Sheer Terror

For Dave Dugan, it happened almost 20 years ago.  His first shift as a solo paramedic. His first time running a fully stocked ambulance with no partner and no one nearby to call for help. He remembers all the nights he spent pacing in hallways, hoping no one would call. Because nothing prepares you for your first multi-vehicle car accident, when you show up by yourself and every uniform turns in your direction. It’s a feeling of sheer terror that every paramedic remembers…and it lasts for months.

Dugan’s journey started when he joined his local volunteer fire department at 16, earned his Emergency Medical Technician (EMT) certification at 18 and graduated from paramedic school at 22. “I don’t get nervous anymore,” says Dugan, but like all paramedics, he still works in chaos. Since the dawn of his profession, paramedics have been the first ones called to crime scenes, accidents, tragedies and war zones.

Like Dugan, they may respond to 1,000 calls a year. After two decades, they find themselves at 36 years old, unable to recount how many deaths they’ve seen or lives they’ve saved. “It makes you cynical, cold and callous,” says Chris Dove, 40, Dugan’s officer in charge, but it also illustrates the contradiction inside every paramedic.

The job demands so much and pays so little, yet remains irresistible to a sub-group of type-A personalities, a mixture of adrenaline junkies who follow orders, chaos seekers who crave organization and deeply caring individuals who avoid any emotional attachment to the patients under his or her care. Every paramedic would like to make more money, to be paid on par with police officers and hospital nurses, but part of the paycheck will always come in adrenaline, and they can’t get that anywhere else.

On a cool summer morning in late August, the thought of Dave Dugan as a fretful rookie seems unimaginable as he walks into the Harrisburg headquarters of South Central Emergency Medical Services. He’s a 20-year EMS veteran now, an experienced battalion chief who hasn’t seen it all but probably will someday.

Dugan holds onto his rookie memories – not for nostalgia, but because it helps him relate to the younger paramedics and EMTs now under his leadership.

Passing through two code-locked doors, Dugan walks down a carpeted hallway, past a lounge and into the battalion chief’s office. The station is quiet at 6:54 a.m.

The previous battalion is still on call, and its chief, Angela Pinti, won’t return for another 15 minutes. Dugan settles into his tiny office and wakes his computer.

It’s the Friday morning before Labor Day – a time when most people are planning their vacations – but it’s just another Monday for Dugan, the start of a new workweek.

Dugan checks his email and attends to the administrative duties of running a battalion as Chris Dove enters his office. Four years older than Dugan, Dove is a pot-bellied, thick-armed comedic motormouth, a man with too many opinions and not enough time to share them.

Dugan, however, is a man of few words. He’s tall and fit with the disciplined upper body of a police officer and the shaved buzzcut of a new Marine.

For lunch, Dugan eats baked chicken and applesauce. Dove will eat anything.

Naturally, their odd-couple routine works, with Dugan as the straight-laced man sweating the details, while a freewheeling Dove serves up the hardbitten comic relief. Further noting this disparity, Dove points to a small sign taped on Dugan’s filing cabinet, a phony certificate of recognition congratulating Dugan as “The Most Likely to Have an OCD-Induced Mental Breakdown.”

“He’s the only guy I know who alphabetizes his lunch box,” says Dove, as Dugan laughs.

Dugan’s been organized since he was a kid, and the trait serves him well as battalion chief. In the hallways outside his office, the nightshift filters in, and the voices of arriving paramedics echo down the hallway, growing louder with the arrival of Angela Pinti.

Dugan and Pinti hold a brief informal meeting in their tiny office where they catch up on the minutiae of running an emergency-services provider in 2013: the paperwork of scheduling, regulatory compliance and inventory supply levels.

Dugan oversees medical supplies for the entire company, and before leaving the station, he checks the inventory levels on his own vehicle. He pops the trunk on his police-package Chevy Tahoe and begins counting every supply within. Paramedics love the freedom of working outside without bosses over their shoulder, but they can’t afford to be forgetful. EMS vehicles are filled with duffel bags, which are divided into tiny compartments stuffed with just the right amount of life-saving drugs.

If a paramedic arrives on scene having forgotten a medication, the mistake can kill.

Accordingly, Dugan checks his medications with the thoroughness of a safety inspector. He opens a multitude of tackle-box-type containers and checks various vials, needles and medications outfitted with special emergency applicators developed for EMS personnel.

