Curbside Carnage

There I sat, like a minister of death praying for war listening to the radio, I waited there hoping and wishing for a case. Our air condition had been broken for 2 days now and I sat in our sweltering hot station wallowing in my own juices due to the fact it was over 100 degrees F outside. A dead mosquito and some grains of sand stuck to my skin and all the energy had been sucked out of me. I just needed a case so I could get out of the station.

That case finally came at 430am as I lay there in the dark, hot, sweaty and miserable. I jumped at the oppertunity to get out of the hot station and hit the road. I could hear dispatch calling ambulance after ambulance from several stations across the city all to the very case we where just sent on. Update en route to the scene confirmed there was at least 10 people injured including some that where listed as critical. My partner floored it and we flew down the highway. I started playing things out in my head and trying to prepare myself mentally for possible injuries and scene management issues with a large accident.

Flashing lights, twisted metal, bodies, and a large crowd began to form in the horizon as we approached.  We entered the event horizon of this catastrophe and our unit was directed right into the middle of it. The ussual unruly mob of bystanders and on lookers stood in our way. The fire department who where busy cutting entrapped people out of cars had to help create a gap in the crowed as we slowly drove into the middle of this mess, there was no going back now. Time seemed to slow down and there was an erry silence inside the ambulance despite being surrounded by all this mayhem. I looked outside from our almost sound proof window to see people bleeding laying on the ground all over, people crying and screaming walking around with dirt, sut and blood on there faces.We navigated our way right to the middle and stopped. It was almost like a movie watching it from the inside of our unit. The silence I was experiencing from inside was soon broken the moment I cracked the door. It was like the front door opening to an amphibious landing ship full of soldiers at the beaches of Normandy on D day.

I tuned out all the noise as best I could. I had become accustom to all the chaos around me by now after a year as a self proclaimed flesh mechanic in Riyadh.  I grabbed the trauma bag and off I went. I could see other EMT's and Medics arriving and pouring in behind me to help. The first man I came to was bleeding badly from the head and the bone from his leg was sticking out.  He had been pulled out of the car into the dirt and had broken glass and sand all over him. He was pale, cool,. clammy in shock and had no palpable radial pulse but was breathing. Another U.S. paramedic arrived as I was assessing the first man. I told him to continue triaging the others while I managed this guy.
 I ensured his airyway was clear and we placed a large bulky dressing over his  bleed. I got some of the EMT's to help me place a neck collar on him,  and package him up on a backboard with some oxygen. Another EMT worked on his broken leg. We started a large IV whilst this was going on and checked for any other injuries. The guy looked like crap and I was not sure if he was going to make it. but there where so many others and there was not much more I could do for him. Time was of the essence.  I left him with the EMT's and another Paramedic once he was ready for transport and went to check on the others. A man came up to me with a broken arm begging for help but I had to tell him to wait with other "walking wounded" until we gathered all the people who where unable to walk and critical. I wanted to make sure we did not miss anyone in this mess.

Like a dysfunctional easter egg hunt I went searching through the vehicles, debris, pieces of flesh, groups of rescue workers and crowd for the injured. We had more than enough resources at the scene now including some doctors and I just wanted to ensure all the critical patients on the scene had been found, stabilized, and transported before we left. I loaded up the last  patient that was unable to walk my partner had found. He was showing early signs of shock and had been hit by a car as a pedestrian. I jumped in the ambulance with him and our journey to the hospital began. He got a full work up and was treated for shock. His condition improved en route and he was successfully delivered to a hospital further away from the accident to scene to help distribute the large volume of patients across multiple facility's. Its important to do this during large accidents so one hospital does not become over whelmed and under staffed. I think our guy will be fine.

I found out later what happened. Apparently only 1 or 2 vehicles had a car accident and the people where transported by ambulance with no problems. However there was such a large crowd of bystanders and onlookers that had stopped to check things out or ran over to help that oncoming traffic hit a group of the bystanders and also caused a car pile up. 

