Photo by Sandy Huffaker, Jr.
American Medical Response Paramedic Paul Maxwell: "Once you’ve seen one mangled person, you kind of detach."
“Walkup...Walkup...Walkup," I said over and over again.
“What are you saying?” he asked.
"Why?" he laughed.
“So I’ll never forget how wonderful you are.... Walkup...Walk-up...Walkup."
I was 19, and after the “Jaws of Life” extracted me from my father's totaled BMW, paramedic John Walkup became my best friend for the minutes that felt like hours it took to get from Poway to Palomar Hospital. (Pomerado didn't have the trauma facilities to deal with my extensive injuries) Walkup let me make his nametag my mantra and gave me the reassurance that everything would be okay. He was right — I’m happy and healthy now, six years later.
Thanks, Walkup. I still haven’t forgotten how wonderful you are.
— Jennifer Bladen
Paramedic work is not always so gratifying. It can be messy, it can be dangerous, it can be depressing, it can be heart-wrenching. John Walkup no longer works in San Diego County, but I did spend a day with American Medical Response paramedic Paul Maxwell, a straight-speaking man who bears some resemblance to Dennis Quaid, and he told me some stories. One involved those first two possibilities, messy and dangerous.
“We were transporting an AIDS patient. His complaint was, I think, general malaise. He just didn’t want to get up off the couch. His caretakers called 911 practically every week. The home-care nurse is pretty well set up with what to do in case of emergency, so most handle it through appropriate channels, but they called once a week. Some dementia was setting in, and if you kind of left him alone, he was fine, and he’d just stay there. Suddenly, he started projectile vomiting. I gave him a big tub to vomit in, and the second he would fill up the tub, he would sling it across the ambulance. I’m back here, and I’m trapped. If we anticipate, we take precautions, but he didn’t present it that way initially. The walls and me and everything was covered with his vomitus, and that was an extremely uncomfortable situation."
Paul has been doing this sort of work for 12 years, including 3 as an Emergency Medical Technician. I meet him at his office, located in the San Miguel Fire Station in Spring Valley. Together with his partner Mitch, younger and with a looser air about him, he covers the 44 square miles of the San Miguel Fire District, “Spring Valley, the unincorporated areas of El Cajon, and the unincorporated areas of La Mesa.” The back of their ambulance, where I am riding, has the clinical fed of an emergency room. The interior is mostly gray plastic and stainless steel.
The first call comes in on their beepers while we’re on our way to get coffee. We’re almost at the scene already, so there is no need for lights and siren and zipping along at the legal 15 miles over the speed limit, zapping red lights to green with a strobe light and hoping that people remember to pull to the right and stop, a habit that is lacking in many, according to Paul. “They either stop right in front of us, which is the worst thing, or they pull to the left—they’ll even pull into opposing traffic when the right’s open. Or, they’ll just go really, really slowly, or they’ll pull to the right and continue to drive, which is a problem if our turn is the next right turn. I wish that was a pass/fail question on the driver’s test.”
The call comes from a mobile-home senior park. The wife of a 75-year-old man reports that he has been having small seizures, four since 5:30 (it is now around 8:30). When we arrive, she recites his symptoms without passion, reporting that he had a grand mal seizure in 1994, naming his medication, and assuring Paul that he has been taking it. She is not hysterical, just concerned enough to get him to a hospital, something he doesn’t like.
Because we were on top of the call when it came in, we beat the firefighters by a few minutes. This is a rarity, usually they arrive first. Because of improved building codes and increased fire safety, firemen don’t have many fires to put out anymore. “Seventy to 90 percent of their call volume is medical aids,” says Paul. “They’re trained as first responders, as Emergency Medical Technicians. They have defibrillators semiautomatic ones. They do the things that are most needed — take care of the airway, set up the IV, get the gurney — while we’re doing paramedic things."
“Paramedic things” means Mitch is questioning the man and taking his vitals, while Paul talks to the wife and calls ahead to-the hospital with Mitch’s findings. It can also involve giving “first line” medications and intubating. The firemen bring the gurney and help the man, clad only in his underwear, onto it. They wrap an orange blanket around him and load the gurney into the ambulance. The man says little, from under his strong eyebrows comes a look of resignation and indifference. This is happening; there’s nothing to be done about it except ride it out Paul drives; Mitch sits in back and makes small talk with the man, now and then checking the heart monitor.
