Doctor Jack Wagon

An ER physician cancelled my cath lab activation the other day. No, I didn’t save the 12-lead.  I should have, and maybe I will try to find it once I go back to work.

It was a male in his mid-forties. He had just gotten back home from a walk around the neighborhood, and couldn’t catch his breath, and kept sweating. It’s been a little warm around here for the past few days, but not that warm.

So, duh, he’s having an MI.

For some reason, the interpretation didn’t pick it up. He was in a sinus bradycardia with an (apparently new) left bundle branch block. He met all the Sgarbossa criteria. He was hypotensive. His skin was diaphoretic, even though it was 74 degrees outside.

We transmitted the ECG to the hospital, and I called the cath lab number on my phone, like we always do from the field. After loading up in the ambulance, I called the hospital to give them my ETA.

That’s when I was told my activation was cancelled.

“By who?”

“The ER doc.

It turns out that the nurse who receives the ECGs we transmit shows them to a physician. Not a specific physician, mind you, just any physician he or she can find in the hallway. And this time the physician cancelled my cath lab activation.


Wait for it.

Because my 12-lead didn’t say “STEMI” on the top.

No joke.


This jackass in a white coat cancelled my cath lab activation because the interpretive statement didn’t recognize an MI in the presence of a left bundle branch block. This isn’t a case of a false activation, either. I took the 12-lead upstairs to the cath lab to show a cardiologist friend of mine.

“Where’s this patient?” he asked me.

“Downstairs in the ED.”

“What the hell for? Why isn’t this patient up here?”

“Ask the jack wagon in Trauma 4. I activated you, but jack wagon cancelled the activation.”

Where was the patient?

In Trauma room 4. Twenty minutes after we walked in the doors, he arrested. He went into v-tach and tried to die. He was resuscitated, but now, several days later, he is upstairs in the ICU on a ventilator, with a balloon pump hooked up to him.

Because some jackass doctor can’t interpret 12-leads.


“Medic 4, caller reports a male in his twenties possibly overdosed. PD is en route with you.”

An overdose at the drug-treatment center. This seems ironic.

“Medic 4, update. Caller reports patient is unconscious but breathing. Caller advises come to the intake area.”

“Medic 4 received. Radio, show us on scene.”

Slimm and I make it inside with our equipment, walking with local fireguys. Slimm is still incredulous that Marshawn Lynch didn’t get the ball on those last plays from the goal line.

The scene looks like something out of a sketch comedy: fifteen people running around like chickens with their heads cut off, while some guy is lying unconscious on the floor. There’s two women in the corner, on a floral sofa, crying softly. One appears matronly, and the other could pass for a sister or girlfriend.

“Hey, y’all. What’s going on?” even though it is pretty obvious.

“He came in for <gasp> treatment, but then <pant, pant>, he acted like he was really high, and <gasp> then he went unconscious.”

Fire dudes are taking care of the supine gentleman on the floor. They say something about him breathing 6 times a minute. I see them get a BVM out. The chickens start to run faster.

Slimm looks exasperated. Not about the Lynch thing any more, but the current situation. He turns to the ladies on the sofa; “Ma’am, any idea what he could have taken, or how long ago it might have been?”

His mother tells us between light sobs “He does heroin and oxycontin. He probably took some pills on the way here or something, I don’t know.”

Well this should be easy enough.

“Okay, no big deal. We’ll give him some medicine, make him breathe a little faster, and we’ll get him over to the hospital next door, okay?”

One of the chickens says she will go get their Narcan.

This can’t take long, right?

5 minutes later, she’s still not back. It looks like fire dude’s hand is cramping.

“Any idea where the lady is with that narcan?”

“Oh, she had to go across campus. And then she probably had to get the key from the director”

“You keep the narcan somewhere else?”

“Yeah, we don’t keep it here.”

“You don’t keep narcan in the intake area of a drug treatment center, and instead you keep it more than five minutes away, under lock and key?”

If we had known that, we would have simply left a long time ago. And here I am, trying to save my boss a little money.

They give cops that stuff now days, and I’ve seen addicts with it. But the one place most likely to see an overdose and need the drug, is the one that makes it the most difficult to get to.


“Hi, this is C with Local Ambulance, I have a patient report I’d like to call in.”

“We are on diversion.”

“Yeah, I know. I tried to tell my patient that, but she insisted on coming to your hospital.”

“But we are on diversion.”

“I understand, but my patient wants to be seen there, so we are bringing her in. Would you like a report?”

