Withdrawal

As Ryan drove through the marina entrance, the parking area was dark and deserted, save for one car. The deck lights on Ecnalubma were the only source of light on the dock. He pulled up next to Dawn’s car as she turned her lights on and got out.

“Sorry I’m late,” he apologized. “We caught a late call. I left a voicemail message-”

“I almost got stuck driving out here tonight,” she cut him off. “I can’t understand why you don’t move the boat closer to town, or just sell it.” Her words were flat, dismissive. Emotionless.

“Why don’t you drive DUI Boy’s truck out here, then? He won’t be able to drive it for what, six months?” Ryan retorted just as nastily. “You sure can pick ‘em, I’ll give you that.”

Now why did I say that? Why is it that we can’t just talk any more?

“Why do we have to go through this again?” she asked tiredly. “You start the same argument every time. We can still be friends, Ryan.”

Yeah, you keep saying that, but I don’t want to be your friend. I want to be your husband.

“Sure we can!” he agreed, anger and bitterness creeping into his voice. “And how is DUI Boy enjoying my house? Bed comfortable enough for him? I know he loves my surround sound system. He told me how much he liked it, back before I figured out you were fucking him.”

“Watch your mouth!” she snapped, jerking her head toward the back seat. Caitlin had taken to repeating everything she heard lately.

“Fuck,” Caitlin said distinctly as Ryan pulled her from her car seat. “Fuck, fuck, fuck.”

“Lovely,” Dawn glared at him. “Any other choice words you want to teach our daughter?”

"Don’t say that, Caitlin,” Ryan chided sternly. “Daddy said a bad word.” Despite being the bravest and most strong-willed person he had ever met, his daughter was a very tenderhearted girl. One stern word from Ryan was enough to break her heart. Right on cue, her eyes misted over and her lower lip started to quiver.

“How was therapy?” Ryan asked, eager to find a safe subject.

“We need to work on her sidestepping, and weight shifts to her weak side,” Dawn sighed. “She used her left hand pretty well today.”

“I’m walkin’, Daddy!” Caitlin exclaimed proudly, holding up her arms for a hug. Both arms. Her left hand was almost open, not tightly fisted as it usually was.

“That’s great!” he said excitedly, hugging her tightly. “You’re a big girl! Pretty, too.”

“I’m not pretty,” she told him seriously. “I’m gorgeous.” Little stinker.

“Can you hold her for a minute while I go fetch the runabout?” Ryan asked Dawn. She rolled her eyes and sighed, but nodded and took Caitlin back. He got the gas can out of his truck, took off his boots and waded out to the dock. The water was already over his knees, and the skies were still heavy with rain clouds. Ecnalubma’s aluminum runabout had a couple of inches of water in it, and the motor refused to start without a struggle.

Ryan finally won the battle of wills with Evinrude and the motor roared unhappily to life. He untied the boat and backed it into the current, making a wide loop back into the basin and beaching the boat next to the parking lot. Dawn handed Caitlin to him and he slipped her life vest over her shoulders. She held up her arms and poked them through the armholes in the vest, grinning at her daddy. Not long ago, she held that left arm tucked against her chest, unable to move it, much less use it with any purpose.

“I got my Dora vest on!” she said happily. Caitlin loved Dora the Explorer. She would wear her vest inside the cabin if Ryan let her. She settled into her spot on the floor of the boat, wetting her pants in the process, but she could have cared less. Dawn handed across Caitlin’s suitcase and stood on the bank uncertainly, eyes misting. “Bye Mommy!” Caitlin waved.

“You want to come aboard?” Ryan asked quietly, meeting her eyes. “You don’t have to rush right home.

Please say yes. Just get in the boat and we’ll spend some time talking. We’ll figure things out, and you’ll realize that we’re better together than apart.

She hesitated for a long moment, and then stepped into the boat. Ryan tried to hide his elation as he motored back to his slip. Dawn gripped the side rails nervously, white-knuckled. She had always hated the runabout – too small for her. Ecnalubma was more of a floating house than a boat. Ryan motored slowly back to his slip, easing the bow of the runabout onto the sloping ramp behind his houseboat. Giving in to temptation, he gunned the motor, just a quick little twist of the throttle and a surge of power. Dawn’s eyes widened in surprise and fear, and she flashed him a dirty look.

“Goose it, Daddy!” Caitlin cackled gleefully. Ryan put on an innocent face and Dawn’s expression softened. She even cracked a little smile. Smiling broadly, Ryan gunned the motor again, fully grounding the boat on the ramp. Shaking her head and grinning, Dawn picked up Caitlin and stepped out onto the dock. He pulled the drain plug from the boat and followed her.

“I haven’t seen you smile like that in a long time,” he told her as he opened the cabin door, and her grin instantly faded. Ryan bustled about the cabin, stowing his gear bag and briefcase, taking Dawn’s coat, putting Caitlin’s suitcase in her room – anything to escape the uncomfortable silence. Dawn was still standing near the door, nervously shifting her weight from one foot to the other.

When Dawn was nervous, she always fiddled with her wedding ring, twirling it around and around on her finger. Her fingers were toying with that left ring finger now, unconsciously twirling a ring that was no longer there. The white band of pale skin where it used to be had even faded away. As if suddenly realizing what she was doing, she blushed and jammed her hands into her pockets. Ryan pretended not to notice.

“You want a beer?” he asked casually, opening the refrigerator. She hesitated, biting her lip, almost visibly making up her mind. “For Christ’s sake, will you relax?” Ryan exploded. “You act like we’re strangers. I just offered you a beer, that’s all. If I were trying to get in your pants, I’d offer you tequila. Remember the July Fourth party at Royce’s?” he reminded her with a lewd grin. And just like that, the tension was broken. She sighed, chuckled and walked past him, getting her own beer from the fridge.

She settled onto a barstool and twisted the top off, taking a long pull. “Which part?” Dawn chuckled. “Us in the pool house, or you having to pull over five times on the way home so I could puke? I’ve never been so hung over in all my life.” She shook her head ruefully.

Ryan couldn’t decide which was funnier – the fumbling, giggling quickie in the pool house, or watching Dawn match Royce Trenton shot for shot until he passed out and had to be put to bed. Never bet a redneck girl that she can't do something.

“I was so proud,” Ryan teased. “My wife; the nurse, paramedic and world-class power drinker. You were the redneck dream girl.”

“Some dream girl,” she snorted. “I puked my guts out half the night. You sat on the bathtub and held my hair out of the way, and handed me wet washcloths all night.”

“And I kept reminding you of the price of victory, and all you would say was, ‘Thash okay. I taught that lil’ shumbish a leshon,’ between retches.”

Dawn did a spit take, spewing beer across the room. “Well, I did teach the little sonofabitch a lesson!” she laughed.

“Sumbitch,” Caitlin said, quite distinctly. “Sumbitch, Mommy!” Dawn and Ryan stared at each other and dissolved into a fit of giggles. She put her beer on the counter and scooped Caitlin up, trying to fix a stern expression on her face.

“Caitlin, that’s a bad word,” Dawn admonished, unsuccessfully stifling a smile. Caitlin just grinned back, the spitting image of her Mommy at that age. “Go play in your room, stinker,” Dawn laughed, putting Caitlin on the floor and swatting her lightly on the rump.

“Nice to know I can still make you smile,” Ryan said, and instantly her smile faded.

Christ, what did I say now? Why is talking with her like walking a minefield?

“You always could make me smile,” she said quietly, sadly. “You just forgot how to do it yourself.” She pushed her half-finished beer across the counter and stood up. “I have to go,” she announced abruptly. “It’s dark and I still have that pig trail you call a road to navigate…” She turned and walked toward the door.

“Dawn,” he said softly, pleadingly. “Dawn. Come back and sit down, please.” She paused, her hand on the knob. Her shoulders were shaking. He walked across the room and stood behind her, wanting desperately to put his arms around her, but afraid to touch. He knew he couldn’t take it if she pulled away.

Ryan flashed back to the night they had first met. He had brought a cardiac arrest patient into a rural hospital Emergency Department, and Dawn had been the nurse on duty. She had taken over the code, running the resuscitation while the doctor stood back and took notes. “Damn, she thinks like a medic!” Ryan remembered thinking. “A good medic.” Two days later, Ryan had gone back and asked her out.