Occasionally, he comments on the price of a certain medication or piece of equipment.

Pointing to a Medtronic Lifepak 12, a life-saving defibrillator no larger than a portable stereo, Dugan mentions a price tag higher than the average mid-sized American sedan.  Driven by technology, modern medicine is an increasingly expensive endeavor.

When South Central EMS opened its doors in 1957 – under the name The Firemen’s Ambulance Association of Lower Paxton Township – they used a donated Buick ambulance and a combined $150 start-up capital from three local volunteer fire departments.

Today, that money wouldn’t last 45 minutes. Training and technology marches forward every year, improving a paramedic’s ability to save lives. But that ability comes at a cost.

“The biggest misconception about us,” says Dugan, “is that we’re ambulance drivers.”  A second misconception is that EMS providers are solely supported by the municipalities they serve, in other words, by the tax dollars of those who receive care. From 2008 to 2012, South Central received $224,000 per year from Lower Paxton Township.

Today, due in part to competition, that annual allocation stands at $27,500. In fact, companies like South Central EMS are nonprofit entities that bill insurance compainies on behalf of those receiving care. Tax-payer funding for EMS remains a fraction of the money given to police and fire departments, says Dugan, and many EMS patients are older and covered by Medicare, not known for its high reimbursement rates.

By 9:35 a.m., Dugan has completed a solid hour of paperwork and restocked his vehicle in preparation for escaping the office. He hops into his Tahoe and drives toward the Lower Paxton station where he’ll unpack a shipment of medical supplies.

South Central EMS orders between $6,000 and $7,000 of medical supplies every month, and Dugan speculates about the funding disparity between EMS and its more generously endowed siblings in police and fire departments.

“Historically, we started as volunteers,” says Dugan, noting that some of the first ambulances were operated by funeral homes. In those days, two well-intentioned men simply showed up in an ambulance, loaded patients into the back of the vehicle and both returned to the front seat as they raced to the hospital.

Dugan shakes his head at the thought that EMS personnel actually started as volunteer drivers. “It’s always difficult to start paying for things that were once delivered free,” says Dugan.

“A big challenge now for the EMS community is lack of depth,” says Dugan, meaning the most experienced paramedics are leaving because of low salaries. Tired of working two or three jobs, Dugan sees experienced paramedics reach a certain age and then transition into police or paid fire departments, often in the south where jobs are more plentiful.

Dugan’s former partner is now a deputy sheriff in Virginia, where he enjoys a better salary and the satisfaction of a more proactive job.

Arriving at the Lower Paxton station, Dugan unlocks the entrance door and makes his way toward a well-organized medical-supply room. Inside an adjacent delivery alcove sits a large pile of cardboard boxes filled with supplies including medicines, drugs and blood-pressure cuffs.

Dugan explains various drugs like Zofran, an anti-nausea medication, and holds up an epinephrine pre-filled syringe, which treats cardiac arrest. “I’m OCD, remember, so it all has to be laid out nice,” he says.

It’s an ideal task for a mind like Dugan’s. He uses a razor to open each box and unpack its contents, placing each new supply in its correctly labeled container, before breaking down each box into a tiny pile.

Upstairs, in the station’s lounge, 27-year-old EMT Bryony Foltz is talking with EMT Assistant Steve Harman, a retired county dispatcher. Foltz has college degrees in both finance and economics and previously worked as an accountant, but after losing her job, she entered EMS.

As a young girl, Foltz wanted to be a coroner. She describes herself as shy and accommodating, someone who goes with the flow. But working as an EMT gave Foltz confidence and forced her to get involved.

Earlier in the day, Dugan said you can’t be shy in this line of work, and Foltz experienced the transition firsthand. “I’m so much more proactive now,” she says. “Now with people I can be bam-bam-bam with questions. And we deal with so many different types of people: rich, poor, young, old.”

Dove says paramedic personalities are drawn to action, toward chaotic environments into which they can bring order. They don’t like down time. “We don’t sit well,” says Dove. “We don’t play well with others. Generally, the longer we sit, the more trouble we get into.”

Paramedics all have stories of showing up to scenes where knives have been drawn, guns brandished; they’ve got stories of being attacked, assaulted or driving 70 mph down a highway with a patient spewing blood from an artery, coating the ambulance walls.