“I don’t think you heard me. We are on diversion. You can’t bring her here.”

“Okay then. No problem. I’ll just need the name of the physician refusing to accept my patient.”


(and later on…)

“We don’t have any beds. You’ll have to wait there by the wall.”

“Okay, sure thing.”

The ER is virtually empty. The tracking board says they have five patients and more than twenty available rooms. It’s 6:45 on a Sunday morning. I spot two nurses playing checkers and drinking coffee.

Seriously, checkers.

“Hey, C, the bed in 6 is empty.” Slimm tells me after about 15 minutes of waiting and being ignored.

“Sweet. Let’s do it.”

(and later on, after being ignored for a few more minutes, and moving the patient to the empty bed in the empty ER…)

“Excuse me, would you happen to know who the nurse is for room 6?”

“We don’t have a patient in room 6.”

“Yes, you do. If you’ll look right over my shoulder, you’ll see a patient in the bed in room 6.”

“Where did that patient come from?”

“My stretcher.”

“You can’t do that!”

“Sure I can.”

“I’m getting the charge nurse!”

(charge nurse appears, obviously upset that her game of checkers was interrupted…)

“I told you we were on diversion.”

“But you hung up on me before I could get the name of the doctor refusing to see the patient.”

“But we are on diversion. I’m not accepting your patient.”

“It’s a little late for that.”

“No, it isn’t. You had better put that patient back on your stretcher and leave!”

“I can’t do that.. That’s against the law. Sign here, please.”


“Okay. Thanks. Bye.”

New Doctor

Newguy and I are taking an older gentleman into the hospital having an active stroke. It’s a legit stroke: all of a sudden he couldn’t move his left arm or leg, and his face started drooping, then his slurred speech started.

“Hot stroke” as we call it.

I’m giving my report to the nurses, and apologizing for sticking the guy 5 times without getting an IV.

Literally, all I did on the way to the hospital was 1) call a report on the radio, and 2) make this guy a pincushion.

I’m in the midst of a bad IV streak. I was 2-for-9 that day.

Some new doctor I’ve never seen before walks into the room. Most physicians in this emergency room wear scrubs, and occasionally a white coat, but this guy looks like a Brooks Brothers catalog cover model. Pressed khakis, cordovan wing tips, light blue pinpoint oxford, and a regimental rep tie.

He listens to the rest of my report while he walks over to the patient.

As I’m finishing up my report and grabbing a signature from the nurse, he looks at me.

“So y’all didn’t get a line?”

“No. I tried a bunch, but I didn’t get one. Sorry.”

“That’s cool, don’t worry about it” he says as he turns to the nurse. “Let’s go ahead and get him over to CT, and call Neurology.”

He takes his stethoscope off and begins listening to breath sounds, and turns back to me.

“Did y’all get a sugar on this guy?”
“Yeah, it was one-forty-four.”

“Good. We need to know the sugar. That’s some important shit.”

“Fixed it”

Slimm and I are taking some poor lady to the local rehab hospital. This poor hapless soul made the mistake of slipping on ice, and banging her head on the pavement. Now she has a tracheostomy and needs a ventilator.

Unlucky for her, she is now here.

We make our way to the room after the obligatory signing in of the patient at the front desk. Which makes no sense to me, but I’m just an ambulance driver transporter paramedic, and not a policy maker.

We hear the alarm before we make it to the room.

Slimm makes it to the door first and I can hear his eyes roll from the other end of the cot.

Inside the room is an obviously exasperated respiratory therapist, fumbling with the hospital ventilator. Obviously, something is not like it should be.

“I can’t get it to work! Something is wrong!” she says very excitedly. “I’ve never heard it do this before!”

Slimm catches my eye, and his eyes glance at the wheels of the hospital bed, and back up to mine, and I get it. Three years of silent communication are good for a partnership.

Meanwhile, the RT has reached the end of her wits. She looks like she is about to quit.


She turns to us: “I’m going to have to go get the vent from across the hall” she says as she walks out.

Slimm’s face doesn’t move, and his eyes don’t turn. His right foot makes an almost imperceptible movement to the foot of the bed, and activates the bed’s lock.

The alarm stops. Like we both knew it would.

Our patient continues to be unconscious and unresponsive on our cot.

The respiratory therapist reappears at the door, less exasperated and more perplexed.

“What happened?” she asks.

“I fixed it.” Slimm replies. “It’s cool now.”