Easy Street

Silence..... Serenity.... The Sun was shining in the clear blue sky as a gentle breeze swept by. It had been like this for hours now and only the peaceful songs from birds off in the distance could be herd. My apathy was a distant thought as I stepped inside my new home away from home. It was inviting me to have a sit down as I wafted in the pleasant aroma of fresh tea and coffee being made. A smile began to slowly stretch across my face and I conceded to the aroma.

Mean while outside our sparkling clean ambulance shimmered in the sunlight. It was washed, waxed, armoralled, and detailed daily. Wait, did I say ambulance? Thats right I was at work. But wait this is not the internal burning inferno of  hell I normally describe to you.
I took a deep breathe and looked around, had I finally died at work responding to a call and now I had gone to a better place? I had plenty of close calls and  it would seem so but that was not the case. I was actually at work at my new station. As I mentioned in an earlier post I was rewarded for all my hard work and was transfered to a new medic station. It was a special duty assignment located in a very high profile and secure area.  It was the opposite of my old station in every way. Ive been here for almost a month now. The story's I wrote to you about at my previous station where just the tip of the iceberg of what I actually encountered out there. If I wrote you about every critical case I encountered the past 9 months I would have to write multiple times a day every day... but not now haha.

The new stations nice, almost to nice for me and I missed my old station sometimes. The chaos, carnage, anarchy, and destruction from my previous duty assignment. Was I crazy, Was I an addreline junky? God I am picky, first I complain about things being to crazy then I complain about them not being crazy enough. However if I liked it or not I needed a change and this was my new duty. I have already found positive attributes of working here, and I am only here until the end of July. I can sleep a few hours on night duty now which is pretty remarkable. I only work with 1 other person and we no longer use another crew for transport, which is better for me. I found now that I try and say good bye to every patient or shake the hand of everyone I deliver to the hospital and personally wish them luck if there conscious... something I never use to do much. I had regained some of the emotions and feelings that make me a human being. However I still had what it took inside me to go back to the insanity and get things done quickly with a strait face.

In addition to this I did some more community outreach this week and gave another presentation on road safety, this time to the British International School of Riyadh. Ill try and drum up some business for you guys to hear about later this week. I know hearing about other peoples misfortune and listening to exciting experiences is more interesting to read about!

Break a leg

Just a quick story:

I can hear the screams through the thick crowd. I do my best to push and shove my way further into the large group of on lookers thats gathered. I continue following a path destruction thats all around me. I begin honing in on the screams until I reach the patient. He does not speak Arabic or English so non of us can communicate with him. However its safe to say he is saying some pretty vulgar things in Hindi. He is laying on the street supine and his leg is severely deformed and in a very unnatural position thats placed his foot next to his head. As he lay there screaming in pain he stairs at his deformed foot just inches from his face. However he is unable to move the extremity and his bones are so broken that there is no structure left to his leg. We feel for a pulse in his foot and of course there is none. The whole leg moves like a gummy worm and requires several of us to support it. 1 sharp piece of broken bone is starting to cut its way out the leg so we must move it very carefully. We can not transport him with his leg in this crazy position and with no pulse so we have to relocate it.

We give him the maximum start dose of morphine for pain that we can give and also give him another medication to sedate him so he will not be completely aware during the procedure. We carefully relocate the extremity to a neutral inline position and splint it. Its about this time the helicopter lands I send him off with the chopper crew and attend to the other patient who is dead. He lay there in the street surrounded by fruit and vegetables covered in blood. I place some electrodes on his body and run a quick flat line ecg rythem strip to attach to my report then cover the body with a blanket.

So what happened to these guys? Well from what I gathered someone possibly fell asleep at the wheel and drove there car into an open air street market hitting some fruit and vegetable stands killing the 1 man and injuring the other man with the broken leg.

A twist of events

As I mentioned in a previous posting, we have ran so many critical calls that our minds had adapted to our environments. We could do our jobs flawlessly like robots, but at what cost? What about our empathy and caring.... Had we lost some of it or all of it along the way? What about  our personal lives? Help others and then help yourself...  Sometimes the hardest life to save is your own. As a medic how does one save themselves?