“What happened to us?” Ryan asked quietly. “You walked out on eight years of marriage without so much as a fight. You never once told me you were unhappy. It’s like one day you just woke up and decided you didn’t love me, and I don’t know why. I’m still the same person you married, Dawn.”

“No, you’re not,” she accused, turning to face him. Her eyes were red-rimmed, teary. “Not since your sister died. You still blame yourself. You act as if it doesn’t bother you, but you just quit. You went back to work the day after the funeral like nothing had happened.”

“I was okay with it,” he protested. “I hadn’t seen or talked to her in years.”

“Sure you were,” she snorted. “That’s why you got into a fistfight with your father at the funeral. Sell that shit to someone who didn’t live with you. You can joke around and pretend with the guys you work with, but I was there. You just withdrew into your own little world, and you wouldn’t let me in.” Her voice rose, and her eyes flashed with hurt. “How many nights did I go to sleep alone, begging you to come with me? How many nights did I cry myself to sleep, wishing you would just come to bed and hold me? Do you know how long I wondered if it was me, wondered why you didn’t want me any more? You cold-hearted bastard! You walked out five years ago!”

Now what do I say to that? She’s right. I withdraw, and I zone out. That’s my defense mechanism. If I didn’t have that, I’d have ended up just like Renee.

“I wasn’t shutting you out,” he protested, knowing it for the lie it was. “We had bills to pay, jobs. Obligations. When Caitlin was born, I was trying to be strong for you both. I thought that’s what I was doing.”

“Yeah, you were,” she said bitterly. “You had it all under control, just like you always do. But I didn’t need Hawkeye fucking Pierce. I needed you,” she spat, the anger like venom in her voice. “Goddamn you Ryan, you made me cry again. I swore I’d never let you make me cry again.” She bolted outside, slamming the door behind her.

Aaaahhh, shit. I loved you because I didn’t have to be Hawkeye Pierce around you. All I had to be was Ryan. We used to be so comfortable together, like the female mirror image of me. Now you're gone, and I feel like a ghost. Hollow, no reflection. I’m afraid I may never again be the person I was. It scares me.

You could laugh, and I automatically knew what you found so funny, without your having to say a word. I could have a bad day, and you were the only person I trusted to tell about it. We used to be able to know what the other was thinking, and now I fumble for what to say like a stranger on a first date.

After a few minutes, Ryan walked outside to find Dawn sitting on the bow of the runabout, still sobbing. He said nothing, just pushed the boat down the ramp and climbed in. There was nothing to say, anyway. They both knew he still loved her, and they both knew that wasn’t enough. He motored back across the river and into the basin in silence, with Dawn looking down at her feet and Ryan pretending to be too busy navigating the boat to notice.

God, why is it that I can conduct a patient interview with a stranger, but I can’t find the words to talk to my own wife?

Ryan beached the boat down the embankment from her car and waited silently for her to step out. Before she did, she stepped toward him and leaned over, kissing him on the cheek. Ryan could feel her tears on his cheek. He tried to kiss her on the lips, but she pulled away.

“Goodnight Ryan,” she whispered. “Happy birthday.”

Ryan said nothing, just quickly backed away from the shore and turned back into the basin so she wouldn’t see him crying. Back aboard Ecnalubma, he found Caitlin sitting on the floor next to his chair, eyes filled with tears and lower lip quivering. “Mommy crying,” she said accusingly.

“Yeah sweetie,” he sighed, scooping her up and hugging her. “Mommy crying.”

Black Cloud

Steve pulled into their posting location, across the river in West Oneida. "Control, 306," he radioed. "We're in Zone Six." The radio crackled an affirmative reply.

"So we just sit here until we get a call?" Mike asked. "We stay in the truck the whole shift?"

"That's why they call it Systemic Sado-Masochism," Steve offered. "There are hemorrhoids in your future, kid."

"It's called System Status Management," Ryan explained. "They post the trucks in areas of higher call volume rather than at fixed locations. Supposedly, it reduces response times."

"I can see where it would," Mike agreed.

"I said supposedly reduces response times," Ryan rolled his eyes. "It's statistical voodoo, Mike. Mental masturbation. They think they can predict call volume by doing a computer analysis of the last six months of calls, when any statistician will tell you that it takes many years worth of data to come up with any valid figures. But go tell that to the managers, kid. They'd rather wear out trucks and personnel, than admit their system is flawed. The emperor isn't wearing any clothes, and nobody is brave enough to point it out."

Steve chuckled and shook his head, taking another sip of coffee. He has heard this rant many times. As brilliant a paramedic as Ryan Pierce is, he has topped out at the level of shift supervisor, with little prospect of advancing further.

Must be nice to be filthy rich and brilliant, Steve mused about his partner. He intimidates the hell out of everyone without even trying, and says what he wants. It’s easy to be fearless when you’re loaded, I suppose. Nah, that’s not it. He had the reputation of being a maverick before his old man died, back when he worked at Collins Ambulance. They fired his ass, too, so I suppose there are some things that even Hawkeye Pierce can’t get away with saying. Not that I’m complaining, though. Being the partner of Hawkeye Pierce, The All-Seeing and All-Knowing, has its benefits.

Steve Hatfield chuckled to himself and stroked his mustache. Steve, an angular country boy, sported a bushy Fu Manchu mustache that extended nearly to his chin. Three times in the past five years, the suits from corporate had issued memos about excess facial hair, quoting company policy in clipped bureaucratese that “beards and goatees, or any other facial hair that interferes with the proper fit of a particle respirator, are expressly forbidden.”

Each time, Ryan had sent in copies of the company newsletter to the StatCare corporate headquarters, each with the photos of goatee-wearing employees from other regions prominently circled.

And every time the suits let the matter drop. That is, until the next time some human resources weenie gets a bug up his ass.

"Hey guys, look at this idiot," he said, nodding at a Toyota Camry speeding north on Harrison Boulevard toward the intersection in front of them.

"He thinks he's gonna beat the light," Ryan observed, gauging the distance with his eyes and coming up with only one conclusion. "He ain't gonna make it."

"Who isn't going to make it?" Mike asked, frustrated. "I can't see shit from -"

"BAM!" a sport utility vehicle hit the compact car directly on the driver's door. The forty-mile-an-hour impact slewed the smaller vehicle around, spinning it around in the road in a wet spray of rain and twisted metal. The SUV careened on through the intersection, out of control and headed directly for the parked ambulance.

"Ooooohhhh shit," Steve and Ryan observed in unison. The SUV continued across opposing lanes of traffic, jumped the curb and finally came to a stop wedged against a coin-operated air and water machine in the convenience store parking lot, barely ten feet away. Ryan and Steve stared at each other in disbelief, and Steve was the first to react.

"Control, 306." Steve radioed as Ryan bailed out of the rig. "We have a serious MVC at the intersection of West Twentieth and Harrison. Two vehicles, multiple patients. We need another unit and fire rescue for extrication ASAP."

By the time he reached the SUV, Ryan had opened the driver's door, leaning inside. Steve tried the passenger door, and it opened grudgingly under his hand, the twisted metal creaking and buckling as he tugged on it. The passenger sat dazed, still wearing her seatbelt, the lubricant powder from the airbags leaving a fine white dust on her blue dress.

Ryan held the driver's neck, asking, "Can you tell me where you hurt, sir? Any one place in particular?"

The man grimaced and tried to shake his head, "Nowhere, really. I think I'm just shaken up. It all just happened so fast!" As if just realizing that he was not alone in the car, he tried to turn to see the woman in the passenger seat. "Jen?" he asked frantically. "Are you okay, baby?"

"She's fine, sir." Steve answered. "Just try not to move, either one of you. Okay?"

Ryan popped his head out of the car, looking for Mike, who was unloading the stretcher from the ambulance. "Hey Mike!" he yelled, getting the student's attention. "Leave that, and just bring the jump bag and the cervical collars!"

Mike nodded and disappeared into the rig momentarily, reappearing from the rear doors lugging two gear bags. Breathlessly, he ran to the wrecked SUV. Before he could say anything, Ryan took a collar from the bag and ordered, "Stay here with Steve. Do whatever he tells you. I'm gonna go check the other driver. Get a collar on this guy before I go." Mike nodded nervously and leaned through the driver's window as Ryan, hands still on either side of the driver's head, leaned as far out of the way as he could.

