The Third Bullet

An EMT reckons with abbreviated phrases and abbreviated lives.

Colin Laurel

There are things you’ll learn from books full of acronyms, whose titles are themselves acronyms, during your training to become an EMT-P (Emergency Medical Technician-Paramedic) on an ambulance. These books will teach you how to be more adept at foreseeing everything that can go wrong inside a person. 

Take the PHTLS (Prehospital Trauma Life Support) text, for example, and the many traumatic ways that people can spill out, detach, become crumpled. You’ll learn that there are three ways you can die from a single explosion. Let’s say that each explosion has three separate phases. Let’s refer to these phases as “bullets.” 

The first bullet is invisible. It’s the wall of air rippling through your body. The hip-checking of all your hollow organs. Maybe this is when your lungs collapse, or maybe not—really, that can happen at any stage. Remember your first kiss? The way it took the breath out of you? This is probably nothing like that. 

The second bullet is more like an onslaught of bullets, more like a Gatling gun. It’s broken concrete and rusty nails and tabletops and saltshakers and shattered glass and every piece of flying debris you can imagine, all coming at you and trying to merge. By now you know that not everything that seeks comfort in you is a good thing. This is the point where you’re going to want to do that slo-mo limbo-yoga shit from The Matrix if you can. But this isn’t the movies. And you’re not that limber. If your heart’s ever going to be impaled by a chopstick, it’s probably now.

The third bullet (the last injury profile from an explosion) is whatever your body lands in, on, or through once you stop flying through the air.

You are the third bullet.

It would be best if this part happened in one of those parkour gyms with a foam pit and a bunch of strong dudes ready to unbury your ass. But chances are it will happen in a place with brick-bricks instead of foam bricks. Chances are it won’t ever happen, because this section of PHTLS is geared more toward the military, and you’re not part of the military. You’re just a guy on an ambulance. But you’ll have to know how to treat these kinds of wounds just in case. 

When you’re done with the PHTLS section, there’ll be another class to take ASAP.

You’ll get your PALS (Pediatric Advanced Life Support) certification to learn how to care for babies and kids in situations that babies and kids should never be in. You’ll need your ACLS (Advanced Cardiac…) for other matters of the heart. You’ll need more acronyms like PEEP and BP and JVD. You’ll monitor SpO2 levels in your CHF patients while holding their gaze and telling them that this CPAP mask will feel confining, but will save them if they can embrace it. You’ll pray it does save them, while preparing for the next step in the algorithm.

You’ll picture the worst-case scenario in every scenario, until you get enough real-life experience to see the bigger picture. That picture will expand and contract. It will trick you into complacence. You’ll count its respirations. You’ll feel for a pulse. Sometimes it’ll be there. Sometimes it’s your imagination—just the faint beating of hope still warm from the environment. 

Sometimes you’ll come home after a shift and feel like you’ve made a difference. Other times you’ll hug your kids tighter and worry more about everything that can happen to them.

One day you’ll be in the ambulance, waiting for the next call to drop, and will start making up acronyms on your own, because there are never enough secret ways to convey information faster. There’s no better way to reframe something than with fewer letters that mean much more. Plus, an acronym is a space saver. Just think of what’s written on almost every gravestone and under the tattooed faces on biceps. Think of the space saved there. You’ll recognize that acronym right away. If you take the periods and capitalization away from R.I.P., it’s a word. In that way it’s a little like a backronym. 

You’ll make up a backronym for F.A.I.T.H.—Falling and Ignoring the Heat—because you’re an old dog at this. You’ll make up one for C.O.M.P.A.R.T.M.E.N.T.A.L.I.Z.A.T.I.O.N., but it’s too long to remember.  

Because it might be a crime scene, you’ll confirm your first DOS suicide while he’s still hanging by his neck from a tree. It’s in the section of town where all the street names are inspired by Lewis Carroll. There’s Madhatter Lane. There’s Wonderland Park. There’s Alice Lane. The moon will be a giant, smiling Cheshire Cat in the sky while you attach the EKG leads to the man’s body, one at a time, from right to left, using the cooking mnemonic that corresponds to the colors of the electrode cords: salt, pepper, ketchup. You put salt and pepper by the shoulders. Ketchup goes by the left hip. 

You’ll keep thinking about how this guy’s knees are only inches above the ground. How his legs are folded behind him. You’ll know that all he had to do to stay alive was stand up. You’ll wonder why he didn’t.

When you get back to the rig your partner will say, “He really had to want it.” 

He’ll say, “You’ll get used to it after you’ve had enough of it.” 

He’ll say, “Hey, let’s grab something to eat. I’m hungry.”

You’ll stop using acronyms and backronyms and any other abbreviation on principle alone, because they all feel cheap—the bastardization of language, the poor man’s aggrandizing of wit, the elitism of tribe. You’ll always use full sentences when you text. You’ll question life—what it means and all—and then realize how ridiculous that is.

One day your partner will tell you that maybe it won’t be one thing, but the buildup of all these things—the chest pains and drunken traumas and fatal MVAs and dead babies—that end up emotionally weighing you down. He’ll say you won’t know until it happens, that it may be a run-of-the-mill call that finally breaks you. 

He’ll say, “Maybe it’s as simple as a kid waving at you from the sidewalk with a melting orange-cream Popsicle running down his hand.” 

