Across from Lincoln High School, San Diego Fire Station 12 has three fire trucks and an ambulance. Although all firefighters are trained medical assistants (most are paramedics), the ambulance crew is the most critical life-saving link between the victim and the hospital.
Chuck Delao and Janet Terlouw have worked as partners on the Station 12 ambulance ("Medic 12") for about a month. It's one of the busiest ambulance units in the city. Next month, they'll change partners again. Both are experienced paramedics and work 24-hour shifts on the ambulance. Delao, 43, has been with the department for ten months. "I worked at the Sycuan Fire Department for two years. Before that, I was in the city of Indio." His current job requires long hours. "We've worked ten shifts this month. You work 24 hours, then you're off 24 hours. You do that four times, then you get four days off; then you do it another four times, and you get six days off." Terlouw, 32, has been with the department since July of 1997.
It's 8:30 p.m. on the first Thursday in December, and they've been on the job since 7:30 this morning. According to Terlouw, the busy hours are consistent but not always predictable. "The last few days have been very busy during the daytime and slowed down at night, but on Friday and Saturday nights -- any night of the week can be busy; it doesn't have to be a weekend night. But lately it's been very busy during the day and slower at night, but this is before the flu season hits. During the flu season it's busy all day, every day."
At 9:05, Delao and Terlouw's pagers go off, and they head for the ambulance without saying a word. As we board the ambulance, Delao explains the computer display that sits between the seats. "Somebody called 911. When a caller calls our dispatch center, he will be asked a series of questions to determine the acuity of the call or the type of call." He points to the information on the screen, which includes a description of the patient (a 39-year-old male) and the address. "This one fit the unconscious/fainting category. Does that mean the person is unconscious? No. It just means that the questions they've asked through the triage process have determined that category." A voice on the radio calls out for an engine to respond. Delao turns on the lights and sirens but drives just over the speed limit. Terlouw, holding a Thomas Brothers map, navigates him through the streets. "Head north on 47th to Market, turn left and go to 41st Street. It's on 41st between F and Market." As we approach intersections with red lights, Delao stops before crossing. Cars remain in front of us, in spite of the siren. Delao explains, "Many of these drivers just don't know what to do. Safety is our biggest concern, and there's really no need to drive recklessly. Anyway, we have different levels of calls -- a Level I, which is an ambulance, an engine, lights, and sirens Code 3. A Level II call is just an ambulance, lights, and sirens Code 3. Then we have a Level III call, which is just an ambulance at its own leisurely pace. This is a Level I call."
We arrive at the house at 9:11. The engine has arrived before us, and several neighbors are standing out on the sidewalk to watch. This is a poor neighborhood, with small, one-story houses. Delao opens the side of the ambulance and pulls items out of a compartment. "The engine company responds with a captain and some EMT firefighters. We always bring in a heart monitor, an airway bag, and the drug box." There are already four firefighters in the house.
We enter a dark house with religious artwork on the walls. The patient is a young, long-haired Hispanic man who speaks no English. He lies shirtless on his bed with his wife standing by as they monitor his breathing and check vital signs while questioning him in Spanish. He is surrounded by firemen, all doing some task. We are told he has the flu and has already been in the hospital once this week. Delao continues to explain what is happening. "We always try to rule out the most life-threatening types of problems, like heart attacks, strokes. We always hook them up to a monitor, take blood pressure, read oxygen saturation, pulse rate." There are several sensors taped to the patient's abdomen and chest. As Delao reads the printout, he says, "That's an EKG machine, and it's got all the little bumps in the right spots. That's a normal rhythm. We found out that his age is really about 38." His wife tells the paramedics what medications her husband has been taking. He has not responded well to the medications, and she was concerned that he was not talking so she called 911. The patient is given a glucose IV and loaded into the ambulance on a gurney. His wife rides with him in the back on a padded bench.
At 9:27 we leave for Paradise Valley Hospital without the lights and sirens -- that's only for acute-status patients who will die without immediate hospital treatment. Terlouw is in the back administering oxygen and monitoring the patient. According to Delao, this is a typical call. "The majority of the calls we get are chronic problems. They've had something and it's gotten worse, or they don't know what's wrong with them, but it's been an ongoing problem. [They] have a history.