I stepped outside my dark hotel room into the bright hallway when I caught the attention of 2 of the other U.S. medics eyes. "jesus, you look like S**t Mike" they exclaimed. I just mumbled agreeably as I made my way outside to hail a taxi and get to work.  Dark bags under my blood shot eyes squinted in pain. Off to work... I have now been in country longer than most of other western medics. I am salty and short timing.


  Upon arrival to the station I dropped my gear inside and went for a walk to the local store. As I walked down the busy dirt road covered in old plastic bags, rusty cans, paper, wrappers, needles,  and other random debris I enjoyed the amaturer  graffiti that covered every business and every wall around me. Many of the businesses window's where broken and all of them where covered with bars. As I continued my journey for a redbull I observed all the children living in poverty in our neighbored.


 They all had there soccer jerseys on and loved playing soccer, unfortunitly they only had a dirt field and used garbage with stones to mark the field goals. By the looks of there raggedy soccer ball it was unbelievable it still held air. I was based in a very poor neighborhood that taxi drivers refused to go to at night. I serviced the poorest, and busiest area in the city. In addition to that my coverage area expanded for miles outside of my response area due to the shortage of Paramedics and doctors. I never got a break and with back to back day/night shifts I did not sleep. The other american medics could not believe how I did it. Some of them had came for ride a longs with me, one day was enough for them... but no one could believe I had been working this station for 8 months everyday. 


I have been working as a rapid response paramedic at the busiest station  in Riyadh Saudi Arabia (a city the size of Los Angels) for about 8 months as of writing this. The incredible shortage of Advanced Life Support staff has resulted in severe sleep deprivation, overtime every week, exposure to an incredibly high volume of critical cases, and places my safety in jeopardy on a daily basis in multiple ways, including 2 ambulance accidents I was involved in and a combative patient that I received a dirty needle stick from, a man with a knife that tried to stab me, an explosion that knocked my colleague to the ground, and the list go's on and on. I was not just a medic working a regular job I was fighting a freaking war with the streets of Riyadh.


 The critical cases I see have began to blurr together for me, from explosions, to gun shots, to stabbings, to huge car accidents, people being struck by cars and assaulted, abused, heart attacks, strokes, baby's being born,  and many many other things, thats just in the past 2 weeks. Even the medics in Iraq and New York City I have spoke to do not see the kind of volume. I am proud to serve the community I do, and to also have the busiest station, but a break would be nice.


I could deal with our heavy call volume, bad niegorhood, and frequent safety hazards... Sure they run a toll on me, but there where other factors in place. The ambulance crews I use to enjoy working with where switched around and theres been a lot of conflict with the new crews and I. Work has been very stressful lately.


I have been a real train wreck.... BUT today things started looking up.


As I write this today is my last day at the busiest ALS station in Riyadh. The manager from a brand new station called me today.  The station is in a very secure nice area where many high profile patients live. The call volume is much slower and the crews  seem great.  I was transfered there effective today and I feel great. I will be the first medic at this station and can not wait to start. In addition to this I moved out of the hotel today that I have been living in for the past 8 months and finally got my own apartment on a western compound!
It appears I am on easy street now, fate had saved me from burnout. Don't worry Ill still see crazy exciting things to share with you all. Ill make sure of it!

My Road safety and Seat belt presentation

It gets frustrating over here everyday with all these car accidents and unsafe driving practices. I felt compelled to do some community outreach and gave the below presentation to kids at the american international school last week. I also brought an ambulance down to the school and let the kids check it out. It was my first time doing this so forgive the excess "um's" for the first few minutes of the video. I was a bit nervous.

