WHO HEALS THE HEALERS? Notes On Trauma & Child Sex Abuse

* * * * Trigger Alert: This post deals with physical and sexual abuse of children. It's mostly non-specific and doesn't go into graphic details, mostly chronicling the emotional response of this first-responder to the event. * * * *

Last week, for the first time in I don't know how long, the job made me feel cracked open and emptied out. I know why. Much as it hurt, I tip my hat to the somber reminder of my own humanity and keep it moving, wiser and stronger for it.

I've written on this blog and at The Rejectionist about how the action of healing, even when the patient doesn't make it, is a built-in instant form of self-care. We don't carry around the ghosts of all the horrible shit we see because we don't just see it, we work with it, throw our bodies and minds full throttle into the thick of it and become, however momentarily, part of the story. There's a cleansing that comes with taking action, even action that ultimately fails. It's as true in the larger community/world aspect as it is in the day to day grind of this job.

Anyway, that's exactly what didn't happen last Tuesday and that's exactly why I struggled with it so much after that fact. My mind was already heavy with the Penn State rape tragedy. Think it was a day or two after the JoePa riots and the news was all awash with creepy justifications, including that ghastly interview with Sandusky himself, and that shit was weighing on me. They sent us to a "BURNMAJOR" job. PD had been called in on a child abuse alert and found burn marks, old ones, on the kids arm.

I'm not gonna do details right now. It's all horrific, triggering type stuff and not necessary to the story. I'll just say that without anything being acutely wrong with the kid - who was running around and laughing, giving everyone high-fives - it was still the worst, most horrific job I've ever been on, for the unravelling of each nauseating detail of abuse as the detectives and my partner and I tried to understand what had been going on.

And then we drove them to the hospital, dropped them off and that was that. No IV, no oxygen needed, just some highfives and smiles and a gentle ride without lights or sirens. It was the end the tour and there was paperwork to be done and supplies to be restocked and radios to be handed off to the oncoming crew. And I felt...empty. Angry and horrified and full of sorrow and wrath and disbelief and heavy with the confused imaginings of wanting to deck the bastard who did it and knowing how useless and stupid an action that was and wanting to be still and hurl curses at the sky and run and call up everyone I knew and be all alone, all at the same  time. And still; horribly empty.

It was raining when I walked out of the hospital and down Gun Hill Road towards the train.  The Brooklyn-bound 4 was empty but thoughts of the past hour crowded in on me; the dull throbbing sorrow of nothing-you-can-do and the clenched up frustration of a hundred impossible thoughts. I let them come, mostly because I knew there was nothing I could do to stop them. And when the only action that's left to us is processing, that's what it has to be.
I'm blessed to have those sacred type of people close to me that know how to be there just enough in times of need without overwhelming; people that can be light with my heaviness and prod me to go deeper when I try to fake blow it off. Over the course of the night, through sad, hilarious, challenging conversations with
myself and my loved ones, I resurfaced, found my feet again, stopped feeling so empty and so began another day, full and ready for life.

NOTES ON ENABLING & A COMPLICATED EXTRACTION

There's a scene in the Buddhacarita where the young Buddha-to-be is sneaking out of his palace one early morning after another night of debauchery. They spend about a full chapter doing the literary equivalent of a slow-pan over all these once gorgeous women all splayed out, makeup smudged, body parts erupting from their clothes in all kinds of rude ways - a total morning after fashion catastrophe.
My job is like that scene sometimes, most specifically between the hours of say 4 AM and noon, when folks that are trying to make it out home from the clubs for one reason or another don't and end up in the back of my ambulance instead. And then puke.
It's not the puke or pee or, worst of all the #2s that I mind so much...Okay, no, I take that back, it is. But what adds insult to, ugh, to injury, is the sheer regularity, the predictability factor that's involved with ferrying the same, yes the same, damn drunks back and forth to the ER night after night after night. It's to the point where you start to feel like an enabler, because really, that's all you are: someone who gets these folks off the street and into a warm place so they can wander out a few hours later and do the whole thing again. And again and again. And you try, you really fucking try, not to let the regularity of all that depravity get to you and make you into some gigantic asshole. And usually you succeed. But it's really that, moreso than the death or the danger or the severed body parts or exposed intestines or whatever, it's THAT that makes this job so difficult and the burnout rates so high.