"Okay, I got it!" Mike's voice said from inside the car.

Ryan withdrew his hands, clapped the kid on the back and started across the street to check the driver in the wrecked Camry. The young driver was unconscious, thrown all the way across the car by the impact. She lay crumpled in a heap against the passenger door. Ryan tried the unlocked passenger door and found it jammed from the impact. The driver's door and b-pillar were caved in at least a foot. Sirens heralded the approach of their backup as the police, fire department and the second-in ambulance converged on the scene.

"Whatcha got, Hawkeye?" Mark Perry, the medic from 305, asked as he pulled on a pair of latex gloves.

"Two moderates in the SUV, one critical in this one. You and Kenny help Steve with them, and send the EMT student over to me. Send the fire department guys over here right away."

Mark nodded briskly and trotted back over to the SUV. He clapped the EMT student on the shoulder and said something in his ear. Presently, Mike Granger came puffing up with a crew of firemen in tow.

"We need to get this passenger door open, folks. Mike, go get a rescue blanket from the rig." When he returned, Ryan handed him a cervical collar and the blanket and told him, "See if you can worm in there and get c-spine."

He broke the passenger rear window, swept the glass away, and gestured for the EMT student to climb inside. The firefighters fired up a portable generator and began attacking the passenger door with a pair of hydraulic spreaders.

"What do I do?" Mike asked, bewildered. "She's all crumpled up!"

"You reach over her as best you can, align her head, and check her breathing, that's what you do," Ryan answered. "Very few patients will be found lying supine on the floor, kid."

Mike obediently wormed between the two front bucket seats and grasped the woman's head. "She's breathing!" he reported excitedly.

"Great! Hold her still, and see if you can spread this blanket over the both of you." Ryan reached through the shattered rear window and assisted in positioning the blanket.

"I can't see anything under here!" Mike's muffled voices came from somewhere under the blanket.

"Head down, kid!" Ryan called. "I'm gonna break the glass." He placed the window punch against the lower front corner of the passenger door window and pressed until the glass shattered, collapsing in a thousand glittering pieces onto the rescue blanket. He swept most of the fragments away, leaned in and lifted a corner of the blanket. He placed his hands on the woman's head, over Mike's hands.

"I got her head. Now get the c-collar on her." Mike withdrew his hands and quickly wrapped the collar around the woman's neck. Creaking metal and several loud pops announced that the firefighters had succeeded in freeing the passenger door.

"Hold her still for a few more seconds, kid.”

"Door's off!" they announced unnecessarily. Ryan backed away as the firefighters pulled the ruined door away from the car and casually dropped it on the ground out of the way. The edge of the blanket lifted and Mike's face appeared, nervously looking around. Seeing that the door was off, he broke into a grin and straightened up, flipping the blanket back completely. Ryan knelt on the wet pavement next to the car and examined the woman. His practiced eyes swept over her thoroughly, hands confirming his visual impression.

Left femur and hip, left arm and possibly ribs on that side as well. Probably a head injury, too.

Ryan straightened up and motioned the firefighters in. "Time to get her out, fellas. Let's do it."

The firefighters wedged the foot of a spine board against the cushion of the passenger seat as Ryan directed the action.

"Mike, I got her head. You take her hips. We're gonna come out onto the board just a little bit, then we roll her onto her back. Then it's straight up the board. Got it?" Everyone grunted affirmatively. "Okay, here we go. One, two, three. " In one fluid, practiced move, the men slid the unconscious woman up the board.

Her breathing was ragged, tangled honey-blonde hair obscuring her face. Ryan gently swept her hair away and looked into her ashen face. The woman moaned unintelligibly. "Okay guys, let's all get out of the drizzle and into the rig," Ryan ordered.

The firefighters paused only long enough to secure the straps on the board, and then carried the injured woman to the ambulance. Ryan walked alongside, still holding the woman's head in alignment. He paused at the rear of the rig, nodded and motioned for Mike to take over. The EMT student assumed his position, freeing Ryan to slide an adhesive cervical immobilizer into position. Not surprisingly, the damned thing refused to adhere to the wet board.

Goddamned flimsy pieces of crap, Ryan fumed. If they fired one business development specialist, whatever that is, they could afford to buy some real head blocks.

Cursing, Ryan quickly rolled two towels and placed them on either side of her head. With two quick wraps of extra-strong tape, the woman's head was secured to the board. He climbed inside the rig, releasing the strap buckles on the ambulance cot and flipping them out of the way. The firefighters handed him the head of the spine board, and collectively they slid the woman onto the stretcher.

"I'll go get Steve," Mike offered, but Ryan shook his head.

"Would one of you guys go fetch my partner?" he asked the firefighters. "He's probably found a dry spot and is off playing grab-ass somewhere," Ryan winked.

The crew chuckled and slammed the rear doors. Ryan took his trauma shears and quickly shredded the woman's clothing, exposing her naked body. "Oxygen, please," he politely ordered. "Make it a non-rebreather."

His suspicions were confirmed with a thirty-second, but thorough examination. The woman had a crushed left leg and arm, and her pelvis was unstable. Most of the ribs on her left side were broken. Mike Granger obediently applied oxygen and then wrapped a blood pressure cuff around the woman's right arm. He pumped the cuff up, listened intently, and shook his head in frustration.
Welcome to the real world, Mr. Granger. Sounds a lot like a diesel engine, doesn't it?

"I can't hear anything but engine," he said.

"No big deal," Ryan shrugged. "I'm pretty sure I know what her blood pressure isn't and that's good enough for now. Now all we need is for Steve to get here..."

As if on cue, the driver's door opened and closed and Steve's face appeared in the window between the cab and the patient module. "Ready to go?" he asked.

"Light it up!" Ryan confirmed. "West Oneida ER. Call a report, too! Left femur and humerus, pelvis and left chest wall. Unresponsive and hypotensive."

Steve nodded and presently he pulled into traffic, sirens screaming down Harrison Avenue toward West Oneida Regional Medical Center, barely two minutes away.

Ryan gestured toward the cabinet next to Mike. "Grab an IV setup out of there, would you? Should be a bag of fluid with a drip set and blue tourniquet wrapped around it."

Mike Granger stood up and dug through the IV cabinet, nearly losing his balance as the ambulance changed lanes. Ryan chuckled and looked up significantly at the grab rails running the length of the ceiling. Embarrassed, Mike reclaimed his seat as Ryan took the IV setup from him.

"Watch me as I do this, okay? That way you'll know how the next time I need it." He quickly spiked the bag and flushed the air from the tubing, tossing the bag onto the spine board between the woman's legs.

"Auscultate her chest and tell me what you hear," he ordered as he deftly inserted a 16-gauge IV catheter into the woman's left arm, taping it securely with three wraps of two-inch tape.
The Ryan Pierce gorilla wrap. It's ugly, but strong as hell.

Mike obediently listened to the woman's chest with the stethoscope, eyes screwed shut in concentration. "I think the sounds are decreased on the left," he announced.

"Think, or know?" Ryan pressed with a hard look. "Could you hear anything at all?"

"Definitely decreased on the left," Mike said decisively. "I can't tell much about what I'm hearing, but she doesn't have much of anything in the way of breath sounds on the left side. Just some funny clicking noises."

"Those are broken ribs you're hearing," Ryan grunted as he felt the ambulance turn sharply to the right, then lurch to a stop. He looked out the rear window. "We're here."

Ryan stood up as Steve backed the ambulance into the nearest open bay, bringing the ambulance to an abrupt stop. Mike Granger nearly lost his footing a second time. Ryan smiled tolerantly. "Mr. Granger, if you must stand up in a moving ambulance, it helps to hold on to something. That's what all those shiny chrome rails are for."

Before Mike could frame a suitable retort, Steve Hatfield opened the rear doors. "Trauma Room Three," he announced as he unlatches the cot. "They're waiting on us." Ryan disconnected the oxygen mask, handing the tubing to his partner. Steve strapped a portable oxygen cylinder next to the woman's undamaged right leg and reconnected the oxygen tubing. Ryan held the IV bag at shoulder level and adjusted the flow to wide open as they rolled the cot into the ER.