When we arrive at Grossmont Hospital, nobody takes much notice of us. Paul goes to report to someone, and a room is cleared out. While they wait Paul and Mitch smile at a shirtless man who is receiving bandages on his hand. The man bobs and weaves his head as he sits on a gurney. He is barefoot. “He’s totally tweaking on crystal meth," Paul tells me later. “I was saying ‘We’ll be getting a call on him soon—“difficulty breathing.’”
Drug-related calls come up again when I ask about people getting violent “If the call comes down as an assault, then we’ll stand back and wait for law enforcement to arrive and secure the scene. But if it comes as ‘difficulty breathing’ there’s no law enforcement. If it’s ‘difficulty breathing’ because they’re so spun out on crack or PCP.... We’ve had a situation where the guy was on PCP and the call came down as something completely different, ‘diabetic palp’ or something like that. We got there, and he was slumped over, and as soon as we went to arouse him, he went sideways. He was headed straight for a big bay window—this was a second-story building — and so we tried to keep him from injuring himself, because, of course, that would look tacky— ‘We called for you and he was alive, and now he’s not.’
“That was perceived by the people in the apartment building as the paramedics attacking him, and then it was all of them against us. I had to address the crowd and explain to them that he had a medical emergency. We ended up giving the patient Valium just so that he wouldn’t be so riled, and that’s how we got out of the building alive and unharmed.”
Other sorts of calls include “chest pain, seizures, strokes, asthma attacks, all those medical-aid types of things.” What about violence? “Domestic, a lot of domestic It depends on what area of town you live in. In Southeast San Diego, they do guns; in South Bay, they do knives; East County, they do a lot of blunt objects— baseball bats. We specialize in that. They’re alcohol-related most of the time. Assaults, just general assaults.”
Another East County specialty is child drownings, because there are a lot of old pools in the area without fencing. Two-year-old males are the most common victims. Paul uses the data he collects as a paramedic to raise public awareness and form prevention strategies. “Drowning kids are the worst death there is," he says. “To get involved in the prevention thing is a really good way of defusing it”
Another call comes in, this one for a child whose finger was caught in a door. This time, we arrive after the firemen. The police are there as well, making sure it wasn’t an abuse case. The boy, three years old, is not seriously injured, but the mother didn’t have a car and called for an ambulance. Paul tells me this is a code 50— private transportation would have been appropriate. Code 40 is an EMT level call, 30 gets an IV, “just in case,” 20 means some medication has been given, and 10 means lights and siren, even going to the hospital, “usually a trauma patient.” After bringing the boy into Grossmont, a long drive during which Paul hooks him and his brother up to the heart monitor and gives them printouts along with stuffed animals, we head back to the fire station. Two calls in the first few hours. They normally get six or seven in a 24-hour shift (the station is equipped with bunk rooms for sleeping between calls). Each call takes an hour and a half to two hours. As soon as they report themselves arrived at the hospital, they are eligible to receive another call.
“As I get older,” confesses Paul, 35, “getting up after midnight in two-hour intervals gets harder and harder." The difficulty is offset somewhat by the six days off he gets once a month— the rest of the month is four days on, four days off.
A couple of phone calls later, we head to Gloria’s Tropical Fun Food in Spring Valley for a late breakfast/early lunch with four other paramedics. I’ve got as much morbid curiosity as anyone, so, needless of the impending meal, I ask about the worst thing they’ve each dealt with.
“Most people want to hear the juicy stuff,” begins Barry, a paramedic Paul accuses of having a round face, “but usually, that stuff doesn’t faze us anymore. Once you’ve seen one mangled person, you kind of detach. The worst call I had, probably, I was working as an EMT, and it was an elderly female. She was awake and she was dying, and she knew she was dying, and her biggest fear was that she was going to die alone. She had no more family left. We were going to the hospital, we had our lights on and stuff. She was near the end, and she was just squeezing my hand because I was her last attachment at that point I had become her last person, and she died in my ambulance on the way to the hospital. That was kind of disturbing, because her biggest fear was to die alone. I had the chance to be there with her, but it was still… That was a call where I sat down afterwards. Just kind of sat on the curb and said, ‘Wow.’"
A bespectacled, mustached paramedic to my right speaks up. “Sometimes it’s the smell. I remember walking into one room, and there were bugs all over the floor. You took a step, and it was like the whole floor was moving. The patient had been in bed for days, urinating and all this, maggots crawling all over him."
“Dead, right?” I ask.
“It’s easier if they’re dead,” says Paul “Then, you can just walk away, it’s the coroner’s deal at that point.”
