Right on Schedule

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It has been said that there are two rules in EMS; Rule number one, is that some of your patients will die. Rule number two, is that you can’t change rule number one.

Another pronouncement, this time authored by yours truly, is that; “Anything can happen, at any time, to anyone.”

That all sounds a bit morbid though.

On a (slightly) lighter note, I have begun to notice that some types of emergencies occur at particular times of the day. I have listed them below, and would point out that whilst the reason is clear for some, others are a complete mystery.


0100   Late night is the perfect time for a fight to break out between, well, whoever is still up.

0300   Very often Chest Pain (Heart Attack) will wake the patient up in the wee hours of the morning.

0500   This is undoubtedly an auspicious time for pregnant ladies to give birth in their homes.

0700   An unconscious patient at this time of day is normally an “X”, having died in his sleep.

0900   Hectic time of the morning and ripe unfortunately for a MVA – Car vs. Child.

1100   Construction sites are getting into the swing of things & someone is bound to get hurt, badly.

1300   Your average teenager will now faint, having walked in the heat, and not drunk all day.

1500   A social worker comes to visit an elderly patient & finds them ‘locked behind closed doors‘.

1700   Attempted suicide – been planning it all day and makes an effort – but fails miserably.

1900   The very young & very old are being fed supper – someone / somewhere might choke.

2100   Actually it’s rather quiet at 9pm.

2300   This is an apt time for parents to find their kids having either Febrile Convulsions, or Stridor.


Like I said, some of these are approximations, and others are dead on. (Mind the Pun).

And you’re probably saying, “That’s disgusting, how is he making light of such serious matters?”

Answer, I most certainly am not. I take what I do exceptionally seriously. But there has to be a respite from the depressing talk if we are to be able to continue to do what we do.

I denounce in the strongest terms EMTs who shmooze and joke around outside a failed CPR for example; and yes, it does happen. Not because they are bad people – they’re not. These guys are dedicated and hard working. It’s because having seen it a thousand and one times, slowly but surely, sensitivity wears thin.

Case Study: There was a particularly messy CPR recently; the lady was very skinny – the compressions had broken her ribs, which in turn punctured her lungs, causing blood to rise up the endotracheal tube and make an awful mess. She eventually died, and while the Doctor was filling the death certificate in the house, one of the other members of the team went downstairs to complete the other forms. He switched on the engine of the ambulance, sat in the front seat, rolled down the window, and popped in his favorite ‘top of the pops’ CD. The music was loud, the tempo spirited, and the bereaved family was on the balcony of the first floor apartment.

There was nothing fundamentally wrong with what he did. He couldn’t have been expected to bury his face in his hands and weep; he would be crying all day every day. By default, he had no other choice but to give the CPR his every effort – and once death was declared, go down and eat his favorite snack – or – listen to music.


He should have closed the window!

Please understand that 98% of the calls I respond to are by their very definition – Sad. And that’s the best case scenario.

Worst case scenario, I am despondent for hours afterwards, unable to get the image of the patient’s face out of my mind. (That’s why I try not to focus on the faces anymore.)

Even the small percentage of calls that are happy – births; are also often laden with stress and tension.

Bottom line:

Take the job seriously, but find time, and lots of it, to be happy, joke around, and seek humor in any rotten corner you can find it.

The Doula

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“Good Morning! #54 to your Ambulance please,” said the tired voice over the intercom.

Several things though – for starters it wasn’t the morning. 05:00 is in middle of the night. Secondly, the voice most certainly did not say ‘Good Morning’, nor did she say ‘please’. That was just me trying to make Control seem more human. They’re not. They are lean mean working machines, functioning under immense pressure for 8 hours at a time. It’s true that a shift can sometimes pass with only a handful of calls. It’s also equally probable that during a particularly fateful morning, the dispatcher can talk a distraught mother/father/child through a home birth and/or a CPR – sometimes in the span of a few minutes.

Furthermore ‘Control’ staff doesn’t have the luxury of (attempting to) sleep through a night shift like regular ambulance staff does. The three or so personnel in MDA main Jerusalem station stay up the whole night irrespective of the volume of calls. Less calls = more reruns, more calls = less reruns. You get the picture.

Bottom line; they get immense joy in waking us up to go out on a call.

Did I say ‘waking us up’. That’s not entirely accurate. Though when on standby we are technically allowed to sleep (night or day,) the reality is otherwise. Every room has a speaker, which manages to blare out incomprehensible blurbs every 18 minutes, keeping everyone in a unique limbo state between blissful sleep and stressed consciousness. Besides, you need to be in the ambulance within a minute of the dispatch, so;

Bottom line; no restful sleep on shifts – ever.

“J’M #54 – you are going to Ramot, on Urgent, for a paturient woman, 41 weeks, 3-minute contractions.”

Five am is a particularly auspicious time for Matern-a-Taxis and if you are lucky, a home birth. Why in the wee hours of the morning, you ask? I’m not entirely sure. I think it’s partly due to the night being a ‘scary and dangerous’ time, when people seem to have a difficult time differentiating between real and imagined emergencies. By 7am the day sheds light (pun intended) on the matter, and people often realize that things are not half as bad as they seemed before. But when the contractions are coming rapidly at 5am, people are quick to call an ambulance: sometimes not quick enough.

