era that unfortunately is ill-prepared to deal with my flamboyant nature. I have always envisaged myself living in an era where you could just smoke wherever you wanted to – this was obviously a smoker’s bar.

My excitement was dialed up a few notches when I discovered that the bar had an electric gate and that I had to be buzzed in. I have always appreciated the notion of having to be buzzed into a bar through an electric gate, as it always raises the curious suspicion as to whom is being buzzed in and whom is being buzzed out.

My excitement reached a peak, or so I thought anyway, when I heard slot machines as I entered and the acute realization dawned on me that I had discovered a real bar. Momentarily I considered turning around, as I was fully cognizant that this majestic old institution would in all likelihood get the better of me, but poor decision making had sort of become a sub-specialty of mine.

I walked closer to the bar and there, behind the counter she was. She had majestic, long black hair, fiendish hazel eyes with long eye lashes, plush red lips, pale skin and was in possession of a good 10kg’s of baby fat, something that has always appealed to me. Then she spoke … she was Russian, or so I thought, and I knew that she would get the better of me.

She immediately planted little worms in my brain and I could immediately feel the little bastards skilfully scraping against the inside of my skull. The locals of the bar were giving me the eye and I felt a tad uncomfortable. I ordered two black labels and two double shots of silver Tequila, and they knew that I wasn’t fooling around. I would elaborate on my interactions with this girl, but my description thereof would in all likelihood pale in comparison with the actual experience.

So let me cut right down to the nerve of the thing: I fell in love with this girl and she said that she fell in love with me – although I never knew whether she was just on the clock, in a manner of speaking (although my tips weren’t that good).  Anyway, the lines got blurred and I lost my way. I started drinking there on each off-day and our conversations started extending beyond the usual friendly banter of day-to-day life, which was wrong of me as a married man. My penance for visiting her on every off-day was that I had to sit and experience first-hand how the dregs of humanity that comprise her daily clientele treated her.

It was during this time that the unraveling started. I started losing interest in treating patients and was in the process of ruining my marriage. I had only known two constants in my entire life: Firstly, the treatment of patients and secondly, my wife, and I was losing both.

I also felt like I had no control over it; as if I was experiencing a great loss of autonomy at the time. I suppose one could speculate that the second round of burnout or the third or PTSD or just working long shifts whilst helping very sick patients, was getting to me but, it was as though the veil had been lifted and the spirits of all calls passed were swirling around me.

Every intersection, every outlying road, schools, hospitals and houses suddenly revealed to me past calls that I experienced with such vividness that I struggled to distinguish between reality and what had happened in the past – or what had never even happened at all. Before long I felt like a passenger to my body. Like my body was just carrying out actions and I was following.

I sat down on each off-day, drinking, writing down my thoughts and dealing with whatever drifted up from the time fog in as gracious a manner as possible. I couldn’t explain how I got to this particular juncture in my life.

Sometimes, with the right kind of mind, I could think back and uncover certain intersections in time, like peeling back the layers of paint on a wall and discovering the remnants of earlier days – recalling the first time I wasn’t excited for shift, the first time I hated being woken up at night, the first time I made an unethical decision, the first time I wanted to withhold analgesia, the first time I threatened to anesthetize I patient if he touched my face again, the first time I didn’t want to go to work and, finally, the point where I felt like I never wanted to see another patient in my life.

It felt to me like my only passion had slowly chipped away at me until there was nothing left and that I had somehow lost myself out there in the streets within the interminable dross that is my job, with no prospect of ever recovering any part of me ever again.

I was staring out in front of me and the bar lady, whom I later found out to be Belarusian, leaned over to me and said: “Penny for your thoughts handsome.” I looked at her reluctantly as I was unsure of whether it was safe to share what was floating through me, but simply replied: “I wish I was here.” I think she knew what I meant and reached out in concern. “But you are.” “No ma’am, you should have seen me when I was still here, I was something to behold.”

Just in case you were wondering, I’m better now and I wasn’t always this bent, burnt and broken. More than a decade ago, before my eyes became less bright and my tail less bushy and more crooked, I entered the service with the best intentions.

I grew up watching my EMS heroes on the television and I decided on the spot that I wanted to become – that guy. After years of hard work, I became that guy and more than just that guy, I became the guy that people phoned when others were struggling.

I loved it all from the start. The rush, the sweat, the blood, the guts, the swearing – everything, and then I went and flushed it all down the toilet. Now you might think that, considering my flamboyant nature and my recently discovered penchant for Belarusian bar-ladies, that I flushed it down the toilet through some malevolent or self-destructive act, but you would be wrong.

If I am being honest – when I lay awake at night, listing my regrets, the regret that surfaces most frequently and clearly through the ether was never being able to utter one simple word: “No”.

Can you come in early? Can you work late? Can you cover the whole weekend? Would you like to be a full-time manager and full-time paramedic at the same time? Can you do an extra shift? Can you stay for another after that? Can you work Christmas?

Had I said “no” to those questions, I would probably be a stable individual happily treating patients on a full-time basis, as opposed to providing you with the ramblings of my idle mind.

I have flushed my operational career down the toilet in little over a decade, like so many of my predecessors. The story never seems to change, only the characters shift in and out of the same story: young practitioners, pushed until they can no longer carry on, tossed aside and replaced by another young, unsuspecting practitioner.

To all new Paramedics, be forewarned by the words of a famous poet:

“My dear, find what you love and let it kill you. Let it drain you of your all. Let it cling onto your back and weigh you down into eventual nothingness. Let it kill you and let it devour your remains. For all things will kill you, both slowy and fastly, but it is much better to be killed by a lover.” Charles Bukowski (allegedly)

Post Scriptum: My apologies if you find my thoughts to be esoteric, protracted, convoluted and difficult to follow. This should give you some insight into what it is like to be stuck within my own unfortunate mind.

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