1 survivor

The Blades from the helicopter had just stopped spinning. A small amount of dust could still be seen in the air as the moon light shined down upon us. It was a beautiful and otherwise quite night on this old rural highway. I did not have much time to take in scenery on the way due to the fact that we had reached speeds of over 210kmh(130mph)
 Dispatch suggested we where to far away to take the call, but boy did we prove them wrong.
The sounds of panic around me would occasionally be replaced by shouting in multiple directions. It was dark but my eyes attempted to take in all the pandemonium surrounding me. I started constructing a plan. The helicopter crew and 1 ambulance where already on scene and  2 other ambulances could be herd in the distance responding.
The first thing that caught my eye was the mangled wreckage of what I think use to be a large white van or possibly a small bus. It was impossible to tell any longer through all the twisted wreckage and broken glass.

Now I am no weatherman, but in my 28 years of watching the news I don't ever recall the meteorologist calling for "a clear day with a chance of falling vehicles". So as we know a mutilated white bus does not just drop from the sky, some one had to be driving it and being as it was some type of large passenger vehicle the chances of there being multiple occupants are high.

I was about to find out just how high.... As I walked over for a closer look and started scanning the ground I could see the body's everywhere. Several had been covered by blankets, body bags and sheets by the helicopter crew and police that arrived before me. Others remained on display in the position they had died in.

The police soon ushered me to some of the victims that might have been missed during the initial triage. Somehow some of the victims made it to the other side of a 4 lane highway. Where they ejected, did they crawl there, did someone drag them there? Ill never know. I looked down at the first person I was brought to finding his mouth and eyes wide open as if he was frozen in time screaming. Further assessment revealed he had no pulse, no respirations, and his pupils where fixed and dilated. I assigned one of the police to cover the body with a sheet as I moved on searching for others in the dark. Soon my partner could be herd yelling for me. I came to his side to find another victim, this womans brain had managed to partially come out of her skull, she had no pulse and no respiration so we moved on. The more victims we found the more we had to cover with sheets and blankets until we ran out of things to cover the bodies with.

I stood there in the dark silently with bodies scattered all around me, crying and screaming surrounded me in the distance. I now noticed the smoking remains of another vehicle that had completely burned up. I did not even realize its presence during my initial scene sizeup. What a mess! I had confirmed everyone was deceased outside I needed to check inside all the ambulances and helicopter to see what was inside. I peered inside the first ambulance to find the helicopter medic preparing to place a breathing tube in a 2 year old child that had been ejected, then I went to the helicopter to find a confused man complaining of backpain being assessed by the flight doctor in training. I was soon summened back to the ambulance to find the helicopter medic doing CPR. The child had gone into cardiac arrest. There was probably no brining him back from a traumatic arrests but since he had a pulse on arrival, he was only 2, and this was a wittnessed arrest we gave him a full workup. 20 minutes of drugs, cardiac monitoring, ventilations, and CPR did nothing

The helicopter medic had to go back to the chopper and transport the only survivor of the accident. He could not take the child because the helcopter does not take patients that require CPR prior to take off.  I sat there in the ambulance with my partner and gazed into the lifeless boy's eyes.  I decided to call the code. I told everyone we did a good job and there was nothing more we could. I called online medical control to confirm that we where going to discontinue efforts. To my surprise the doctor on the telephone said no and to continue CPR to the hospital.... He knew there was no bringing the child back but did not want us to just throw the body out of the ambulance back onto the street in front of the bystanders. We where 45 minutes away but I had to follow orders and continue efforts.

I sat there for 45 minutes taking turns with the EMT's doing chest compressions, monitoring the ecg and ventilating the patient as I pushed drugs every 5 minutes a long the way. We talked about other things on the long trip to the hospital in a a calm casual conversation. We arrived to the hospital and they had a team expecting us. They took over care and also prepared to terminate efforts. The nurse in charge of the team asked me how many more patients they should expect as the hospital staff began prepping things. She said there hospital had been placed on stand by because of the large accident involving so many people. I just told her "there all dead." "there was only one survivor and he was taken to another hospital by helicopter." They just stood around me in silence as one of the other nurses started to cry. It occurred to me later that we had become so accustom to death and ran so many critical calls that our minds had adapted to our environments. We could do our jobs flawlessly like robots, but at what cost? What about our empathy and caring.... Had we lost some of it or all of it along the way?