So we make it to the address in about 8 minutes, climb the stairs (an exceptionally pertinent fact), and knock on the door. A burly man opens up – promptly notices that we are a three man team, and promptly closes the door in my face. There was nothing, I repeat nothing, that could hold back the torrents of laughter that engulfed us. Yes we were overtired, yes we were called out in middle of the night to the middle of nowhere, and yes, he had just slammed the door in our faces.

“Why?” you ask. Well we (and you) were about to find out.

He called through the door and said “I am not, under any circumstances, having an all-male team delivering my wife”. Full-stop. “Please send somebody else.”

“But the baby’s coming,” we hear the distraught mother shriek in the background.

30 seconds of silence, followed by 30 seconds of muffled dispute.

The door opens again, and he angrily waves his hand towards the bedroom. I walk into the room to find a lady clearly in the pangs of birth, and her doula clearly in the pangs of, well, some sort of mysterious ritual. She had a waist-pack full of vials, which she quickly closed as we approached the duo.

I asked the usual questions; what number birth, whether the pregnancy was uneventful etc. and found out that all was normal and this was her first baby. “How many minutes apart are the contractions?” I asked the doula. She shrugged and said “3 or so.” I went over the facts in my mind, took another look at the mother-to-be, and decided we would try and make it to the hospital. Firstborns are almost never born at home. The process is just too long and the women too jumpy; so they generally get themselves to the hospital hours, or days, before the actual birth.

Remember those stairs I was telling you about. Now imagine this;

4 flights

230 pounds

3 minute contractions

Angry father

Peculiar doula


3 scrawny schleppers

The experience was like a bad dream, except much more painful on my biceps.

Two in the back and me in the front, we carried her down the endless stairs on our ambulance chair, and made it safe and sound to the ambulance, at 05:25.

We set out towards the hospital with Lights and Sirens, when all of a sudden…

I smelled…

No it wasn’t a burning smell…

It was eucalyptus, yes, unmistakably eucalyptus. And that’s not all. There was music as well. Amidst the din of my siren, was the sound of Beethoven’s 5th Symphony, blaring from…

You guessed it…

The Doula’s waistpack.

Turns out she had placed droplets of eucalyptus strategically all over the back of the ambulance and put on, in her words, “zee kalming muzikk” so that the whole saga would be more relaxing for us. Yes, not only more relaxing for her client, but also for me. How thoughtful. “We should take this lady on all our calls,” my colleague snickered from the back in English. “I zpeek Inglish yoo knowe” she retorted. Oops.

05:38 we reached our destination.

05:40 our patient was in the labor room.

05:43 the baby boy was in his mother’s arms.

05:44 he wanted to know what that awful smell was.

Miracle on Ethiopia

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It was a dark and stormy night… No seriously, it was a typical cool Jerusalem night and I was on one of my first nights shifts on a MDA ambulance. At about midnight we were called to Ethiopia Street, which (as the name doesn’t suggest) is located in the Jewish Ultra-Orthodox center of the city. Control informed us that there was “Danger to Human Life;” in other words the health of a patient behind locked doors was in question. In such situations, all three services are called; The BLUES – to give authorization to knock the door down, REDS – to knock the door down, and EMS – to treat whoever lies behind the door.

Barreling down the street on the way to the call, the first thing I did was phone my cousin Rafe. He lived nearby and I knew that he would be eager to see me in my new uniform tearing down the street with lights and sirens. As expected, he was waiting for us when we arrived. I jumped out of the ambulance with much glamor and finesse. I’m pretty sure I saw him roll his eyes. Jealous lad.

As usual, we were on location before police or fire. We waited. And waited. The police finally showed up and started investigating. The address was an old Ethiopian church, as the street name would suggest. The patient in question was a priest, a generally unwell man who hadn’t been seen for a while. His friend assumed he was in his room in a small outbuilding connected to the church. Problem: He wasn’t answering his phone.

The first hurdle we had to overcome was the towering wall surrounding the church, locked from the inside. The wall was soon scaled by a fireman who had suddenly turned up, out of the blue red. He opened it for the rest of us who were not quite so adept at climbing 9 foot tall gates. We surrounded the little room, also locked from the inside, and began yelling the priest’s name, but to no avail. One of the nuns who had been awoken by our banging and screaming came running anxiously towards us, her habit slightly askew. We explained the goings-on and soon the whole compound was in an uproar. A superfluity of nuns appeared out of nowhere; Prayers were said, candles lit, incense offered – and I was chatting with Rafe.

Eventually Father Habtamu was seen through one of the windows, lying motionless on his bed. Now that we knew for certain that he was inside there were two options. Either he was in grave danger, clinging to life or worse. Alternatively, he was in a very deep sleep.

Blues, Reds, EMS and Nuns, screamed his name; still no answer. By now everyone was getting genuinely nervous. I quickly ran back to the ambulance to get the defibrillator, preparing for the worst. In tandem with me was a young fireman running to his truck. As I exited with the AED, he exited with a large sharp disk, designed to cut through (almost) anything. We ran back to the room where the nuns now stood chanting and swaying, holding hands. With a loud whirr, the firemen began cutting the bars of the window.