And you’ll know that this sentence is more than hypothetical—it’s too specific. And that’ll make you wonder if this guy hasn’t been doing this for too long. If he shouldn’t get a car that needs a little TLC to work on, or more R&R in his free time, or an SSRI to make his outlook brighter. And the acronyms will be back, because really, they never left. You deal better with them. Shortening has its place. Abbreviation can be a virtue. 

One day we’ll be partners, you and I. Because everything changes. We’ve learned to expect the unexpected and we know that consistency is the mother of complacency, but mostly it’s because the company is short on paramedics. It’s our second shift together. We’ll be talking about music when a “Possible OD” call drops down the street. 

When we get there, there’s a fifteen-year-old female unresponsive and cyanotic, lying supine on the sofa. It’s morning. The apartment’s small. The lights are dim.

The girl’s mom is holding her daughter, saying, “I was just talking to her before making breakfast.”  

There’s the smell of eggs from the kitchen, heavy in the air. 

The girl’s mom says, “I think she was out all night with her friends.”   

You say, “We need to look at her,” as you gently pry the girl out of her mother’s arms. The mother stands a few feet away and watches. She sees everything. She should see everything. She’ll have to interpret what it all means later.

The girl’s eyes are open. Her pupils are fixed. Her gray T-shirt reads OMG in white, blocky letters across her chest. She’s apneic but still warm. Her extremities are flaccid. There’s vomit everywhere: in her hair, on the floor, sticking to her shirt, to the armrest. 

I drop the medic kit and airway bag as you take the girl on the sofa in your arms and place her on the floor between the TV and the coffee table. And she feels as light as H.O.P.E. as you put her down. You feel for a pulse and start CPR. With the second compression, you feel her sternum separate from her ribs. It’s a feeling you don’t forget.

I attach the defibrillator pads and say, “Stop.” 

You check for a pulse at the carotid, look at the monitor, and say, “PEA,” beginning compressions again. 

Her heart has electricity but isn’t beating (good circuitry, bad generator).

There’s the BVM.

The IV.

The ETT.

And even though this girl still isn’t breathing, she also isn’t R.I.P. 

She still has a C.H.A.N.C.E. 

But this mom’s not OK. And you and I are EMT-P’s flipping through the acronyms. And we are ourselves acronyms. And we’re silently praying to an unknown G.O.D. to intervene. But there is no ETA for miracles here. There is no longer any rhythm on the monitor. No QT intervals. No QRS complex. No track marks or drug paraphernalia. No place for Narcan in the ACLS algorithm—but we talk about pushing it anyway. We speak in grunts and abbreviations.

The girl’s mom says, “Speak English. What’s happening?”

And you know we need to be clear here. We have to remove the periods from the letters for the words to make any sense. We know that some things are shortened for convenience, but some things aren’t meant to be shortened. Ever. 

I look at you, with your mouth hanging open. And I wonder what words you will choose when there’s no right way to package them. 

I watch your jaw tighten as you look from the girl’s ashen face into her mom’s hazel eyes. You’re still doing chest compressions. Up and down. And this mother’s daughter has a tube down her trachea. And her unbeating heart is being externally manipulated by the heels of your hands. And there are EKG pads on her chest. And your lips part as you say, “We’re doing. Everything. We can, ma’am.” And you mean it. And her mom nods, and cries harder, and doesn’t believe you. And there is the smell of eggs from the kitchen still in the air. And your lips begin moving, but they are not speaking. They are only silently counting their way from one to thirty and starting over again. Not because they have to, but because they’ve been trained to, because there’s no way to make this easier. There’s no way to make this right. There’s a lump forming in your throat and rising to your eyes and clouding your vision. I know, because it’s happening to me. It’s happened to me. And now I’m the old guy. And you’re the newbie. And we’re in this together. We’ve always been in this together. And mostly we remember that. But sometimes we forget. 

On the ambulance ride to the hospital you administer another epi 1:10,000 bolus and an amp of sodium bicarb, and you blink back that lump in your throat, and swallow it down, and bury it somewhere inside. You don’t have time for an epitaph. 

At the ER, we transfer the girl from our stretcher onto the hospital bed and the nursing staff continues working the code. Until they don’t. Until they call it, and the doc has to tell the mother that her daughter is dead and there’s nothing they can do.

He says, “Dead.” 

He doesn’t say, “Passed on.” 

He doesn’t say, “Gone to a better place.”

The mother is given a chaplain to help her with the higher concepts. 

We put fresh sheets on our stretcher, put the stretcher back into the ambulance.

It’s not until we’re back in the cab of the rig that I think about that third bullet of an explosion. 

I think about all of us passing through this.

I think about the girl passing through this. 

I think about the girl’s mom passing through this. 

Our pagers go off for an MVC up on Farmington. We climb back into opposite sides of the rig. You turn the ignition. My mind automatically starts thinking about C-spine and TBIs, and OSS vs. backboards, and the entire anatomy of a car wreck. You hit the switch for the emergency overheads as we pull out of the ER bay. 

We both know that those lumps we’ve buried inside ourselves are growing. But it’s not something we can afford to let ourselves feel yet. 

Comments

3 comments have been posted.

Well Jason, that was superbly written. Thank you sir.

Tom | December 2017 |

Brilliant. Love your writing style. I’m working with our local to help build a peer support program, and this is why. Heard a new acronym the other day, ERES (Emergency Responder Exhaustion Syndrome). Thank you.

Darrek Mullins | December 2017 |

Jason, this is beautiful and shattering and elegant, all at the same time. So well done. And thank you.

Dacia | December 2017 |

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