There is a dark side to EMS and I do enjoy talking about it sometimes. Doing cpr on a 2 year old child while casually having a conversation with your partner about something unrelated. Stepping out of the car and looking at the dead and injured laying all around you but your heart does not skip a beat, calculating drug dosages as someone lay there dieing while everyone around you is screaming and crying, responding over 130mph(210kmh) while sipping on your lattee as you prepare to enter hell on earth.... We will talk more about the dark side next entry.

Broken hearts

Its been a hell of a week. Probably one of the most intense weeks I have ever had. I was working on writing you all a story about a stabbing, an ambulance crash and a 12 year old boy that was hit by a car and unfortunately died. Pronouncing him dead and telling his father was one of the hardest things we had to do in the past couple weeks. However as much as I love sharing with you the dark, depressing, and sad parts of the job, I had a lot of positive things happen this week. Things that made me proud to be Paramedic and people who ALS actually made a difference in. This is a short summery of my 2 Favorite cases from this weeks duty.

CASE 1: As we pulled up to the house I could I see we where alone. The ambulance had not yet arrived so I grabbed all our Advanced Life Support gear and had my partner grab the BLS gear as well. Our foot steps echoed as my team and I marched up the sidewalk with 50+ pounds of equipment. We where prepared for anything as I opened the front door. Upon entering the house I was led to a makeshift bed in the living room where I found an elderly women unconscious. Further assessment revealed that her airway was patent, respirations where clear, and pulse seemed to be slow. In fact her heart rate was 32. I hooked her up to our cardiac monitor to confirm she was in symptomatic bradycardia. Sometimes certain medications elderly people take such as beta blockers can cause this. Upon further investigation we found out the women did not take beta blockers or any other substances which would cause this. Time was ticking and her condition was getting worse. Her heart was not beating fast enough, which had lead to extremely poor perfusion and loss of consciousness. I had two choices to make. Option A. was to give her a drug called Atropine to try and raise her heart rate. Option B. was I cut her shirt off and placed the pacer/defib pads on her chest to start start pacing her with electricity. Due to the severity of her condition, lack of proper circulation, poor oxygenation to her tissue and the fact that she was unconscious I elected option B. After receiving permission from the family I cut her shirt down the middle and slapped the pads on her bare chest then began programing the monitor. While I worked on this I assigned the rest of the team to start oxygen and inter venous therapy. I adjusted the pacer settings (manually shocking her heart every couple seconds) I dialed the beats per minute to 80 and then started adjusting the mili amps (electricity) until I could see I was receiving capture on the monitor which was around 60 miliamps and began shocking. I could see her body twitch every couple seconds a shock was delivered. I confirmed that our electrical therapy was working by checking her pulse and making sure it matched the 80 beats per minute the monitor said, it did. I was now in control of when the womans heart beat. Our electrical Therapy was working and I continued pacing her until we could reach definitive care. Her skin color and condition improved en route and the receiving facility took over pacing on there machine upon arrival. The woman may need to get a permanent internal pace maker installed. She was lucky her family called 997 when they did and that an ALST crew responded.

CASE 2: The above case was still fresh in my mind when I got called at 3am for chest pain. I rubbed the crust from my blood shot eyes and reluctantly took my position in the camery. I was trying my best to start the report as we speed down the road towards the call. However I soon felt my stomach sink as I realized we had became airborne, we must have been going about 180 on a strait away when we encountered a small dip in the road. We simply flew over it and hit the ground fairly smoothly considering our speed. Only a few sparks could be seen behind us. I did my best to get back into writing the report which can often be a challenge traveling at these speeds and dealing with the insane driving in this country. Your nerves just become accustom it.