Dr. Tanya Boyer was waiting in the hall outside the door to Trauma Three. She greeted them with a rueful grin and a shake of the head. "It's too damned early in the shift to start with this, guys."

"You know you're happy to see us," Ryan retorted with a wide smile, then turned serious. "We got an unrestrained driver of a compact car, T-boned right in front of us at maybe forty miles an hour. Caved in the driver's side maybe sixteen, eighteen inches. She's got a fractured femur, humerus, and ribs on that side. Pelvis is unstable and decreased breath sounds on the left." Steve and Mike quickly moved the woman onto the ER bed.

Dr. Boyer frowned and listened to the woman's chest. She flashed a penlight into the woman's eyes. "Conscious at any point?"

"Nope."

"Gimme that IV, Hawkeye," a nurse asked, reaching for the bag. "That's a sixteen in there," Ryan informed her with a wicked grin as he handed the bag to her. "Just in case you couldn't tell through all the tape." The nurse rolled her eyes.

Ryan turned to Dr. Boyer. "We're outta here, Doc. And by the way, 305 is probably only a few minutes behind us with two others from the other car. Neither of them near as bad as she is, though."

"Out. Don't come back." Tanya Boyer pointed to the door, feigning anger.

Chuckling, Steve and Ryan rolled the empty cot outside and began readying the rig for the next call.

******

Approaching sirens heralded the arrival of Mark Perry and Kenny Hadden on 305, and presently the ambulance arrived, backing into the slot next to 306. Ryan opened the rear doors to find Mark holding an IV bag of saline dripping slowly into the man strapped to the cot. "Had a little extra time while Kenny and the firefighters were extricating the woman," he grinned.

Ryan unloaded the cot and Mark followed it out of the rig. "Go ahead with him," he said. "Steve and I will get your other patient." Ryan loaded his stretcher into Mark's rig as Steve climbed into the back.

"How ya doing, ma'am?" Steve grinned down at the woman. "Long time, no see." She smiled weakly up at him. "We're gonna move you over to this other stretcher and bring you inside. Just fold your arms across your chest and hold still, okay? And don't worry, we only drop people on Thursdays," he said, deadpan.

"But today is Thursday," she wailed, half-crying, half-laughing as they placed the spine board on the cot.

"Really?" Ryan asked, feigning astonishment. "We're doing good for a Thursday, then." The woman chuckled as they rolled her into the ER. Ten minutes later, Ryan had completed his run ticket and put the unit back in service.

"Response time was zero minutes. Thirteen minutes on scene, three minutes to the hospital, back in service at oh-eight-ten," Steve announced, reading the times off his pager.

"Not bad," Ryan judged, "considering we had to do an extrication."

"But still over the Platinum Ten Minutes," Mike Granger pointed out. Ryan sighed and rolled his eyes in exasperation.

"Now you've done it, kid," Steve Hatfield grinned. "Professor Hawkeye will be on his soapbox for the next ten minutes."

"Are you aware, Mr. Granger, that there is absolutely no scientific data to support the concept of the Golden Hour?" he asked. "Or for that matter, the concept of a scene time of less than the 'Platinum Ten Minutes', as you so quaintly put it?"

"But in EMT class, we were - "

"The Golden Hour was an idea sketched out on a cocktail napkin in a hotel bar at an American College of Surgeons conference, by none other than R. Adams Cowley," Ryan interrupted. "They were looking for a PR tool to demonstrate the wisdom of getting a trauma patient to surgical intervention as quickly as possible. While it seems intuitively obvious that the quicker a critical trauma patient gets to hot lights and cold steel, the better the outcome, there are no scientific studies that indicate surgery within sixty minutes is the optimum time frame."

Steve groaned and quietly banged his head against the window glass as Ryan warmed to his subject.

This is why people think he’s arrogant. The bastard never forgets a fact, and wonders why everybody can’t do it.

"Furthermore, people seem to think that a ten minute scene time is the best for every patient, including medical calls," Ryan lectured. "The managers and bean counters use it as an excuse to get a unit back into service as quickly as possible, but what it really does is promote shoddy assessments and poor care. Sometimes Mike, faster is not better."

"Who was R. Adams Cowley?" Mike wondered. Steve whimpered aloud and closed his eyes.

"'Who was R. Adams Cowley'?" Ryan parroted incredulously. "What the hell did they teach you in your class? He was the founder of the Shock Trauma Center in Baltimore, Maryland. He was only a true pioneer and a giant in our profession."

"So he was a paramedic?" Mike wanted to know. Steve sunk lower into his seat and started massaging his temples.

"A paramedic? No, he was not a paramedic. He was a surgeon!" Ryan spluttered. "For pity's sake, do you know none of the history of our profession? Do you know who Johnny and Roy were? Frank Pantridge? Have you never gotten drunk and watched Mother, Juggs and Speed?"

Steve leaned forward, turned the radio up full blast and looked pointedly at Ryan. Catching the hint, Ryan stopped his tirade, turned back around in his seat and folded his arms across his chest. Steve looked back and fixed the EMT student with a withering glance. "You get him wound up again, and I'm kicking your ass, kid."

**********

"Let's say a sweet little old lady has passed out," Ryan hypothesized. "You arrive on scene, and you find her on her back in the bed, covers pulled to her chin. She's awake now, but says she hasn't felt well in a couple of days. She's been weak and tired, and has thrown up several times. What do you want to do?"

With no other calls all morning, he had been relentlessly quizzing the EMT student for the past three hours. They were parked near the Riverwalk in Oneida, watching the rising waters lap at the seawall.

"Well, I'd want to get some vital signs," Mike mused. "Gather up her medications and stuff, too."
"Her blood pressure is 108/60 and her heart rate is 88. She's breathing 18 times a minute. What else do you want to do?" Ryan pressed.

"Uh, I guess I'd want to, you know, find out what's been going on with her. Why she passed out, has it ever happened to her before, that sort of thing? I'd ask her about her medical history, medications, allergies and stuff."

"She's allergic to penicillin, and she takes medicines for high blood pressure and high cholesterol, and OTC painkillers for arthritis."

"OTC?" Mike asked, confused.

"Over-the-counter, Mike," Steve explained sleepily. "You know, Tylenol, Motrin and stuff like that." He sat slumped in the driver's seat with his eyes closed, using a folded sheet as a pillow.

"So what's wrong with her?" Ryan continued.

"Well, her vital signs are fine," Mike stalled for time. "What's her oxygen saturation?" Steve took his improvised pillow and hurled it violently over his right shoulder at Mike's head.

"Why does that matter?" Ryan asked with an evil grin.

"Well if it was low, I'd give her oxygen," Mike answered. Steve groaned.

"So if the pulse oximeter reading was 98% but the patient was wheezing and struggling for air, you wouldn't give them oxygen? What if they were breathing fine, with a saturation of 86%? What then?" he pursued.

Without opening his eyes, Steve reached out and punched Ryan hard in the left arm, then picked up a soda bottle and brandished it at Mike like a club.

Mike shrank away and answered cautiously, "I guess I'd put oxygen on them if I thought they needed it, regardless of what the pulse oximeter says." Steve smiled peacefully and put down the bottle.

Ryan rolled his eyes and grinned. "And what else would you do for the lady? What will you tell the ER doc when you get her to the hospital?"

"I have no fucking idea," Mike blurted, exasperated. "I'd give her a ride, and tell them 'sick lady' when I get to the hospital." Steve laughed out loud.

"More assessment and history," Ryan advised patiently. “You want to know what she was doing when she passed out. How much has she eaten or drank for the past few days? What did the vomit look like? Has she had diarrhea? What if I told you that when you sit her up to move her to the stretcher, she gets dizzy and her heart rate shoots up to 110? Ever heard of taking orthostatic vital signs?"

Mike shook his head.

"Take blood pressure and pulse first while they're lying down. Then take them again when they sit up, and when they stand. If the blood pressure drops, or the heart rate shoots up twenty points or more - "

"It means they're dehydrated, kid," Steve interrupted sleepily. "Or suffering from some kind of blood loss." He sat up in his seat and yawned, rubbing his eyes sleepily.

"So what do you do?" Ryan wanted to know.