"Communication is really important. Our communication center is known for its triaging -- the sorting of the calls as they come in. The answers to their questions determine how the patient is treated. This guy might have said chest pains or paralysis or hemorrhage. Those buzz words or complaints will trigger a Level I, II, or III call. A broken arm won't get an engine.
"This call was triaged as a Level I call. He called in and said he'd been sick for a couple of days and had chest pains. If that patient went downhill quickly or was dying, my partner and I could not take care of it alone. We'd need more hands, so that's why the engine was there too. And everybody in that man's room was doing something. We have a contract with the city that says that each call will get two paramedics. We at San Diego Fire and Life Safety put a paramedic on each engine, so they would get a 4-minute to 6-minute response time. Then they put a paramedic in the ambulance -- it just so happens that there are two paramedics tonight -- with an 8- to 10-minute response time. So you're guaranteed a paramedic and an advanced level of care within 4 to 6 minutes and another transport within 8 to 12 minutes."
Driving at Code 3 presents risks for the ambulance crew as well as other drivers. "It's a pretty dangerous thing. The general population doesn't know what to do. We're putting ourselves at risk by going through red lights, even though we stop at them to insure that everybody has stopped before we go through. We don't demand the right of way, but we request the right of way. A lot of people try to outrace us. They want to get where they're going, and they don't want to be bothered with pulling over and stopping."
We arrive at Paradise Valley Hospital at 9:34 and pull into a special ambulance entrance at the emergency room. Before Terlouw and Delao unload the patient on the gurney, Delao punches in a numerical code at a sliding glass door, which opens automatically. When the patient is wheeled in, two doctors recognize him immediately. One of the doctors addresses him in Spanish, jokingly asking what he's doing back here already. Evidently, this man was discharged this afternoon. While Terlouw briefs the physicians and fills out a pile of forms inside the hospital, Delao removes all materials that touched the patient -- gurney covers, pillow covers -- and disposes of them.
Delao confesses that he is starting to feel very tired. "We're one of the busiest stations. The other busy areas are Normal Heights, Sports Arena, and Station 26 at Krenning and 54th. Those are usually the hardest hit. They can average 8 to 14 calls in a 24-hour period. And each call usually runs from an hour to an hour and a half. You get to the scene, take the patient to the hospital, restock the ambulance, do all the paperwork, and get back to the station." To emphasize his point, Delao goes back to the computer in the ambulance's cab and punches in a code to bring up a display of all relevant information on the call he just completed. "This call came in at 21:03, we responded at 21:06, we arrived on the scene at 21:11. We departed the scene at 21:27, so we were only there about 20 minutes. It took another 8 minutes to get here, as we arrived at 21:34. We'll spend another 10 to 15 minutes here, finishing paperwork, so that's about an hour. And this was a mundane, low-key, run-of-the-mill, everyday call. Things like New Year's Eve, holidays, Super Bowl days -- things like that we always have a higher level of activity. Full moons affect it, and so do paydays."
Triage -- sorting patients according to need -- is critical to the efficiency of the paramedics. "They'll page us and say, 'Twelve, you got a call.' We'll get in the ambulance and head out. We don't know what the call is for yet, because they'll say [on the radio] it's still in triage. So they're continuing to define -- to upgrade or downgrade the call as we are going to the scene. They want to minimize the down time by getting an ambulance going to the call as soon as possible. They know that someone accessed 911 because he or she needed help, and that's what we're here for. When we get to the scene, dispatch has triaged it to whatever level call it is, and we're there to render assistance."
The ambulance computer provides a wealth of information for all the drivers in the system. Another entry provides a list of every ambulance unit in the city by numerical code, and next to each unit is a status designation. The designations read, "In Quarters," "At Hospital," "En Route," "Dispatched," "Departing Scene," "At Scene," "Available," or "Out of Service." Delao explains why one particular ambulance, Medic 3, is special. "That ambulance is designated for the airport. We have a contract with the port authority that even though it's listed as a medic unit, it doesn't leave the airport. After the airport closes, it's available for areas around the airport.
