A Year in EMS

When I left HashiCorp in May of 2022, I told my colleagues I was going to go be an EMT.

I had spent my 20s working remotely with long hours and the exciting stress of the company growing from the two founders and me to nearly 2000 employees when I left.

Remote work had always felt efficient, convenient, practical, a privilege. But sitting in the corner of the room alone in front of the machine was inherently isolating. Relationships with my colleagues scattered across North America and Europe had given me a broad perspective but kept my emotional output pointed at my computer monitor, not the sidewalks and streets right out the door of my apartment. Some are able to maintain both sets of relationships, but I was not.

I am not quite sure how I landed on getting a job on an ambulance. I was filled with philanthropic goals on the heels of Coronavirus and some feeling reminiscent of a post-9/11 "coming together". Within that, my instincts told me that I didn't understand the practical issues with healthcare, housing scarcity, addiction – all things I might get real exposure to in the back of an ambulance.

But I think that was more of an excuse and a story I told. Something was itching at me craving distraction, anonymity, stimulation. Work that I could get lost in.

So I enrolled and started a 4-week "accelerated" EMT certification course at UCLA a few months after I left my tech job. Having always been a bad student and an abysmal test taker, I found it challenging. I had to teach myself how to study and memorize for the first time, reminding me why I always avoided it in high school (my grades had reflected that).

In an EMT course, you learn language and workflows, focusing on preparing to arrive on a scene, arriving, evaluating, "treating", and transporting patients. This was a BLS program, my first acronym, referring to Basic Life Support, a.k.a attempting to keep someone alive by helping them breathe, performing chest compressions, and managing bleeds. It was akin to a very in-depth version of the CPR course you've likely taken, with some added vocational skills related to transport and reporting.

When I told my friends that 4 weeks was the length of time required to train to be an EMT, they were usually surprised, shocked, and then, as it dawned on them, concerned. They will be grateful to know that they likely – in their well-funded municipality or county – have multiple experienced paramedic responders with a two-year education, as well as a number of EMTs supporting them, all with many years of experience in total.

After I finished this program and passed an NREMT (which is the national standards / certification body) exam, I found a job with a private, for-profit EMS transport company that was contracted with LA County to respond to 911 calls alongside the LA County Fire Department. I loved the job, and my experiences, and saw a tremendous amount of humanity that I would not have had the privilege to see otherwise.

Below is a summary of those observations.

Someone's worst day

On one of my first shifts, my partner and I were paged for a cardiac arrest call. When we arrived, the fire department was already there. A man was in the last minutes of his mandated CPR and epinephrine cycles before all efforts to save him stopped and he was declared deceased. Lying on the floor, cold, body temperature dropping, his organs, systems, his life, shutting down.

Six of us were in the room responding to the call. Standing around someone after their final moments, as each round of CPR continued, whispering quietly. Checking watches. It was clear to the paramedic, and clear to me looking at his body language, that this man was gone. You could hear the chief in the other room speaking, and moments later, a choking, gasping scream from his wife learning that her husband had passed away. Sobbing from his children echoed through the house.

Back in the room, quiet giggling about the new EMT's bad haircut. Discussion of what's for lunch. Have you tried that new place? The rhythmic thunk-thunk-thunk-thunk-thunk of an automated chest compression device attached to the guy, lying on the floor. His skin, cold to the touch. Ham or turkey?

This, a call where someone lost their father, their husband, their grandfather, was one of many calls that day for those who responded. I realized then that everyone in the room had seen this scene many times before. Maybe even that day.

I was told that you would be present for the worst day of someone's year, or someone's life, every day, multiple times a day. You, naturally, would get used to this. Just another day for us, but for him: the end; for his family: the nightmare. The day still spoken about in quiet tones.

Intimacy

You're supposed to just walk right into someone's house. They called you – they have asked you to come in. So you walk up the steps, or the stairwell, or the walkway, and you knock and open the door at the same time. Usually someone greets you, waves you down, walks you in.

