Comments and Follow Ups

I wanted to thank everyone who has posted comments. I always read them and have learned a lot from many of them.

I want to use this post to followup on comments and some recent entries.


I particularly want to thank the commentator who brought up the tidbit that Nitro spray (NitroLingual) doesn’t have to be sublingual.

I have heard from many of you on this issue and have asked lots of medics and doctors about it. It is surprising how many people like me were unaware that nitro could be sprayed on the tongue. The consensus now seems to be if you can spray it under the tongue, this is best. It may work slightly faster and has less unpleasant taste, but if you can’t get it under the tongue, and don’t want to have to go through all the contortions of 29 Ways to Lift Your Tongue just go ahead and spray it on the tongue.


Thanks to those posters who have picked up on my occasional patient gender shifting in stories. In light of HIPPA privacy fears, I use a randomized method of disguising patient identities that sometimes includes writing about a man when the patient was actually female. Sometimes in the heat of writing “the he” who I am writing as “a she”, sometimes slips back into being “a he.”


Thanks also to everyone who wished me better health after reading Medicine for Paramedics. I am feeling much better now. Spring is here and I have even been back out running.


In a recent post about ceasing a resuscitation (Faces of Death), I mentioned that we took the tube and IVs out after we have presumed the patient. Some commentators thought that odd. As I noted in a comment:

Our discontinuation protocol reads: “Tubes and Iv lines may be removed if patient is being transported to or by a funeral home. If the patient is deemed a medical examiner’s case. leave tubes and lines in place.”

Most patients that will end up being medical examiner’s cases usually fall in the transport category. We rarely, if ever, work and discontinue a trauma. Our tubes are documented for the record by capnography print outs, both wave form and trend summary.

I sit on the regional medical advisory committee and have fought for the right for medics to remove tubes in certain cases. It is not rare in a town like the one I work in most regularly to have a wife or husband summon 911 when their longtime spouse has just passed on. We often find the patient warm and asystole with no DNR paperwork. The people are in their eighties or nineties and are living in the homes in which they have raised their families and spend most of thier lives.

We put the patient on the floor, work them for twenty minutes, giving them full ACLS (CPR, intubation, IV, epi, atropine) get no response, and then presume them. We often pick them back up and put them back in bed, their head resting on a pillow, close their dead eyes and pull the sheet up to their neck. Afterwards I often see the husband or wife come in and give them a kiss on the cheek or lips or hug them or sit with them while waiting for the medical examiner.

I think it is more humane for the patient to lie in their bed looking as peaceful as possible and not have a big tube sticking out of their mouth. Fortunately, the committee agreed with me and so we have have this provision. Again, we can only remove the tube for those patients where the police, who are on usually on scene with us, will be calling for the funeral home to come instead of calling the Medical Examiner.


I have thought more about the novel Black Flies by Shannon Burke that I reviewed. I know many EMSers are upset or disturbed by our continual portrayal as burned out stereotypes who no longer care about our patients, but I still think this is a worthy effort.

I reread an interview with the author and he mentions that his book is a “story of good and evil.” And it certainly is. Burke presents a stressful environment where weaker individuals (new medics) can fall prey to bad influences.

The older medics represent an array along the spectrum of good and evil, including the good, a medic who struggles to grow a garden in a small strip of earth next to the Harlem ambulance headquarters, the burnout, a once decent medic who is having trouble caring and who is descending into despair, and another medic (pure evil) who carries a picture of himself holding the head of a decapitated girl like a bowling ball (pretty nasty stuff).

I have found myself thinking about this novel weeks after I have read it, and that I think is a mark of a good book — it makes you think. I hope Burke writes another EMS novel that while dealing with as important issues (good and evil) as this book deals with, can do it without leaving a lay reader with a distasteful impression of your average paramedic.


In My Death I railed against ambulance safety and posted a link to the Ambulance Crash Log.

The most recent news on the log concerns a young EMT in New York state who lost her arm in an ambulance crash and is still in critical condition. Prayers and thoughts go out to her and her family.

The streets aren’t getting any safer.


  • JKosprey says:

    I am a regular partner of both EMT’s involved in that horrible accident. Seems to me there wasn’t much that could have been done to stop it unfortunately, but both are progressing slowly but surely into recovery. I don’t wish to beg so if this is inappropriate feel free to delete it, however a fund has been set up, it can be found at

  • Witness says:

    One of my coworkers also works at that company. Hits home. Be safe.

  • pozzo says:

    I’ve seen the comments about the novel Black Flies and was holding my tongue, but…I wanted to say that the book was not meant to demean paramedics or the job they do. Just the opposite. I meant to aggrandize paramedics, but not with some cornball catch the baby from the burning building sort of thing, but by dramatizing the real struggles of a first year medic in a hostile environment. After Safelight, which was a sort of love story, I wanted to write a real paramedic novel, a novel where every scene took place on the ambulance, and specifically, a novel that a medic just starting out could read and say, ‘Wow, this is what I can expect in the next year. These are the pressures I’ll be put under. These are the choices that will present themselves. And these are the risks.’ So, I dramatized what I’d seen personally and I tried to mark the psychological stages in that critical first year—what the pitfalls are, and how the job really does spiral down to choices of good versus evil, but those choices come in such banal and offhand settings that unless you’re reminded of those moments you can almost miss them. That was the thing that haunted me as a medic. How small decisions had huge implications for the patient, and if you didn’t pay attention, didn’t follow up to see what impact your treatment had, you could go on blithely mistreating and even hurting patients without even knowing it. And, yeah, there’s boredom, and laziness, and burnout, and I wanted to show how these manifest themselves in the EMS world and how a lapse has real consequences. We all know this. We’ve all seen it. It’s part of the job. Anyway, I wanted to write about the hurdles for a rookie medic, and to have him make some mistakes and start going down the wrong path, but in the end, good does conquer evil, the main character does the right thing and comes out on the other side of his struggles, and will go on trying to do the right thing longer because of his past crises. The endpoint, I hope, is a hard won battle for the rookie medic, and a new respect for medics in general and the struggles they go through to do their job. If this isn’t the impression the book gives, then…I failed in my goal. But that was my intent. And, just as an aside, I know the NYC system has a reputation of being a hostile environment, and it’s hard for me to say if it’s worse than other places because I have nothing to compare it to, but I can say with all certainty that the burnt out medics I wrote about in the book are less burnt out and do less bad things than what the real bad guys I knew did in my first six months on the job. It’s possible I just stumbled into a dysfunctional situation, but I swear to you that what I wrote is an understatement rather than an exaggeration, and anyone who was working out of the old Station 18 back in the nineties can back me up on this. There was some wild shit going on and everybody knew it.

  • Carlo says:

    Good Job! 🙂

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