"Because our unit, 12, is one of the busiest, some paramedics don't like to work here -- because it's so busy. Today we had a fairly easy day, eight calls. But a lot of times when you get back-to-back calls over and over again, you're up until 3:00 in the morning, you get an hour's sleep, you wake up, go home, and you have to go to sleep again." Delao's pager begins to beep. "We've got another call." It's 9:56.
Terlouw comes out of the hospital and jumps in the ambulance. After checking the computer screen, Delao says it's a Level I call. "A diabetic problem." This time, we will be going outside of Station 12's designated area, as no other ambulances are available. We drive east on Skyline Drive as more information comes in. A 62-year-old male is unconscious. Once again, the cars do not respond to our lights and sirens and block the road. The patient's house is on a small street in the Lomita area, overlooking Spring Valley. The street is lined with well-kept, modest-looking one-story houses. We arrive at 10:10. We are met by two paramedics from the San Miguel Fire Department.
As we enter the house, a late-middle-aged woman is standing over the head of a sofa where her older-looking husband lies, barely conscious. His eyes are open, and his arms have a slight shake. Their daughter, who appears to be in her early 20s, stands near the hall at the foot of the sofa. We find out the man is a woodworker; the house is overcrowded with his hand-crafted furnishings. Delao and Terlouw ask questions, which the wife answers confidently. She affirms that he is diabetic but doesn't know when he last checked his blood sugar or injected insulin.
The first sign of life comes when the man's finger is poked for a blood test -- he groans. As they discuss his medications and medical history, a Chihuahua barks in the hallway. After determining that his blood sugar is dangerously low, they start him on an IV. As Terlouw starts the IV, the man slowly regains his consciousness while she tells him what she's doing. She asks him what month it is, and he is alert enough to answer correctly. After inserting the IV, Terlouw pulls out a large plastic hypodermic; she injects dextrose directly into the IV line. When she injects him, the man begins to yell with pain. When Terlouw explains that he's getting a sugar injection, he loudly objects, "I'm a diabetic, for Christ's sake! What the hell are you doing, giving me sugar?"
As his consciousness comes back, they explain what happened to him, and his mood is much friendlier. Terlouw offers her advice. "Here's the deal. Because we don't know why your blood sugar dropped, I would like to run you to the hospital to get you evaluated. There's also a chance that your sugar could drop after we leave. Can I run you to your hospital?"
The man refuses. "Hell, no. I ain't goin' to no hospital." Later, Delao says this is common. "It's sometimes typical of diabetics, because they've been through it so many times. What happens is, their sugar will drop, and their level of consciousness will drop, we're called, we give him the sugar, their consciousness returns, and by law, we can't 'kidnap' them if they're alert and oriented -- they know their name, the date, and where they are. So, sometimes people opt not to be evaluated because they know exactly what is wrong. This could last for another 20 minutes or half hour because it went directly into his veins, where if he were to eat something, his metabolism would take over, and it would be a longer-lasting Band-Aid. The real problem is that he didn't take his insulin. Again, this is one of those chronic problems." They disconnect his IV, and Delao takes the remaining fluid outside and empties it on the pavement. Terlouw radios dispatch to document that the man refused to go to the hospital. When we arrived, his blood-sugar level was at 25 -- a level Terlouw insists was dangerously low. When we leave, his blood-sugar level is 184, but Terlouw warns him that it will not last long as she puts a Band-Aid on his arm. She later says that his blood sugar was at rock-bottom. "We used to call it a diabetic coma, but today we call it hypoglycemia. This man was what I call a 'double-dipper.' He's on an oral medication and insulin. We really prefer to get those types checked out, but once they're oriented and awake, it's their right to refuse. I tried to let him know what the risks and consequences are of his decision and assure him that he can call us back if he changes his mind."
As we ride back to the station, Terlouw and Delao discuss patients who are uncooperative. It's especially common in third-party cases where a bystander places the call, and the victim doesn't want treatment. Terlouw is especially wary of drug users. "You have to approach people carefully. If somebody's under the influence of a substance, they're not in their right mind, and they can be combative. Head injuries can be combative too. You always have to think of your own personal safety and the safety of your crew members. You have to make sure they don't hurt themselves or hurt you. It's not always their fault. They don't know what they're doing, and you just have to be careful."