Inside is someone's home. They spend every day there. Their possessions, their pets. Half eaten take-out on the couch, sometimes spilt onto the floor. Windows darkened with sheets and a TV on low. An unresponsive person on the ground. The pager said it was hypoglycemia, low blood sugar. You're trying to lift their arm to get a blood pressure reading. A paramedic pulls up outside, you start getting nervous that you're doing something wrong. A dog is barking in your ear. It smells like urine. Your partner is asking their daughter what happened. How old is she? She's diabetic? How often does this happen?

Your hands are shaking; you've barely finished training. Family members stand over you. They wonder if you know what you're doing. You wonder if you know what you're doing. The paramedics come through the door, thank god.

Five minutes later you're picking up wrappers and bits of trash you all created. She's sitting on the couch, hazy. Her daughter is making her a sandwich. Someone's got an iPad in her face; Please sign this. You stand in their space, all of you, the firefighters with their heavy boots, on the carpet, creaking on floorboards. The dog has been moved to the other room, still barking through the hollow door. A sense of relief in the room. Friendly chatter with the family.

For that moment, those moments, you're in someone's life, their house, their most intimate space. It is special and strange – but somehow expected. You just walk right in.

Narcan

The tipping point into overdose pushes your breathing to a frighteningly slow pace. It will kill you. You lose consciousness, floating off, wherever you are. In the back of a car, on your couch. Someone, god willing, finds you.

In one case, you're in a truck in the middle of an intersection. Bystanders make phone calls, first responders arrive and have to try and help you breathe as you're wedged into the back seat of a car, too heavy to easily move. Multiple people are in the car now trying to reposition you. They just need to get air into your lungs.

Getting your body in the right place is incredibly hard because of how you fell asleep, how you slipped out of consciousness. Grunts and wheezes from the firefighters and EMTs trying to reposition you. Finally, you're getting some air. Your blood oxygenation creeps back into the 70s. You're still incredibly unresponsive, like a sleeping bag full of bricks. When you wake up in the back of the ambulance, you're telling the EMT in front of you that you just fell asleep – please don't tell my boss. You're totally fine. You don't know you were almost dead for a while.

The effectiveness of naloxone to counter an opiate overdose shocked me. It is truly a wonder drug, one that every family member, partner, housemate, friend of an opioid user should have. A few things about overdoses stood out – more often, the overdose calls I went on were for medical users of opiates, with prescriptions, having taken too many, incidentally or otherwise. Not the dark back alley. Often, they were quite upset with you for pulling them out of a high, which they call a rebound. You think you just saved their life, and here you are being screamed at, called the devil.

Firefighters are EMS responders

Within EMS there is significant controversy about fire departments moving into the medical field. Fire calls have gone down while medical calls have exploded. One firefighter I spoke to claimed that in part, departments seek out medical duties to justify their budgets, but often give lower quality care due to it being "outside of the job description". He said departments force low quality schooling and certification for firefighters who are pushed into medical care. Men and women who dreamed of active firefighting suddenly find themselves running grandma to the hospital and helping people off of the street for the night.

To wear a mask and go into a home, you will need to shave your beard, should you have one. So, if you want some facial hair, and can grow some, you'd don the mustache. Strong and fit from team workouts at the station, mustaches flaring, confidence blaring – you're attractive, self-possessed, ready for whatever you are called to do. Some false bravado sometimes, but real bravado others. At times, I encountered this as a jocular, boyish culture.

But then one of our EMTs had an off-duty accident. He passed away. I went with the firefighters I was working with, and my partner. The family had built a vigil next to the street corner he had passed on. We pulled up in our ambulances. Dozens of fire engines, in all directions, lights on. To hold vigil for him, and for his family. He had worked with them, just for a couple of years, and found his people.

I watched as his family prayed, and as fire captains passed out bouquets of flowers. A mass huddle of men and women in uniform surrounding the family. Laying flowers one at a time. His family spoke. His mother, his grandmother, seemed to swell with pride at their son's legacy, his mark, despite his death.

It was truly a brotherhood on that day, as cliche as it is to say – so evident in this young man's family, barely into his twenties, mourning, surrounded. I wept, standing there, hair on the back of my neck tall, proud and grateful to be in that group for the moment that I was.