We finally reached our destination and after retrieving our gear we where lead to our patient. Upon reaching the patient she was siting upright on the sofa, covered by a vail, a concerned look could be seen in her eyes. I have seen the look before... A bittersweet combination of sincerity and fear. I find out shortly that her chief complaint is chest pain. It sounds as though the chest pain is cardiac and she had a heart attack 2 years ago. I quickly give her some chewable aspirin after confirming she has no allergy's to medication. I begin to prepare the cardiac monitor whilst ordering the crew to start an IV line, place high flow oxygen on the patient, and get vital signs. Suddenly one of my team mates who was acquiring vital signs says "Hey Mike, pulse is over 200" "What, double check that, the pulse oxcemitery unit is probably not reading properly." I replied. I finally get the monitor hooked up and find the heart rate to be only 110, which is slightly fast but normal for someone having pain."See, I told yo..... uh....." then I stair at the monitor in silence as I watch the heart rate quickly climb to 210 beats per minute. I recognized this picture perfect rythem on the monitor. We call this "Paroxysmal Supraventricular Tachycardia" or PSVT for short. Essentially what it means is that its like a car racing down the highway with no breaks. Her heart is beating 3 times as fast as it should, can not keep up at this rate forever and as a result is a less-effective pump, decreasing cardiac output and blood pressure also causing shortness of breathe.

With her cardiac history it can only work this hard for so long... I attempt whats called a vagul manuever on her. This is the least invasive procedure to try first and is easily done by instructing the patient to bare down and hold there breathe, like there having a hell of a bowel movement. Sometimes this can cause stimulation of the vagus nerve slowing down the heart rate. We tried a couple different methods of doing this over several minutes and nothing was working. She was becoming more symptomatic and her heart was now over 210 and climbing. My next step was to try and give her a drug called Adenosine. (Most paramedics have a favorite drug they carry, yeah were weird I know. Anyway just FYI my favorite is Adenosine) Adenosine is an ultra fast acting drug that expires and becomes ineffective just seconds after entering the blood stream. Therefor its imperative to push adenosine hard and fast followed by a large saline flush to shoot it up to the heart as quickly as possible. If done properly the desired effects are obvious. The patient will go flat line (asystole) on the monitor for a second or two. As you can imagine the feeling is pretty intense and this must be explained to the patient ahead of time. Like any drug there are serious risk, especially with those who have special conditions such as WPW.

As I prepare the adenosine I realize my crew is having a difficult time with the IV. There on there 2nd attempt and not sure if this attempt was successful either. I quickly look at the womens arms and can see she is a difficult stick. I continue preparing the adenosine but now I also must prepare my back up plan. If we are unable to achieve an adequate IV to push the medication quickly enough I have to try and move on to plan B. Plan B in this case is the most invasive procedure called synchronized cardoversion. It means I am going to have to deliver a large shock to the patient with the padals. I was really hoping we could avoid this.
The Adenosine was ready but the IV wasn't. Now I started staring at the defibrillator.... The woman and I gazed at the padals together as if she knew what I was thinking, and then... The IV was completed, and seemed to be running fine. We would soon find out. I grabbed the adenosine and saline that had been drawn up and connected it to her IV. We had one of the crew members explain to her that she was going to feel really bad for a few seconds and to just trust us. With one rapid motion I pushed the drug as hard and as fast as I could, quickly doing the same with the saline right afterworlds. It screamed through her vien on its way to  the heart like a runaway roller coaster. We all stood in silence and observed the cardiac monitor. What seemed like a lifetime went by, however in retrospect I am sure it was more like 10 seconds. Her heart rate maintained at 210 and no changes could be noted in her rythem. I was about to prepare a double dose and try again when suddenly the women let out a scream, followed by a moan as her face became extremely pale. I staired at the monitor in awe as I watched her heart stop beating, the heart rate went from 210 to 0 for about 1 second, followed by a large ectopic beat. Holy $%^#  I thought! I did this... and then..... a picture perfect Sinus Tach at a rate of 110. Soon afterwards the women no longer had chest pain or chest discomfort. We transported her to the hospital where several of the doctors shook our hands and gazed at the before and after ECG's we had printed off. They congratulated us on a job well done and had smiles on there faces. Many where surprised we converted her on only 6mg of the drug many people require a second double dose. The woman and her family thanked us and now we could go back to our station and await the next case.