ANYWAY, that's not what I'm here to talk about today.
Last week, we had a patient that weighed damn near 600 pounds, couldn't get out of bed and had had her first seizure in ten years. Her husband was probably not playing with a full deck and stood WAY too close to people when he spoke. He also had the disconcerting habit of treating everyone like he knew them from waybackwhen. Not just in the buddy buddy way; he would go "Oh hey *mumbles*! How's the *mumbles* from before thingy thing? Oh yeah? Great! And anyway *mumbles* remember?"
And we were like *nod nod* "No."
But he was unfazed, dude just rambled along regardless.
We called for Fire because they've got a special basket for removing the extremely enormous. Crazy husband wanted to know why we didn't just put her on the stretcher.
"The stretcher can only hold 400 pounds."
"Oh! Well she's about 475 so..." He looked at us like the explanation was obvious.
We looked at him like O_O
First of all, she was maybe 475 lbs at birth, but certainly not at this moment. Second of all...no. So Fire showed up, after that awesome conversation, and they'd already been there before. You could tell because as soon as they walked in they started stepping away from the Crazy Husband, who went right up waaay too close to the nearest fireman and said "Oh hey Theoihsofihdgdgjk! Remember the ohgiughdughdgd??"
The Fire Captain explained that the patient didn't fit in their special basket, they'd already tried and they'd have to call Rescue, cuz they have an even specialer net system for such situations.
Meanwhile, the husband still didn't understand why we couldn't just put her on our damn stretcher and be done with the whole thing. For everyone's sanity, we had to start tuning him out around this point. We'd been onscene for well over an hour, drifting in and out of the apartment as much as our noses could stand it  when Rescue made an appearance. They did indeed have a complicated gladiator-style cargo net contraption that we ended up wrapping around the woman and using to lower her onto a special sled. "You alright, dear?" I asked as eight of us guided her from the bed to the sled. She nodded, said she was fine thank you very much and asked how much longer all this would take. The whole thing took about two hours, not counting decon time (she had been in that bed a loooong time) but we finally got her onto our ambulance and around the corner, literally around the corner, to the hospital.

CALM THE #%&*! DOWN

Seems the most common way for people to almost die is Acute Pulmonary Edema (APE). This, as I've blogged a lot about already,  is when the heart isn't pumping adequately enough and fluid backs up into the lungs, essentially drowning the person inside herself. It can happen over the course of days, a gradually rising tide, or it can flashflood and kill someone in seconds, pink frothy sputum coming all the way up their airway and out their mouth. Usually folks show some signs as it's approaching, something called othopnea which means they can't lay all the way back without getting short of breath and is measured by how many pillows you can sleep comfortably with (six pillow orthopnea would be a very bad thing). Another sign is Paroxysmal Nocturnal Dyspnea - a fancy way of saying sudden late night breathlessness, (which now that I think about it sounds like a fancy way of saying something else altogether...)

Anyway, Congestive Heart Failure is the chronic condition that causes this, but it can come from a sudden heart attack or fluid overload from kidney failure or massive hypertension, among other things, but basically, it'll kill you. By the way, i just made up the term "massive hypertension" do NOT use it if you want to impress people with your medical lingo.