Nutrition and Obesity

The job of the EMT contains a lot of report writing and a lot of lifting, with far less life-saving than you would hope when you sign up. Lifting of people, out of beds and onto gurneys, off the floor onto beds, off of gurneys and into hospital beds, out of chairs into other chairs, chairs with wheels and tracks, for the stairs. The most junior people in the group are doing the lifting. So I did a lot of the lifting.

You look at a lot of charts, and ask a lot of medical history questions, in the back of the ambulance. Obesity stood out, it seemed to compound other issues, health or otherwise. As simple as getting people physically in the right position for CPR, lifting them onto hospital beds, off of the ground. Good nutrition seems like an American problem – or a problem in the west in general. It never felt like it was an issue with the individual, but much more an issue with the proximity and almost requirement to consume extremely calorie-dense food. I certainly hadn't considered it would feel like the biggest health issue I would see, but it was.

It happened in the front of the ambulance, too. When you're with your partner, whom you don't know, and may not see again (as it was in my company, the way I wound up on shifts), you make small talk. The thing that was always easy to talk about was food. Especially fast food. Who has the best burger? Did you bring dinner or should we get a burrito? Where are we going for dinner?

I want to keep moving and stay moving until I'm old. I hope that I can select good food. I hope other people can too, that they can reach it and it's there for them. I worry if we can't.

Staying Alive

Everyone who's done CPR training in the US may know that Stayin' Alive, by the Bee Gees, is a popular method to get people to understand the pace and rhythm of proper chest compressions. We were taught early that "bystander CPR", or CPR that is started by someone near the victim after their cardiac issues begin (often, a family member), is instrumental in recovery from a "myocardial infarction", or heart attack.

In the densely populated areas of LA County, the private ambulance services have a minimum response time of 8 minutes and 59 seconds. We would "post" ambulances on street corners, parking lots, and small stations – if you're lucky – to try to meet this obligation. If one of the ambulances was called out, the dispatchers would move the rest of us, to maintain "coverage" of the area. Moving around all the time meant no opportunity to sleep. On busy 11 hour or 24 hour shifts, you may receive calls back-to-back, sometimes 8, or 12, or more.

This distance and coverage was to respond to true medical emergencies as rapidly as possible – heart attacks were one of those. You are very unlikely to receive care in less than 9 minutes. Fire departments could beat us to the scene by a couple minutes, police sometimes too. But that still leaves 5 or 6 minutes minimum from when 911 dispatched to arrival.

If your heart isn't working very well in getting blood to your brain, that is an achingly long time to wait. I struggled through the heart section of the class, but, if you learn anything, you learn oxygen needs to get to the brain and you risk everything if it doesn't.

Depending on the severity of the heart attack, the only thing saving your life is someone pushing oxygen to your brain for you. And if they've taken at least one CPR class, that seems like it'd increase your chances just a little bit – their instincts at least will be aimed in the right direction.

For cardiac arrest, or heart attack calls where CPR was performed by a bystander overwhelmingly stood out as more successful. Their friends, or family, saved their lives. You should go take a CPR course.

Hold my hand

Some calls were just about sitting there, looking someone in the eye, and listening. Nothing much else. They've just been driven to superficially cut themselves, or are deep in a panic attack, or are just lonely, tired, at the end. You sit in the back of the ambulance looking at them. Maybe their panic is so severe, so overwhelming, that they ask to hold your hand, grip it so tight it turns white. They look at you, sobbing, fearful. You feel useful just for being there, bearing witness, and giving a modicum of a shit while they struggle through that moment in their life.

I will forever respect anyone who will show up and provide that. It is so humane, and inspirational, and it forges an optimism in me to see it happen, time and time again, out of sight, in the back of the ambulance as it trundles along, bumping through the potholes of your city.

Thanks

Much like working in a kitchen, or in the front of house – in order to recognize and empathize with service industry jobs – everyone should have a brush with working in healthcare at some point in their life. I felt very lucky to quickly get to work with minimal education, and to be thrown into the intense, intimate, imperfect, disgusting, enthralling, and sweet world that is emergency medical services.

I will always admire and appreciate anyone who is willing to be first in the door, willing to take on responsibility for helping you on your worst day. I know so many of them will give you care, attention, and humanity. I saw it over, and over, and over again. I'm immensely grateful for being allowed to watch, and participate, if only briefly.