Sometimes we should refuse transfers

Almost once a month, I see in my Facebook feed a link to the article from several years ago in which a Florida ambulance service was ordered to pay a 10 million dollar settlement to the mother of a baby that was born in the back of one of the service’s ambulances. The mother was being transferred from one hospital to another, due to the patient’s (apparently) precipitous labor. The mother’s water broke, and the baby was delivered (and heroically resuscitated) in the back of the ambulance. Unfortunately, the baby suffers from cerebral palsy, and a jury in Florida found that the ambulance service was liable for the injuries to the baby, because they did not have the appropriate equipment on board.

I trust that the story is easy to find, and has been read by the majority of us already, so I won’t link to it here.

I’ve argued that the service never should have taken that transfer in the first place, and that the service is most certainly liable.

Most of the Facebook comments on these threads follow a common pattern; that: 1) the paramedic performed a heroic thing by resuscitating a 25-week fetus, 2) the ambulance crew should have called their supervisor or medical direction prior to taking the call, 3) shock that an ambulance service would be held liable when they saved a very difficult patient, 4) the plaintiff must be money-hungry, and 5) the ambulance service should have demanded that a hospital employee ride in the back of the ambulance with the patient.

I will never argue with anyone on the first point. I know several people who work for EVAC, though not this particular paramedic. I can only imagine the difficulty this paramedic encountered when faced with having to resuscitate a pulseless, apneic 25-week fetus with only the help of their EMT partner. This was very strong work by an EMS crew, with a much better outcome than would have occurred in a lot of other situations.

I don’t agree with calling a supervisor or medical direction. Calling a supervisor for guidance would be only minimally helpful, and a medical director phone call does nothing to remove liability from the providers. This ambulance service was most certainly liable, from the actions of the call-taker to the paramedic who accepted the transfer.

All too often, if the paramedic had refused to take this patient (as some would), they would be viewed as a “problem” employee who was “refusing to run a call.”

To address point number four, I don’t believe the mother of the baby is “money-hungry” in the least, but that she is now faced with paying for a lifetime of care for a baby who suffered injury at the hands of the ambulance service.

And to address the final point, asking for a rider from the hospital only provides the paramedic with another pair of hands. Hospitals (in my experience) are hesitant to send riders for several reasons. First, because they lose the nurse for several hours, and staffing levels are affected negatively. Second, many nurses are not protected from liability when they leave the hospital grounds. Nurses operate under a physician while in the hospital, much like paramedics operate under a physician while in the ambulance, which begs the question; which physician does a nurse riding along operate under?

Several years ago, I was called in the middle of the night to a small, rural hospital to transfer a patient to a very large hospital that was more capable of taking care of him. The patient was incredibly sick, with a PaCO2 in the 90s, with a PaO2 in the 70s. This patient was on BiPAP, and the sending hospital was absolutely bouncing off the walls to get him out of their hospital. While I was working on a critical care truck, my ventilator at the time did not have the capability to provide BiPAP. I informed the sending physician that I wasn’t able to transfer this patient in this condition, and he was apoplectic. The sending hospital was not in the position to send their BiPAP machine with me in the back of my ambulance, as it was the only one they had, and they couldn’t be without it for the 5 hour round trip.

While the physician was incredibly mad at me, I stood my ground, and he finally asked what needed to be done to have the patient transferred, and we discussed the case. The patient was sedated, paralyzed, intubated, then placed on my ventilator for the transport, which was uneventful.

When I got back to the station in the morning, my supervisor called me into the manager’s office to discuss the call. The phone call they received from the sending physician led them to believe that I did not want to run the call, and that I was rude, and incapable of handling a patient on BiPAP. After explaining the potential liability that the company would face had I transported that patient as he was, everyone agreed that I did the right thing.

I was fully prepared to walk out of that hospital that morning without a patient. I act in the patient’s best interest first, as we all should, but I also keep in mind the company’s position. Those two don’t have to be in contrast to each other. If we act for the company first, by taking the call because it is a paying patient, then that is not always in the patient’s best interest. If we do the right thing for the patient, then the company will, more often than not, be okay.

“Yeah, but…”

I’m doing an ACLS check-off for a group of physicians as part of their biannual renewal. It is some of the easiest work I have ever done, and I have a blast doing it.

I give the delightful gastroenterologist his scenario, a middle-aged male who is waking up from his lower GI study. He doesn’t feel good, and it is only going to get worse from here.

Doctor Endoscopy asks for a set of vitals, and learns the patient is hypotensive, bradycardic, with pale, diaphoretic skin, and very weak.

“Okay, I want to put him on the cardiac monitor.”