Because the work is so intense, the downtime is that much duller. It’s often the camaraderie that helps paramedics cope with the reactive, at times helpless, nature of their jobs. A police officer can actively enforce the law, but the paramedic’s curse is waiting for a crisis, forever reacting after it happens.

This leads to an interesting phenomenon – the act of wishing for action, hoping for the chance to do what you do best – and though paramedics want everyone to be safe, the very nature of emergency response workers shows you how a fire fighter could become an arsonist.

Paramedics help people survive before they get to a hospital. “We don’t want people to get hurt,” says Dugan, “but when they do, we want to be the people called out to help.” On cue, the day’s first call arrives at 10:50 a.m. – a heavyset woman with high blood pressure.

Dugan leaves the medical boxes half unpacked and heads to his car, entering the address into his dashboard computer. Immediately, Dugan sees his ambulance has been en route for four minutes, and as he drives, the radio offers a constant update on the woman’s condition.

“Larger woman, sweating heavily and dizzy,” says the radio. Five minutes later, Dugan turns down a road and sees a South Central ambulance in the distance, parked in the cul-de-sac of a tidy neighborhood in Lower Paxton.

A middle-aged man stands on the porch, watching the ambulance’s flashing lights turn this quiet neighborhood into a scene, where a few neighbors come out to gawk. Dugan walks toward the ambulance and checks inside, but the woman has already been stabilized.

Paramedic Matt Artz and EMT John Hartzel take the woman to nearby Community General Osteopathic Hospital. “Generally we honor the patient’s request for where they want to go,” says Dugan. “But for extreme cases, like traumas, they go to the Hershey Medical Center, a one-stop shop.

Osteo is a small community hospital. Harrisburg is good for heart attacks. Hershey is good for trauma and heart attacks, and Holy Spirit is close, too.” Regardless of the hospital, however, a paramedic must be confident upon arrival.

“It takes a couple years to become confident,” says Dugan, “because you have to go to hospitals and explain what you did to the doctors, and sometimes they want to fight with you.” With emergency rooms best described as organized chaos, a delicate relationship exists between paramedics and doctors. While doctors work inside state-of-the-art hospitals filled with support personnel, paramedics do their work quickly on the sides of the roads, in bedrooms and at county fairs. “People don’t call us to talk,” says Dove. “No one reads a textbook on how to have a heart attack. That’s why they call it practicing medicine.”

Dugan returns to the Lower Paxton station and finishes unpacking the medical supplies, then drives to the Middletown station to drop off more supplies. Paramedics joke about getting calluses on their butts from spending so much time in a car. Around 4:30 p.m., radio chatter suddenly picks up.

Reports of a car accident with injured children, a factor that often disrupts a paramedic’s goal of emotional detachment. Angela Pinti, now working a second consecutive shift for another local EMS provider, is dispatched to the scene. At 5:06 p.m., the accident continues to worsen over the radio.

A 9-year-old has suffered a cardiac arrest in Pinti’s ambulance, and Pinti reroutes to Community Osteopathic, the closest emergency room, but they don’t have the pediatric emergency-room capabilities of Hershey.

Dugan accelerates onto Rt. 283 toward the hospital, hoping to check on the situation. “I’m just here to back her up,” says Dugan, as he pulls into the ambulance parking lot.

Dugan goes inside and stays for a long time. Ultimately, he can’t comment on the patient except to say she’s being moved to Hershey.

Dugan leaves the hospital after 45 minutes and drives back to the Harrisburg station, where he’ll finish the day’s paperwork. The sun fades over the horizon, and it’s been a slow shift.

Relative to a normal day, Dugan says they had no calls, “but 15 minutes from now we could be up to our elbows in blood on the highway.” As Dugan talks, Dove and his partner sit in the lounge, quietly preparing to go home.

It’s just before 7 p.m., and Dove is thinking about playing hockey after work. Dugan sits in his office, talking with the incoming battalion chief about the affairs of the day. A day in the life of a paramedic can be filled with calls: accidents, drug overdoses, murder scenes, “a busload of hemophiliacs overturned on the highway,” as Dove describes it, or it can be like today.

A day spent unpacking medical supplies, ferrying a woman with high blood pressure to a community hospital and transporting a 9-year-old accident victim to a nearby hospital…who ultimately passes away.