Sparks flew, tears fell, and amidst the chaos, Father Habtamu lifted his head and said, in a voice choked with emotion,

“What’s goin’ on out there? Ya crazy man, why are ya cuttin’ my window?”

All the nuns began shouting “It’s a miracle! It’s a miracle! He’s alive!” and, as if on cue, burst out into joyous gospel. The priest opened his front door, well and healthy, and asked that everyone tone it down a bit – he was tired.

We left the singing, clapping nuns + one slightly befuddled priest, and headed back towards the station, hoping to get a decent night’s sleep.

But alas, it wasn’t to be …


From Denial to Hypochondria

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I have begun to notice that many of the patients I treat, can be broadly split into two categories; The ‘Hypochondriac’ and the ‘Patient in Denial’. Both of these conditions are not only unhealthy, but cause unnecessary confusion to medical practitioners. This is particularly true for first responders in the pre-hospital setting, because our access to diagnostic tools is limited. In EMS we rely heavily on signs + symptoms and the patients’ vitals, to make an approximate diagnosis and initiate treatment. If the patient is lying about his symptoms, it can throw us off the mark.

Behold – two fascinating examples of these extremes, on the same day.

The first call was in an apartment in a high rise building, in the center of town, with no parking in the immediate vicinity. None of this bothered me, because I easily maneuvered my motorcycle between traffic, and found a perfect ‘parking spot’ on the sidewalk, immediately outside. The call was for a 60 year old – male – ‘Weakness’. Calls that come in as ‘weakness’ are, more often than not, absolutely nothing, or at least not life threatening. For heaven’s sake, I feel weak after an afternoon out with the kids!

As I rode the elevator to the 7th floor, it occurred to me that I might be alone with the patient for a while; the ambulance didn’t stand a chance in the mid-afternoon traffic. I began to think of conversation topics, because once I confirmed that there was nothing wrong with him, I would have to sit and make small talk till my colleagues arrived.

‘Weakness’ is normally a straightforward BLS call, and so I approached the apartment ever so casually. An elderly lady with few teeth and a big smile opened the door, and ushered me into the room where her husband was lying on his bed.

I asked him how he was feeling.

“Leave me alone” he said in heavily accented Hebrew.

“And a good day to you too, dear Sir,” I replied – “What’s bothering you?”


I persisted in my questioning, and he eventually admitted that he felt slightly weak. His wife confessed that she had been the one to call the ambulance, ignoring her husband’s protestations. I gave him a quick once-over. He looked OK – good color, not sweating; this still appeared to be the run of the mill ‘weakness’. Then I felt for his radial pulse, found it, and started counting heartbeats.

Uh Oh.

His pulse was 28. I thought I had made a mistake so I tried again. His pulse was still 28.

A Normal pulse rate ranges from 60-100; 50 being borderline Bradycardia. 28 is significant bradycardia and life-threatening. It was a miracle he was conscious at all.

As I reached for my phone to request a NATAN, an ALS crew headed by a doctor walked through the door.

“How did you know?” I asked incredulously.

“Know what?” they responded in unison.

Turns out that although this call came in as a CAT B, the NATAN was the closest available ambulance, and protocol dictated that they had to respond. This patient was very lucky to have a full paramedic team and a doctor land unsuspectingly on his doorstep. He needed them to survive.

“Do you feel alright?” the Doc asked.

“I feel fine,” he insisted again.

He was, however, much closer to death than he could’ve imagined as the ECG subsequently showed. He was suffering from a third degree AV block, also known as complete heart block.

A heart block is a disease in the electrical system of the heart, and can cause lightheadedness, syncope, and if left untreated, death.

Before we rushed him out of the house, a line was started and defibrillator pads attached to his chest – just in case. A cardiac emergency response team was waiting at the hospital, and this man eventually had an artificial pacemaker implanted.

Just your regular ‘patient in denial’ claiming perfect health, while his life hung in the balance. At least heaven ordained that he get the proper care he so desperately needed in time.

As I was leaving the first scene, another call came in as “Severe chest pains, suspected MI” at an address 1km away. Expecting the worst, I did an immediate U-turn and headed to the call.

I arrived at the bungalow style house, walked inside, and found a man strewn across the couch in the lounge.

“Hi, I’m from EMS; what’s wrong?” I asked.

“I have pain in my chest,” he grimaced.

“Can you show me exactly where the pain is?”

“Right here,” he moaned, pointing to his belly button.

Things now took a drastic turn to the bizarre.

Further questioning revealed that (a) he was in no pain right now and (b) the last belly button attack had occurred the previous week! The reason he decided to call now, was, in his own words, “because it was convenient.” I held back laughter / disgust and took his vitals; all within normal ranges. Ultimately, he decided against going to the hospital and remained at home.

Just to recap for those of you out there doing a mental differential diagnosis. We have;

  1. Pain near the belly button
  2. From last week
  3. Normal vitals

If you guessed hypochondriac in the first degree, you’re spot on.