"If I'm out in the sticks, I'd call for a paramedic to meet me en route," Mike answered. "If I'm in the city, I'd probably just give her a ride and tell them 'sick lady' when I get to the hospital," he grinned at Steve's reflection in the rear view mirror. Steve winked back.

"Both you guys are hopeless," Ryan chuckled, shaking his head. He grabbed the portable radio off the floor between the seats. "I'm gonna go stretch my legs," he said as he climbed out of the cab, groaning and massaging his lower back.

"He thinks I'm an idiot," Mike said quietly.

"Nah, he's just demanding," Steve assured him. "They teach you to memorize things and use the toys in EMT school, Mike. He wants you to use your head and think about what you're doing. He wants you to understand why you're doing something."

"All the guys in my class are scared shitless of him," Mike observed, "and still my instructor says he's the only medic he'll let precept his students."

Steve chuckled knowingly. "That's understandable. He taught your instructor ten years ago," Steve explained. "Everybody worships their EMT instructors - the good ones, at least."

"Is he that good?" Mike wondered. "Everybody talks about him like he's Supermedic."

"The best I've seen," Steve confirmed. "But he fucks up now and then like anyone else. Most people are too intimidated to call him on it. Except me, of course," he concluded with a nasty grin.

"Does he get pissed at you?"

"Nah, he gets pissed at himself," Steve explained, "but he knows I've got his back. He's taught me a lot, so when I pick up something he missed, he doesn't get his feathers ruffled about it. He's just glad I caught it, because partners are supposed to back each other up. Sometimes it seems like Ryan is thinking two or three steps ahead of everyone else. That's his gift. He sees everything in slow motion, when the rest of us have a hard time keeping up. Problem is, sometimes he thinks everybody can do that."

"Is it true he's rich?" Mike wanted to know. "I hear he inherited a load of cash from his parents."
"Jesus, what do you guys do all day in your classes? Sit around and gossip?" Steve snorted in disgust. "Yeah, he's rich. I have no idea how much, but he damned sure doesn't have to work. Ryan didn't get along with his parents. Hadn't had any contact with them for years before they died. Ryan doesn't talk about it."

He took a sip from his water bottle and paused, obviously contemplating whether to say more. He sighed heavily. "Everybody says he's Supermedic, right? That he's got ice water in his veins?"

Mike nodded, leaning forward.

"July seventeenth, five years ago. I'm working with Ryan; we get a call to an overdose. Some junkie takes too big a hit, and the chick that lives in the same flophouse calls the cops, right? I'd been working with Ryan maybe six months." Steve closed his eyes and shook his head.

"Anyway, we get cleared to come in to the scene, and there's this chick on the floor, needle still in her arm. She’s soaking wet from where her roomie poured water on her – junkies think that wakes ‘em up, kid – and she’s got vomit all over the front of her shirt. Anyway, she’s laying there dead as Elvis. Ryan takes one look at her, tells me 'suction, right now', and starts working the code. So I stick a suction catheter in her mouth and start pulling up last night’s Taco Bell or whatever the hell it was that she ate, while he gets the cops doing CPR. There’s enough puke there that she had to have aspirated a lot of it. Ryan butts me out of the way, tells me 'cardiac monitor', and gets a tube in about ten seconds. By the time I get the monitor hooked up, he's got an IV running WFO..."

"Wait a minute," Mike interrupted. "What does WFO mean?"

"Wide Fucking Open," Steve explained. "Anyway, my point is, he was smooth. Fast, never seemed to hurry, never raised his voice. The Ice Man. I'm thinking this chick is gone – she was asystolic, totally flat line - but he starts with the fluids, epi and atropine, and we boogie with her to St. Matthew’s. By the time we get her to the ER, she's got a rhythm and a pulse. We drop her off and give report, and the ER unit clerk asks if we know her name. Ryan goes, 'Renee Pierce. Date of birth is October 26, 1968. No known allergies, history of depression and drug addiction'. The unit clerk, kinda half-assed joking, asked if she was a relative. Ryan says, 'yeah, she's my twin sister' and walks out of the room."

"Holy shit, his sister?" Mike asked wonderingly, admiringly. "And he never freaked out? Wow."

"Never freaked out? No, I wouldn't say that." Steve shook his head, opening his eyes and looking sadly at the EMT student until Mike took his meaning. "His old man came and signed the DNR papers the next day, but Ryan had to know she’d never come back. She was just down too long. Anyway, none of us were invited to the funeral. Just a small family affair, his wife told us, so we just sent flowers. The next day, he was back at work, same old Ryan."

"Were his parents alive then?" Mike asked.

"Yeah, his dad was. The plane crash didn't happen until a couple of years later. You know who his old man was, right?"

"Yeah, the cardiologist." Mike nodded. "They lived in that big house on River Road."

"Well, his Dad was a Big Man around here. His mother made a ton of money in real estate, too. I asked Ryan once about his parents. He told me that he had left home at eighteen and worked his way through EMT school. He didn't care for his old man, that much was plain. He doesn't talk about his family at all," Steve warned, "so don't even ask."

********

Ryan Pierce walked along the seawall, watching the rising floodwaters and pretending he didn't know they were talking about him.

Right about now, the kid is grilling Steve about me, and Steve is telling him The Legend of Ryan Pierce.

It was one of those war stories that grew with every telling. Everyone knew Ryan by reputation back when he worked for Collins Ambulance, but he was still the new guy at StatCare, yet to prove himself. Like so many calls, Ryan didn’t remember much of the details. He did what he always did - lost himself in the task at hand. He had a resuscitation to manage. Truth be told, had it been anyone besides Renee, he wouldn't have even worked it. But Ryan Pierce had been paying the psychic price for walking away from his sister since he was eighteen years old, and something in him saw it as penance for leaving her behind.

Steve Hatfield had found Ryan outside in the rig after the call, curled into a ball on the squad bench, sobbing and calling his sister's name. He just quietly shut the doors and drove back to the station. The supervisor had wanted to butt in, get involved, do something; Steve had convinced him, not easily, to simply call Ryan’s wife and tell her what had happened.

Dawn was waiting outside when Steve drove up to the apartment. Eyes red-rimmed, clutching a bathrobe around her, she had asked what happened, and Steve numbly gave her the details. Dawn Pierce had taken about five seconds to get over the shock, and then she had tenderly put her arm around her husband and walked him inside.

Steve had stood silently watching as Dawn walked Ryan up the stairs, wishing he knew what to do. He tried to reach out to Ryan after the funeral, tried to tell him how sorry he was, but Ryan had brushed him off. He couldn't talk about it. Still can't. Steve just let it ride, but he was worried about his partner. He had told The Legend many times since, but he had never once told a soul about what went down after the call. Steve Hatfield was one of the good guys.

"If the water comes up much more, we'll be evacuating Azalea Manor again," Ryan sighed as he climbed back into the rig, "and you remember what a bitch that was last time." He looked suspiciously at his partner. "Did I interrupt something? Want me to leave so you can keep talking about me?"

"I was just telling Mike a few Hawkeye Pierce war stories, that's all," Steve replied with an evil grin. "You know, giving the kid a glimpse of the man behind the legend."

"Fuck you," Ryan retorted, fastening his seatbelt. He turned in his seat to look at Mike. "You know the difference between a fairy tale and a war story, right?"

"No."

"A fairy tale begins with 'once upon a time', and war stories always begin with 'no shit, we had this call once'. Other than that, they're pretty much the same."

********

"Control to 306," the radio crackled "Cardiac arrest at Azalea Manor, room B19."

"306 en route," Steve groaned as Ryan engaged the lights and siren. "You're a fucking black cloud," he said to Mike, who was kneeling in the passageway between the patient module and the cab.

The kid couldn't hide his excitement. Steve was ragging him, but the crew of 306 had actually had a pretty light day. Aside from the wreck that morning and a few uneventful transfers, they had done nothing but drive from one posting location to another all day. The latest call should carry them until right before shift change, so Ryan was in no mood to complain.

"Why don't you throw the cardiac monitor, jump bag and oxygen tank on the stretcher, Black Cloud?" Ryan requested politely. "If you'll be so good as to spike a bag of saline as well, Steve may even let you do CPR. Isn't that right, Steve?"

"As far as I'm concerned, he can do it all," Steve agreed. "I'll just fetch and tote equipment. Less work for me." Mike looked excited at the prospect, the poor unsuspecting kid.