When a body is starved of oxygen, there's a period where it just goes batshit before it gets exhausted and starts giving up. So batshit could be described as a latesign, something foreshadowing total respiratory failure and then cardiac arrest. this is bad news because getting all worked up increases demand on an already taxed heart and makes it very difficult for us rescue folks to do complicated things to you like start IVs and put on oxygen masks. In fact, as I've said before, not tolerating an oxygen mask is almost always a sure sign someone's about to go down the tubes (unless they just broke up with their girlfriend and they're trying for attention). It means the body is SO confused, the brain is SOO starved of oxygen it can't even figure out what it needs to get better any more.
This lady we had last week (betweeen the 2 arrests I blogged about previously) was already at that point when we got there.
She was also a fighter, so not only would she not tolerate the mask, she was throwing old lady punches every which way to keep us back. And here we are with needles in our hand trying to be like, "Ma'am...ma'am...we're here to *ducks*...ma'am!" and my partner trying to get near enough to put the oxygen mask on...not happening.
Fortunately, her daughter happened to be an EMT so she got in close and tried to calm her with a mix of loving caresses and CalmTheFuckDownCoños. Grandma didn't calm down but it distracted her long enough for me to grab her arm and put the IV in, but then of course she started flailing again, so I had to hold the arm still with everything i had to keep the catheter secure while I with one hand undid some tape and mummified that shit tight so it wouldn't go anywhere.
Meanwhile, my partner wants to put her on CPAP, which is an even more intense kind of oxygen administration, basically a reverse vacuum cleaner strapped tight to your face, shoving air down your throat. It's a lot to take even if you're not panicking.
She'll stab you before you get the first strap on, I mutter beneath her screeches.
that may be true, he says, putting the mask down.
Thing is, she does need it. Lack of oxygen is what's making her crazy and CPAP is the best way to get her lots of oxygen fast. But not if she's too busy tearing it off her face throwing it at us to get any good from it.
At this point, our IVs in but I'm really looking at this lady like she's going down at any second, from the sheer amount of excitement her heart might damn well explode. Okay, not really, but it will continue to suck valuable resources from her body, and she can't maintain for long.
We call for backup, on the premise that if she codes, we will need more hands to do it all right, and put some energy into calming her as we start setting up to get moving.
I think it must've been the daughter's helping out, because slowly, gradually, the screaming and yelling subsides and we're able to get close enough to give some medicine. That one thing, the calming down, sets of a chain reaction of events that basically guarantees our patient will get to the hospital without indrowning or even a tube down her throat. The medicine opens up her blood vessels some, dropping her blood pressure, relieving more burden from her heart. She finally lets us put the o2 mask on her, raising her oxygen levels and calming her down even more.  By the time the EMTs arrive she's so quiet I actually have to check a pulse, but then she looks up at me, still with defiance and her eyes but mercifully calm, and takes a breath.
I put the daughter on keep-her-calm duty and we zip off to the hospital.

THIS WEEK IN DEAD PEOPLE

Lord my blog is morbid! i forget sometimes, because it all's become a pretty harmonious aspect part of my everyday life, but then I scroll down the past bunch of entries and make boggly eyes at some of the shit that's come up. Anyway, for an ongoing collection of stories that are so much about death, the thruline really is Life: sustaining life, living life amidst death, letting go of life when the time is right. Alladat.
aaaand, this week is no different. It was a morbid ass week, i won't lie, but only in that tumultuous, joyful, challenging way that it so often is in my job.

Started with The Stench. Never a good job to get. I think PD gets it as the FOUL ODOR, for us it's a CARDIAC ARREST because if something smells SO bad you have to call 911, it's probably dead. Fire trying to get themselves canceled the second they get there- "Um, you really gonna need us? It says Possible DOA in the job descrip..." which is an absurd excuse to leave because "possible DOA" can mean anything from dude taking a nap to...well, to what we ended up finding.  So i tell Fire no, y'all comin up there with us, possible DOA or not. As I've said before, the main thing you need on a Cardiac Arrest is enough hands to have CPR ongoing while we do the other stuff, and I wasn't about to be the jackass that cancels Fire only to have a just-died dude on his hands and no one to pump the chest.