“Sure thing. That’s what you get when you turn on the monitor” I say, as I press the button on the rhythm generator that hints it will display something resembling a a complete heart block.

“That is a third-degree heart block. I need someone to start an IV, and put the pacing pads on him.”

“Okay, your secretary has started an IV, and the janitor has applied the pacing pads.”

“Okay, I want to give point-five milligrams of atropine.”

“Are you sure?”


I pause the scenario, as best as a scenario can be paused. “Um, atropine isn’t going to work in a complete heart block.”

“Well, I’m the doctor, and that’s what I want to give.”

“Yeah, but…”


“This is Jose’. He had a little bit too much to drink and he fell-”

“How do you know he had too much to drink?”

“Have you been in the room? I can still smell him from here. Anyways, he tripped over the carp-”

“Did he tell you that he had too much to drink?”

“He isn’t here because he is drunk. He’s here because of the big gash on his-”

“So he isn’t drunk, and you are just judging him because he is Mexican?”

“Actually, he is from Guatemala, but when he tripped, he fell forward and-”

“Where do you want me to sign?”

“Right here,” I point to the appropriate spot.

“Good. You can go now” comes the reply, as she walks into the room. “Good morning, sir. What happened?”

“I got drunk then tripped over some loose carpet in my house.”

I can’t resist. I stick my head behind the curtain.

“Told ya so.”

Things I said today

“I really like this crown molding. Do you think I could get your carpenter’s name and number later? Now, which hospital do you want to go to?”

“She really doesn’t have room to call anyone racist. There’s a framed picture of Huey Newton hanging on her wall.”

“I don’t know what it is. Call it atrial bigeminy. That should confuse them long enough.”

“No sir, I don’t want to see your testicles. I believe you.”

“I’m sorry you are having a bad day. Perhaps you shouldn’t have come to work?”

“Dude, we just hiked half a mile in 90 degree heat to get to you; you’re going to the hospital.”


It was a busy day.


Your hospital doesn’t ever answer your med radio. Like, ever. You say that I am supposed to call in by telephone, but the number you want me to call gives me voice prompts that tell me to do several things:

  • “If this is a medical emergency, hang up and call 911.” Lady, I AM 911. The emergency already happened.
  • “Press two for English. Oprima siete para Espanol.” I’ve been in this field since the Clinton Administration, and I have yet to find the need to call a report in anything other than English. I have used Spanish, German, French, and even Sign Language to communicate on the scene of a call, but have yet to meet a nurse that doesn’t have a rudimentary understanding of the English language.
  • “Press one for billing inquiries. Press two for radiology scheduling…” Seriously. The chances this bill is getting paid in the first place is slim-to-none, and I sure ain’t the one that’s gonna pay it. And I sure as heck don’t have time to be paying attention to your voice prompts.

Further complicating the matter here are three more things: First, I do not carry my cell phone with me on scene. It stays in the ambulance. My friends and family know what I do for a living, and they know how to get in touch with me without calling or texting. Any communication I do can wait until I am done taking care of my patient. Second, my company does not issue me a cellphone to carry with me. They do issue me a radio, and there is one in the ambulance. The same one that I try calling you on. Lastly; my employer requires me to call reports to a hospital on a recorded line. Interestingly enough, the 800mHz radio channels are recorded while my phone is not.

So I don’t call on the phone. But you know that. And you get mad every single time I show up with a patient who would probably do well to sit in triage until shift change. And every single time, I tell you the three points above. I don’t have a phone in the back. The company does not issue me a phone. My company policy is that all reports have to be recorded.

We should agree to just stop this rigamarole. For real. It gets tiring.

So when I show up all like “Surprise! A paramedic brought a sick person to your emergency room!” you get all mad and hussy and make me wait half an hour before you come into the room to take report. You aren’t fooling anyone. We all know the ER is more than half-empty, because we saw the lack of people in beds when we walked in. We know you aren’t busy, because we heard the conversation you were having with your coworkers. We heard all about those recipes you found on Pinterest, what your friend said about your boyfriend’s best friend’s girlfriend on Facebook. We heard about your new favorite TV show, New Girl.

We heard it all because your nurse’s station is literally behind the room you assigned this patient to.

But it’s okay. This guy is kinda cool. We chatted about his golf game while you thought you were upsetting me by making me wait. If you hadn’t been an uppity bitch, he wouldn’t have invited me to play golf with him.

In Augusta.

At freaking Augusta National. For free.

So, thank you. I appreciate your disdain for me. I enjoyed your punishment.