"Portable suction unit too, Mike," he called out as they pulled up to Azalea Manor. "Might as well bring it all."

They pushed the loaded cot inside, turning right past the nurse's station down B Hall, navigating around the wheelchairs and linen carts parked in the corridor. At the far end of the hall, an aide beckoned frantically. They parked the stretcher outside the door and pushed their way into the crowded room. An older gray-haired nurse knelt on the bed near the window, doing a half-hearted attempt at CPR on a frail black woman. The woman's head and neck were an ugly, mottled purple mask.

"The aide came in here with her dinner tray and found her barely breathing. We watched her take her last breath maybe five minutes ago," the nurse told Ryan as she straightened and massaged her lower back, groaning.

Judging from the patient bouncing up and down on the air mattress and the distended abdomen, what you were doing could not be described as effective CPR.

"Been doing CPR the whole time?" he inquired politely. She just nodded, out of breath. Ryan checked for a pulse as Steve began clearing the tray tables, motorized wheelchairs and oxygen generators out of the way. Finding none, he motioned for Mike to take over CPR. Steve placed the defibrillator on the floor beside the bed, and Ryan quickly placed the electrodes on the woman's chest.

The screen was a mass of motion artifact as Mike bounced the woman up and down on the bed just as ineffectively as the nurse had done.

"Stop CPR for a second, Mike," he ordered. The rhythm settled into a long, unbroken line of asystole. Ryan turned to the aide as he opened the jump bag. "Would you go fetch your CPR board and her chart, please?" The aide just stared at him blankly. “CPR board, Ma’am?” he asked, pantomiming with his hands. “Big orange plastic thing? Looks like a boogie board with a divot scooped out of it?” Ryan asked hopefully. Recognition dawning on her face, the aide wheeled and waddled down the hallway as fast as her stumpy little legs could carry her.

Chuckling, Steve handed him the bag mask resuscitator and opened the airway kit. Ryan tilted the woman's head back and delivered a couple of quick breaths.

"She's asystolic, Steve," he reported, "and it looks like we've got a lot of gastric distension here." Steve nodded, laying the laryngoscope and an endotracheal tube on the bed next to the woman's head. Ryan delivered several more breaths and noticed the aide standing meekly in the doorway, holding the CPR board and the woman's chart.

Don't just stand there with your thumb up your ass, sweetheart. I didn't send you for the board because I thought you needed the exercise. It would be nice if we finally got some effective compressions done on this lady, don't you think?

He smiled reassuringly at the aide and motioned her into the room. Mike took the CPR board from her and slid it under the old woman's shoulders as Ryan inserted the laryngoscope into her mouth. Her vocal cords winked at him from behind a thin veil of clear mucus. He sank the tube and inflated the cuff, quickly cinching it into place with a tube restraint. A quick check with a stethoscope and a few squeezes of the bag told him that the tube was properly placed, even though the capnograph tracing picked up virtually no exhaled CO2.

Steve was kneeling beside the bed, busily searching for a decent vein as Ryan turned to the nurse. "What kind of medical history does she have?" he asked as he ventilated the woman. "Any idea what might have caused her to arrest?"

Other than being a hundred years old and eating nursing home food, that is?

The nurse just stared at him blankly. He smiled at her and looked pointedly at the chart lying on the tray table. Steve cursed under his breath as he dug around in the bend of the woman's elbow with an 18-gauge catheter. The nurse snapped out of her trance and flipped open the chart. She riffled through several pages, and visibly brightened as she found what she was searching for.

"Says here she has a history of advanced Alzheimer's, hypertension, congestive heart failure, atrial fibrillation, emphysema, hypothyroidism, chronic renal insufficiency, and diabetes," the nurse announced triumphantly.

"Jesus Christ!" Mike blurted, "and we're coding this woman?"

You took the words right out of my mouth, kid.

"I can't find a vein," Steve interrupted in frustration. "She's got nothing I can see."

"Gimme a catheter," Ryan told him with a grin. "She's got enough jugular venous distension that I can dart one from across the room." Steve handed him a catheter and took over ventilations while Ryan made the stick.

"Want me to stop compressions while you do that?" Mike asked dubiously, watching Ryan poised near the vein with a sharp needle. He shook his head as he advanced the catheter.

Stop compressions while I stick? You are talking to the legendary Hawkeye Pierce, my naive little EMT student. For me, the difficult things are easy, and the impossible things merely difficult.

Ryan opened the IV to flow wide open and held out his hand for the first round of drugs. Steve handed him a round of epinephrine and atropine with one hand, while bagging with the other.

"Epi and atropine on board," Ryan announced as he administers the meds. "Let's get her ready to transport." He beckoned the aide closer to the bed and tapped Steve on the shoulder. "Take over ventilations for him for a little bit, Ma'am."

Steve handed her the bag and stood up. Despite the past couple of minutes of effective ventilations, the woman's color had not improved. In fact, the purple death mask was now creeping down over her shoulders.

"Any recent trauma?" he asked as they lowered the stretcher.

The aide looked up. "She rolled out of bed and hurt her hip two days ago. We sent her for x-rays, but it wasn't broken," she told Ryan. "Do you think that fall could have something to do with it?"

Ryan shrugged as he disconnected the bag mask. "Maybe. No real way to tell." They grabbed a handful of bed sheet and Ryan motioned for Mike and the nurse to do the same. "Okay everybody, on three. One, two, three." They quickly slid the woman onto the stretcher and Steve began to buckle the straps as Ryan reconnected the bag and ventilates. "Check breath sounds again for me, Steve."

"You're still in," he answered, nodding in affirmation as he auscultated the woman's bony chest.
"Okay Mike, resume CPR and let's go."

Mike complied, standing on the stretcher's undercarriage as he rhythmically compressed the woman's chest. Steve slung the jump bag over his shoulder and piled the rest of the equipment on the stretcher at the woman's feet. They pushed the stretcher down the hall toward the waiting ambulance, pausing only briefly at the nurse's station to drop off the chart and pick up the paperwork from the unit clerk. Ryan briefly considered telling Mike to get off the stretcher while they pushed, but decided against it.

What the risk managers don't know won't hurt them. Besides, the kid has probably been itching for the chance to go code surfing.

In the rig, the rhythm stayed unchanged - a long, unbroken flat line of asystole. Ryan administered another round of epi and atropine, and just for grins, checked a blood sugar level. Her sugar read 56, a little on the low side, but not low enough to put her in arrest. Nevertheless, Ryan administered an amp of D50% and an amp of Bicarb for good measure.

Not like it's gonna do much good. She's as old as dirt, and from the looks of things, a pulmonary embolus is what killed her, not renal failure and hyperkalemia.

A few not-so-subtle whimpers from Mike told Ryan that he was tired of doing compressions, so he took mercy on the kid and switched positions with him. Mike hadn't yet gotten the knack of keeping his balance in a moving ambulance, and flashed Ryan a grateful look as he settled in to the jump seat. He was bagging a little too fast for Ryan’s taste, though.

"Hey Mike?" he asked gently, and the EMT student looked up expectantly. "The idea is, the ventilatory rate should correspond to the patient's resting respiratory rate, not your own pulse."

Embarrassed, Mike slowed down to a more respectable rate. "Sorry," he muttered.

"No problem," Ryan grinned. "You're doing good." The poor kid blushed like a schoolgirl.

"Mister Granger, it is not very paramedic-like to blush like a tomato whenever someone pays you a compliment," Ryan chided, mockingly stern. "You do better by cultivating an aura of cockiness and arrogance. We have to uphold the reputation of our profession, after all."

"And how do I do that?"

"Just watch me and do what I do," he winked. "Anybody will tell you that I'm the cockiest medic around."

And if you work your ass off to actually be as good as you pretend to be, you'll be a pretty good EMT.

Ryan checked his watch and handed Mike another round of epi and atropine. "Here, give these for me. Try not to stick yourself," he warned as he watched Mike carefully insert the needles into the injection port. "Pinch off the line before you push the meds... yeah, just like that. That ought to last us to the ER." He looked out the front window to see the gothic granite of St. Matthew's Regional Medical Center directly ahead.

"Congratulations, Mr. Granger. You have just officially exceeded your scope of practice as a Basic EMT, even before you became a Basic EMT. How does it feel?"