When the elevator door opened on the third floor, the whole Fire crew literally took 1 step into the hallway, did an about face and went poof. And at that point, I couldn't blame 'em. The smell of human decay is singular, unmistakable, unshakable. Some EMT showed up out of nowhere acting all cocky and loudmouthed about something, I don't remember what, so we let him go in first. He opened the apartment door and then we all had to move out of the way while he ran retching in the other direction and then was never heard from again. Poked my head into the apartment, not breathing through my nose at all. Didn't see anybody, just a dingy old onebedroom, cluttered with old magazines and piles of clothes. I peeked alittle further in, but the door was one of those swings shut quick behind you joints so I kept one foot blocking it. The air was thick and nasty and ahhhhh yes, there on the couch was the gentleman, lying peacefully on his back in a state of total Indiana Jones style decay/damn-near mumification. I hadn't noticed him because he was so perfectly still, obviously, and so many different colors that a human being should never be. 
It's possible that I said "Where's the dead guy? Oh." But I can't confirm that.
Anyway, we made a quick retreat, ganked PD's paperwork so we could write the guy's info down from the safety of our air conditioned ambulance and then went out to breakfast.

The next night we started out with a 55 year-old dementia patient who'd turned up dead on the floor of his nursing home room. He was on the young side, but otherwise, it was the same nursing home "we just saw him alive 5 minutes ago" routine, when clearly he'd been down much longer. It's maybe one of the saddest parts of my job that I've come to expect that kind of utter-incompetency and negligence from nursing homes, but that's what it is. He probably didn't have a chance but we did what we could. The family showed up halfway through, and we tried to have them stand outside but the son, a tall cat in his late 20s who was fasting for Ramadan and had been an EMT for a few years, just stood there shaking his head and saying he'd seen it all before. Family reactions are hardest when the death comes out of the blue, there's no time to brace for the impact and it just seems to sweep people up and knock them over like some angry wind. The son stood there solidly while the patient's wife bawled on his shoulder. I don't like prolonging the uncertainty. As long as we're working on him, all that maybe maybe shit gets drawn out, when really, it's not a maybe maybe situation. So i call, get a time of death and that's that. The son thanked us and then swooped around his mom like a big bird and the true mourning commenced.

Then some lady called us because her back had been hurting for like 18 years and she just couldn't take it anymore.

At six or so that morning, an asthmatic woke up barely able to breathe. He told his brother to call 911, put himself on a treatment and died. We got it as a DIFFBREATHER first, "...unable to speak in full sentences..." (never good) and then as we approached it became a CARDIAC ARREST. The brother had started CPR right away, and the EMTs were doing those real good ribcracking compressions, and the guy was only fifty-something, so everything was basically in place for him to pop back around, but still, he was flatlined, which is the deadest rhythm your heart can possibly be in, and he didn't change in the first 20 minutes of working on him. I did a round of compressions, felt the crunching of breaking ribs beneath my hands, then handed it off to fireman and stepped out the room to call Medical Control.
Passed the guy's ancestor shrine on the way down the hall. I was on hold with telemetry, so I just gave them a nod and mumbled 'go take care your homeboy,' and then the doctor picked up. Laid the presentation out to him, got a few more medications to give and came back in the room. The EMTs are still pumping on his chest. I push the meds, we do some more CPR and then stop to check a pulse.
"Pulse!" the EMT yells. "Strong one!"
Indeed it is - a good solid pounding up his carotid artery. His blood pressure's a healthy 148/72, his heart's a little fast, but that's to be expected considering everything. Okay. now we have to move. People that come back like that can look really really good until all the sudden they're not, and then there's a tiny window when you might be able to get 'em back stable but it's real touchy, and really, they need an ER at this point. So we scoop him up, gather our shit, carefully carefully lift him on the board, because if we dislodge the tube right now it's a wrap, and bustle him off to the ambulance. Downstairs we recheck everything: his heart rate is still good but his pressure's diving. The recently-undead can be so finicky and unpredictable with their blood pressures! It's not low enough to intervene yet, and given said finickiness I tend to be a little tentative about putting major gamechanging medications on board prophylactically, which is what the lieutenant on scene thinks we should do.
So i hold back on the dopamine, and sure enough when we get him in the ER and they take his pressure it's through the roof high, 180/100 or something, and any kind of intervention would've skyrocketed it into guaranteed stroke territory. We give the report, the doctors are always a little wideeyed that such things happen outside of hospitals, and they take over. Before the shift ended we check on him up in the CCU and he was in an induced coma, his body being inundated with cold fluids to preserve the tissue, but he was still alive.