“If they’re alive, you have to stick around and deal with it,” says another.
“Maggots and all,” finishes Paul.
But amid the gruesome details, there is still humor. I ask if they remove the maggots.
“You get the big ones off.”
“The ones that bite back, the ones with fangs.”
Mitch tells a similar tale, one with a harsh qualifier. “Not only the smell, but also the conditions people live in. We went on a call down in National City somewhere, to this house you wouldn’t even know was there, because it was so overgrown. We walked through the gate and the weeds were [armpit] high. The sidewalk was literally a trail that was worn to the front door. It just reeked of cat feces and just smelled like cats. You could hear them from who knows where, they were all over the place. (Inside), stuff stacked from floor to ceiling, and there was a trail, one that went into this room and one that went into the kitchen. There was feces on the wall, the power didn’t work, and there was a gentleman laying on the floor who had been there probably three or four days. He looked terrible; he looked like he was dead. And this guy had family, he had somebody that actually ended up meeting us at the hospital. Families let their own family members get like that, and that’s just absolutely incredible.”
Like Barry, Paul’s story is more emotional than messy. “The worst thing I ever saw was when I was doing my rotation in the trauma center. I was at Sharp, and the helicopter had flown this boy in that had been struck by a car. He was unconscious, and his neck was broken, and because his neck was broken, his spinal cord was severed, and he had no respiratory drive. So he had to be ventilated by hand, and that’s what I was doing. The CHP drove his mother to the hospital, and they told her the condition of her boy. [They cleared] the whole trauma resuscitation room out so she could say good-bye to him, because when her other child was killed in 1978, she never had the chance to say good-bye. So, to keep this boy alive for a while, he had to be ventilated by hand, so I had to be in the room while she said good-bye to her boy.”
As the stories are told, our ranks are decimated by a chorus of sounding beepers. Barry’s breakfast arrives just as he’s finishing his story and just as his beeper goes off. Ditto his partner. Two others leave soon after. Their breakfasts are boxed and kept waiting for their return. Mitch, Paul, and I are left alone at one end of the long table. The traumas they describe, full of the twin grinders of emotional wear and stomach-turning conditions, make me wonder about burnout. But while burnout does happen, it’s not always for the reasons I imagine, as Paul explains.
"It’s usually related to the nature of the calls the paramedic goes on.” One example he gives is of paramedics who work areas that get the same calls over and over, such as violent neighborhoods. Paramedics who do the same thing all the time don’t get to use other skills and may get frustrated. But also, “There’s blatant system abuse out there. Medi-Cal abusers, stuff like that. So if if s one after another after another, people just using you, it can wear on a person. There was a 17-year-old girl that was T-boned, critically injured. We were on 'mouth pain’—a guy had dental surgery in Tijuana, and it hurt now, so he called 911. Simultaneously, there was this other event that we were closest to, and they had to send a distant ambulance to that call. Stuff like that can wear on a paramedic."
He goes on to tell about people in fender-benders who suddenly feel neck pain and call for paramedics for a ride to the hospital, “dollar signs in their eyes all the way there," adds Mitch. “You’re thinking. ‘Wait a minute,’ ” says Paul, “I just rode the Indiana Jones ride, and I know it was worse than this, and I didn’t go to the hospital.’ To be part of someone’s scam is disheartening."
A call comes in. A woman in her 90s has been found on her bedroom floor. “Not responsive,” says the call “If s difficult to respond when you’re dead!” observes Paul. Mitch tells me a lot of people also say, “I think he’s asleep” about people who are, as Paul puts it, “most sincerely dead.” As it turns out, “not responsive” referred to the fact that she wasn’t answering her doorbell when her neighbor rang it. The woman herself is alive and conscious, if not very well. Her flesh is shrunken around the bones of her face and arms. She looks dried. She can’t remember how she ended up on the floor or how long she’s been there. (A neighbor noticed that she failed to open her blinds that morning.) The skin on her elbow, translucent and paper-thin, has torn. She is picked up with a scoop, a metal stretcher with a bottom that slips under the patient from both sides, and placed on the gurney, which is placed in the ambulance. On the ride to the hospital, Paul asks her where she’s from, how long she’s lived here, what she did for a living.
It turns out I was right about her looking dried. After they drop her off, Paul tells me, “I said, 'You look a little dehydrated,’ and she just barely whispered ‘It’ll be over soon.’ So she knows, but she kind of smiled when she said it.”