"What happens in the rig, stays in the rig," Mike answered smugly.

There you go, kid. First day of ride time and you're a smartass already. You'll do okay.

"Unless you fuck up," he pointed out. "If you fuck up in the rig, it matters in the - "

"Beep!" Something entirely unexpected happened - a heartbeat. At first just agonal beats, then more and more until finally the woman showed a funky ventricular rhythm marching across the monitor at maybe forty beats a minute.

I'll be damned. Don't tell me this woman is going to regain a pulse.

"Check for a pulse," Ryan ordered. Mike palpated a carotid pulse, a look of concentration on his face quickly fading into a look of triumph.

"She's got one!" he said excitedly. For good measure, the CO2 detector started to turn a dull tan, indicating at least some exhaled carbon dioxide. "We got her back!" Mike exulted.

This is not one to celebrate, kid. This lady has been down too long, and her body was failing anyway. She'll never make it out of the hospital, if she even lives long enough to be admitted.

Ryan simply nodded and grinned reassuringly at the EMT student as Steve backed the rig into the ambulance bay. He disconnected the IV bag from the roof hook and laid it across her chest, hung the cardiac monitor from the stretcher rail, and switched the bag mask over to the portable oxygen cylinder strapped to the cot between the woman's legs. As Steve opened the rear doors, Ryan backed out of the rig first.

"Just follow the stretcher out of the rig and keep bagging, Mike," he ordered. "And be careful with my tube."

Inside, he gave report to Dr. Donaldson, the ER physician. Donaldson was a friendly enough sort, a genial older man with a fatherly air about him. He always told Ryan that he was a chip off the old block, and out of respect for the paramedic-physician relationship, Ryan refrained from telling him to get bent.

"Ninety-four year old female with a witnessed arrest. She was asystolic when we got there, with ineffective CPR. The tube is a 7.5, placement was good before we unloaded her." Dr. Donaldson listened to the woman's chest, nodded in approval and straightened back up. "Three rounds of epinephrine and atropine, one round each of D50% and sodium bicarbonate. I figured hyperkalemia and/or hypoglycemia might be a cause, so I gave it a shot. She converted right as we pulled up."

"Is she diabetic? A dialysis patient?" Donaldson wanted to know.

"Not on dialysis yet, but she has chronic insufficiency, and the diabetes is on her chart, among twenty other chronic illnesses. Her sugar was 54."

"Pressure is 54/20," the nurse broke in. Dr. Donaldson sighed, flipping through the nursing home paperwork. "Run in another 500 of saline, and start a dopamine drip at five," he ordered, "and someone try to contact her family. This lady ought to be a DNR."

"How much do you figure she weighs?" asked a new nurse, one Ryan had never seen before. She was young, slim and honey-blonde. Cute.

"Maybe ninety pounds," Ryan judged. "You'll need to run your dopamine at eight milliliters an hour to get five micrograms per kilogram per minute."

"How the hell did you know that?" the nurse demanded as the others chuckled. "Did you figure that in your head?"

Ryan just winked at her and tapped his temple. "That's an EMS trade secret. I could tell you, but then I'd have to kill you." The other nurses just laughed.

"Just do what he says, Cathy," one of them chuckled. "I'll explain Hawkeye Pierce to you later."

********

Ryan winked again at Cathy and walked back outside. Steve was making up the stretcher as Mike busied himself cleaning the rig, putting everything in its proper place. It was a big job – Ryan Pierce was notorious for trashing ambulances.

"That was so cool!" Mike was saying, still flush with excitement as he wiped down the floor and gathered up empty wrappers. "My first code and we get a save!" Ryan merely smiled and let him bask in the feeling. Mike Granger would have to work quite a while as an EMT before he'd recognize the futility of what they had done. Even a save wasn't always a save. Not really.

"Yeah, first code and he's already getting cocky," Steve observed with a wry grin. "He's been talking smack about the nursing home version of CPR."

"Yeah, can you believe that?" Mike asked, shaking his head. "I mean, I'm not even out of school yet and did better CPR! They acted like they didn't have a clue what to do. Nursing home nurses!" Mike snorted in derision.

They probably didn't know what to do. Then again, they're not trained to handle emergencies. And you don't have nearly enough hair on your fuzzy little EMT scrotum to feel superior to a nurse, my sparky little EMT student friend.

"No, they weren't doing very effective CPR when we got there," Ryan agreed. "Then again, how effective do you think your compressions were after ten minutes?"

"Not very," he admitted, his grin slowly fading. "I was worn out."

"That's why I spelled you on compressions," Ryan pointed out as he sat on the bumper of the rig and began working on his run ticket. "And you had the luxury of bagging through an endotracheal tube throughout most of it. The nurse had to use a mask. You've practiced it in EMT class - you know how hard it can be to bag a manikin by yourself, much less a person."

"Yeah, but they had the equipment there to do it right! They didn't do anything until you told them what to do. They didn't know shit about the lady, either!"

Ryan sighed and put down the clipboard, looking up at Mike. "Let me paint a picture for you, Mr. EMT Wannabe. Let's say you got to school for eighteen months and pass a licensure exam as a practical nurse. You get a job in a local nursing home. You now work in an industry that considers 40:1 an acceptable patient-to-caregiver ratio. At least half of your patients are chronically bed bound. Most of them have some degree of dementia. All of them have multiple chronic illnesses. Every single one of them requires at least some level of assistance with the activities of daily living. Every single one of them takes a bucketful of medications several times a day. Your only help is a couple of aides that have, at most, a high school education and a questionable command of English, and they're paid minimum wage. Every single eight-hour shift that you work begins with setting up your medication cart to administer the first round of medications of the shift. By the time you have completed that med-pass, your shift is half over, and it's time to begin the next med-pass. By the time you're done with that one, it's an hour away from shift change, and you still haven't done any charting. You've been on your feet for seven hours, and you've managed to spend maybe ten minutes with each patient, if you're lucky. Is it any wonder that you don't know jack shit about your patients without having to look it up? Or that they call EMS when the slightest thing looks out of the ordinary?"

"I didn't know that...I mean I wasn't trying to..." Mike stammered, mortified.

"Now imagine that you get to know these patients. You see to it that they're fed, turned, medicated and bathed. You dress their bedsores. You've spent more time with them in a day than their families have in a year. This lady was from Alabama. How often do you think her family comes over to visit dear old Granny? Now, you know this lady. You know what her days are like. You see her quality of life, or lack thereof. You know she wouldn't want to continue to suffer, if she was still capable of voicing her wishes. Now would you be really diligent about doing CPR when this lady finally, mercifully, passes?"

"No, I guess I wouldn't," Mike admitted, chastened.

"And if some snot-nosed punk fresh from a six-month EMT course came off with a superior attitude, belittling you, would you take it well?"

"No."

"So keep that in mind the next time you disrespect a nursing home nurse. Hate the system all you want, because it sucks. But the people working in that system aren't to blame."

"I won't," Mike promised, looking rather like someone had just run over his puppy. "I was just shooting my mouth off."

"Don't worry about it," Ryan grinned, punching him in the arm. "Bashing nursing home nurses is a time-honored EMS pastime, good for hours of fun and enjoyment. You just have to pay your dues first, and try to remember where they're coming from."

"Control to 306," the radio crackled before Mike could reply.

"306," Steve answered.

"Priority One call, 1500 block of West Tower on a shooting. Oneida Police are on scene."

"Fuck me!" Steve exploded. "Fifteen Goddamned minutes before shift change!" He climbed into the driver's seat and slammed the door, fuming. Mike scrambled into the back of the rig, looking excited enough to soil himself.

Damn, damn, damn. This is going to make me late getting off. Dawn is going to give me hell if I'm not there when she drops off Caitlin.

Mike looked disgustingly eager as Steve wove the rig through a maze of streets toward West Tower Avenue in downtown Oneida. Forty years ago, West Tower was the thriving business hub of the city. Now, it was a dimly lit, barren landscape of abandoned storefronts and decaying buildings. The only thriving businesses there were crack dealers and prostitutes. West Tower was informally known as Crack Alley, its namesake tower burned out in 1987, and finally demolished by the city in 2001.