STAKING OUT A POTENTIALLY DEAD GUY'S DOOR

Last night they sent us to some vagueness at Tracy Towers. By vagueness i mean the job just said "MALE DIFFBREATHER" and not much else. Gave an apartment number but the dispatcher came up to let us know the patient would meet us downstairs. Fine, that's always more pleasant than lugging 40 lbs of equipment up to some stuffy apartment. Thing is, Tracy Towers is this monstrosity of a project made up of many unmanageable somewhat connected ginormous buildings. There's ramps, tunnels, construction areas, elevators that only go to some floors, cross over bridges to nowhere. All the post-apocalyptic Wonderland features of PJs that make it hard to find anybody. So when we finally find the building we need, which involved going the wrong way up a windy-ass ramp and through a cloud of pot smoke, the dude's not there. A few cats are throwing dice in the parking lot, some ladies are smoking menthols on a bench and coughlaughing about the dudes throwing dice. A couple security guards are walking around looking more lost than we are.

We ask dispatch for a callback. There's some confusion. Fire gets called to take down a door that we haven't knocked on yet. The apartment might be A and it might be H, no one's sure. We shrug and hang around with the dicethrowers waiting for someone to make sense of this mess. Somehow, Fire gets on scene and up to the apartment without going past us, surely by going up another series of MC Escher stairwells, and when we show up at the apartment they're all irritated.
-We knocked on Apahtment A and they said they didn't call.
Okay, I say, well we have to...
but they're already in the elevator and gone before I can finish. Thing is, if someone might be sick or dead in apartment H, we can't leave. So we put in a call for the grumpy Fire guys to come back, which surely pisses them off even more and causes them to fake mechanical troubles or whatever, because what happens next is we wait. And wait. And wait some mo'.

A lieutenant shows up. Makes angry gestures and mumbles about Fire. Puts down his stuff and commences pacing with us after he makes some phone calls. Ominously, there's a tv blaring inside apt H but no one answering our incessant pounding. Stakeout the possible-dead guy's door time always becomes storytime, so we recount our other mishaps and victories, like the time some cop decided not to take a door in and they found a dude with his throat slashed in there the next morning.

We wait some more.

Eventually, Fire comes back and it is, predictably, a different crew. They take the door and inside we find an apartment that is almost completely empty except each room has a large screen TV blasting infomercials and Glen Beck at full volume. And the windows are open, a draft blowing the curtains around, givin the place a chilly, semi-alive feel. No body though, so we pack up our crap and begin to work our way back through the serpentine impossibleness of Tracy Towers.

GUEST BLOG!

Was so honored to be asked to write a guest post for The Rejectionist's blog, which i have been reading and enjoying for a while now. Here's a link: http://www.therejectionist.com/2011/07/special-guest-post-daniel-jose-older.html drop by and leave a comment! :)

3RD PARTY CALLER NOT ONSCENE

I was sleeping on the stretcher early this morning and the rain was falling in sheets on the roof of the ambulance. The job they woke us up for, sometime before dawn, sounded like either nonsense or a complete mess: "FEMALE 80 DIFFBREATHER 3RD PARTY CALLER NOT ONSCENE." that usually means someone somewhere doesn't know what to do with their grandma so they call EMS and say she's having trouble breathing and let us handle whatever family crisis was going down. Usually.
In this case though, the patient had called her daughter, gasped "I can't breathe!" and hung up. The daughter was on the way but when we got there it was 4:30 am and no one was answering the door. We buzz, call dispatch for a callback, buzz some more, wait. Nothing. Finally, the daughter shows up, lets us in and there's her mom, laying facedown on the kitchen floor. You can tell right away when a body's a corpse. It's not just that they're not breathing, there's something else; a total inanimate quality to a dead person that even the comatose don't have. She was quite dead, but had been alive at least 15 minutes earlier, so we brought her into the front room (because there wasn't enough space to work her up in the kitchen) and began CPR.

If you're gonna work up a cardiac arrest, the thing you really need that'll let you do your job is more hands. This is because CPR has to be going on throughout, and meanwhile you have to be starting IVs and intubating and pushing medications and all that, so really it takes at least 4 people to do it right, but preferably more. Since this job came over as a DIFFBREATHER and not an ARREST, it was just us. I come up on the radio to call for our backup, as I'm pumping up and down on this woman's chest, and nothing happens. No staticy reply, no other units chattering. Nada. My partner tries too and gets nothing. One radio keeps shutting off and the other gets no signal whatsoever.
Mumbling and grumbling and still pumping up and down while my partner gives ventilations, I call the dispatcher, but of course, the number i have in my phone still goes to the Brooklyn desk, and for whatever stupid reason they won't transfer me.
-i can give you the last four digits of the number you need, the dispatcher tells me helpfully.
How bout you go ahead and give me all ten?
-Oh, I don't know them.
There was a pause then as a million unfathomable curses swung through my head.
Meanwhile, I'm panting, and the phone is cradled in my shoulder and I'm trying not to let it slip and fall onto the patient and the daughter is watching from the kitchen, trying not to burst into tears.
-But I can tell you the first six numbers are the same as the ones you just called for the Brooklyn board.
what. numbers. are. they?
-Oh! I don't know. Whatever you called!
I think I growled at that point. Fortunately I had been repeating everything back to her throughout the whole conversation, including the last 4 digits that we needed, so my partner took out his phone and put everything together.
"We have a cardiac arrest and we need backup..."
In the meantime, I get busy with the IV, which involves doing a whole bunch of chest compressions, stopping to put on the tourniquet, a whole bunch of compressions, finding the vein, which is all the harder when someone doesn't have blood pumping through them, compressions, swabbing the site with alcohol, mad compressions, tearing open the plastic wrappers on the saline lock and the syringe, pushing saline into the lock and unwrapping the catheter, mad compressions, and finally putting in the line, compressions, and securing it down with tape. Whew. Fortunately, backup showed up right around then so I was able to go head and push the first line of medications without stopping every five seconds.

Amidst all this, I'm trying to explain, without being too grim or falsely hopeful, to the daughter that her mother is in cardiac arrest and what exactly that means. I do this because all too often, people believe the crap they see on TV with dead folks popping back alive every time someone bounces on their chest for a few seconds. Without obliterating all hope, I want the family members to understand the gravity of what's going on. It can get even messier when we're forced to transport the patient, for one reason or another, and then people really believe they're going to make it, when in reality they so rarely do. So, I'm panting away, holding the calmness in my voice, and the daughter is taking it really well, nods, seems to get it, although I do see the moment of painful realization flash across her face and for a second she looks like she's going to break but then she pulls it all together.

I start running the cold fluids, part of the new hypothermia protocol we do for cardiac arrests patients now that lowers the core body temperature with a flush of near frozen saline to preserve the tissues. But when my partner goes to intubate he finds the airway full of pink, frothy sputum. The patient had been in pulmonary edema, a fluid overload in the lungs. Pumping more into her at this point will only aggravate the situation that caused her death so we discontinue and move on to the other medications. 

At some point the daughter remembers there's a Living Will that specifies the patient doens't want to be resuscitated. Technically, we can only accept a true Do No Resuscitate order, but at this point we've already pushed all the first line meds and are ready to call the online telemetry doctors for a consult anyway, so I make the call, give the presentation and then let the doc know about the will.
The patient's been flatline the whole time, hasn't shown any change towards making a comeback and the will speaks for itself, so when the doctor asks if I'm comfortable pronouncing I tell him I am and he gives me a time of death.
And that's that.
We extubate, pull out the IV, slide a sheet under her and heave her onto the daybed in an adjacent room. One of her cats comes out to see what all the fuss is about and then somberly walks away. We close her eyes, tuck her in and leave her be.

It takes a while for PD to show up, again because the job didn't initially come over as a cardiac arrest, so I end up sitting at the kitchen table with the daughter, sipping water and chatting about life, death and cats. She's calmed down a lot, made a quick peace with it, perhaps to grieve later. Her husband showed up and took on the grim task of alerting her estranged sisters about the death of their mother. Outside the rain is still coming down and the sun is just beginning to rise.