They were met by a surprise as they turned off of Constitution Avenue onto West Tower. The scene of the shooting, supposedly two blocks further down, turned out to be right in their faces as they turned the corner. Steve had to brake hard to avoid running over an angry group of people surrounding two Oneida Police Department cruisers. The maneuver threw Mike to the floor, cursing. The crowd, equally surprised by the sudden appearance of the ambulance, parted slightly.

"Shit," Steve blurted unnecessarily. "I don't like this. Stay in or get out?"

"Get out," Ryan answered after a moment's consideration. "We're already in the middle of it." He turned to Mike. "You stay here." Before he could protest, Steve and Ryan bailed out of the rig.

A frightened Oneida police officer was standing over a prone body, weapon drawn, while his partner spoke urgently into the microphone clipped to his epaulet. The victim was a young black male, hands cuffed behind his back, with a spreading red stain on the back of his shirt. His breathing sounded wet and ugly. The officers had their weapons pointed outwards, toward the crowd, and the tension was evident on their faces.

“What the fuck are you guys doing here?” the younger officer demanded, not taking his eyes off the crowd. “You were supposed to stage until we cleared you into the scene!”

“That’s not what we were told,” Ryan replied. “What happened?”

“Foot pursuit,” the the other replied, out of breath. “He pulled a knife.”

“Ain’t nobody had no muthafuckin’ knife!” a woman in the crowd screamed. “Fuckin’ cop just shot him down!” The crowd surged dangerously forward, and a bottle shattered against the side of the rig. Ryan flinched instinctively, and another bottle just missed his head, whacking him painfully on the shoulder.

“Get him in the rig and go!” the cops screamed, looking wildly around for the thrower. Steve and Ryan didn’t need to be told twice. They dragged the guy by the shoulders to the back of the rig and beat on the doors until Mike opened the rear doors and peered out cautiously.

“Don’t just fucking stand there!” Steve cried. “Help us pull him in!” Mike hurriedly grabbed the man under his arms and they half-dragged, half-lifted him onto the cot. Steve and Ryan hurriedly climbed inside and slammed the doors behind them as another bottle shattered against the rig. Steve scrambled into the cab and threw the rig into gear, screaming at people to get out of the way. They crept forward slowly, and the ambulance rocked violently.

“Get the fuck away from the ambulance! Get outta the way!” Steve screamed at the people outside. Several of them were beating on the hood and the sides of the rig. “Swear to God, I’ll fucking run you down!” he screamed threateningly, and gunned the engine. The rig surged forward, haltingly at first, and then traveled perhaps a hundred feet before abruptly coming to a stop.

“Shit!” Steve swore, then yelled to the back, “Open the back doors and let ‘em in!”

Ryan flung open the rear doors to find a news camera crew desperately trying to climb inside. The cameraman pushed the reporter through the doors and crowded in behind her. She looked dazed, blood flowing down the right side of her face from a cut at her hairline.

“Jesus Christ!” Ryan blurted, and then shouted to Steve. “They’re in! Let’s get the hell out of here, shall we?” Needing no further prompting, Steve nailed the accelerator and made a hard turn onto Constitution Avenue. A block up the road, they met four police cruisers heading the other way, sirens screaming.

“Hold this,” Ryan told the reporter, holding a gauze bandage to the cut in her forehead and pressing her right hand against it. “You hurt, dude?” he asked the cameraman, who shook his head.

“Mike, get some suction and a BVM and start –“

“Way ahead of you,” he reported. Mike already had a bag-mask resuscitator attached to the main oxygen. As Ryan watched, he stuck a rigid suction catheter into the guy’s mouth, pulling a stream of foamy blood into the tubing. Airway cleared, at least temporarily, Mike started ventilating, frowning in concentration. Ryan watched him for a few breaths to make sure he wasn’t having any difficulty, and then opened the IV cabinet. Mike grinned, nodding at a bag of saline swaying from the ceiling hook. “Already got one set up for you. I did it on the way to the call.”

Pretty damned sharp, rookie. You get an “A” on your evaluation today.

Using his shears, Ryan cut the guy’s shirt open from hem to neckline, exposing a small hole in the left front chest, about even with and an inch to the left of his nipple. A closer look revealed another hole through his left bicep. Neither was bleeding especially badly, but Ryan quickly rolled him partially on his side to check the wound on the back. It was noticeably larger, and bleeding a good deal. He slapped a dressing on it and taped it into place, and rolled the guy back into a supine position. It wasn’t the easiest task to accomplish – he was a big boy, and his arms were still cuffed behind his back. Ryan taped another bandage to the entrance wound and turned his attention to the guy’s breathing. As Mike ventilated, Ryan listened briefly to the man’s chest. To his surprise, he heard breath sounds on both sides of the man’s chest. If anything, the lung sounds on the left were only slightly diminished.

Thank God for small favors. Now if we can just get him to the hospital before he bleeds out or the hemothorax kills him, we’ll be ahead of the game.

The man’s pressure was low at 74/40, and his pulse was fast and thready at 130. The two bullet wounds were the only injuries Ryan could find, but they were enough. He managed to start an IV, bumping the reporter down the bench seat in order to make room. She was still holding the bandage to her head, watching in rapt fascination. The cameraman was standing at the back of the rig, holding on for dear life, his camera on the floor.

Well, at least they’re not filming. This could be worse.

Ryan was still taping down the IV when he felt the truck lurch to a stop and Steve flung open the rear doors, nearly spilling the cameraman onto the pavement. Ryan motioned for the news crew to precede him out of the rig, and they hurriedly got out of the way. By the time they got the stretcher unloaded, the news crew was set up again, filming every move as Ryan and Steve rolled the patient into the ER.

“You’d think she would get her head stitched up before she’d get on camera again,” Steve muttered in derision.

“Not as dramatic,” Ryan said dryly as the doors closed behind them. “That bloody bandage ups her credibility.”

“Guess so,” Steve grunted. “Room Two,” he said, pointing. They rolled the cot into the room, where Dr. Donaldson and the trauma team were waiting.

“Officer-involved shooting,” Ryan told him. “GSW to the left chest, another to the left arm. Lungs were okay, but he’s shocky. BP was only 74/40. Unresponsive the entire time.”

Mike handed off the BVM to a nurse as they moved the patient over to the ER bed. Donaldson leaned over him, auscultating his chest. “Decreased on the left,” he said. “He’s got subcutaneous emphysema in the axillae.” Without being asked, a nurse began setting up a thoracostomy tray.

“He sounded okay on the way here,” Ryan started to defend himself. Donaldson brushed it off.

“You were bagging him,” he said, “and he needs the chest tube anyway.” Ryan dialed his wife’s number on his cell phone as they walked outside, and wound up getting her voicemail. “Hey, it’s me,” he said. “We got a late call, so I won’t be home for another couple of hours. If I’m not there, just let yourself in and wait for me.” He caught himself almost saying, “I love you,” before hanging up.

The reporter was still pontificating on camera outside, and she stuck a microphone in Ryan’s face as he walked past. “Sir, what can you tell us about the victim?”

Shit, just what I need. Keep to one word answers, and be polite, Ryan.

“Nothing,” he replied, saying the first thing that came to mind.

“What can you tell us about his condition?”

“I can’t tell you anything about his condition,” he said, squinting at the glare of the camera light.

“Were you injured in the riot?”

“What riot?” Ryan asked, genuinely surprised. “Somebody was throwing stuff at us, that’s all.”

“Witnesses say that the victim was not acting in a threatening manner, and that the officer used excessive force. How do you respond to that?”

“I know nothing about the circumstances of the shooting, Ma’am. I was called to provide medical care, which I did. Now if you will excuse me…” Before she could ask another question, Ryan beat a hasty retreat around to the other side of the ambulance.

“Ooooohhhh, Mister Hawkeye Pierce, Supermedic,” Steve breathed seductively as Ryan climbed into the rig. “You are so brave and heroic!” He grinned evilly.

“Aw shucks, Ma’am,” Ryan replied. “I’m no hero. I was only there because my fucking partner drove us right into the middle of the scene…” Steve rolled his eyes.

“I wanna be you when I grow up,” Mike chimed in. “Handsome, dashing rescuer of damsels in distress, all-seeing, all-knowing paramedic…”

“Watch it rookie,” Ryan warned with a grin. “I still have to grade your evaluation.”