The Muted Mercy Plea.

Sitting idly in the ambulance and cursing our lack of air conditioning, we are parked in an abandoned corner lot in the very last reserve ambulance of our fleet - meaning, the very worst ambulance we have to offer. Ten hours into the shift and we have not stopped sweating, even as we are resting beneath the shady awning of the abandoned chicken eatery. It's days like these when you beg for a call because at least then you get some semblance of air conditioning with the windows down at whatever speed we may be traveling - much faster than zero, our present speed.

As you will find, this is a lesson on mercy, and it is with this mercy that the dispatcher calls our unit, gives the address, and we're quickly en route to a "person unconscious, possibly not breathing" in a trailer park community on the outskirts of our zone. The response is without incident as I sit idly by in the passenger seat, and the EMT drives me there. In times like these I normally find myself mulling over ACLS protocols, drug dosages, and a bevy of what-ifs. This time I sit and just breathe without any sort of expectation. I do make a mental note, however, that the call address is vaguely familiar.

We arrive and are greeted by a large pit bull snarling and barking, though ineffectually as he/she is restrained by a heavy gauge chain attached to a railroad spike driven deep into the ground. We push our stretcher past, encumbered with so many medical bags and cardiac monitor in preparation for who knows what. A police cruiser arrives shortly behind us and the officer picks up his stride to make sure he can enter before we do, for safety. We follow in behind him.

A wall of odor envelopes us as we step inside the dimly lit trailer. The floor is a patchwork of rotting planks, plyboard, cardboard tamped down with tiny nails and haphazard void spaces throughout the flooring which we identify by both the sinking effect of the soiled carpet and our previous knowledge of having been to this address several times. We ease the stretcher past and the odor is getting stronger. We pass by ten gallon plastic buckets filled with oily yellow urine and clumps of acrid feces. Perhaps it's just me, but I tend to feel more at ease when I discover the origin of the various odors I encounter in this job, even if it is buckets of fresh excrement.

Stepping tentatively into the very back bedroom we hear a baby crying - an infant unattended in her crib. There are three males in the room, 20-somethings, two awake and obviously paranoid and one male spilling in between a mattress and the wall with his face buried in the crevice. It would be a waste of time to interrogate the two conscious males and probably not in the best interests of the guy sandwiched in the corner so we stride past and pull the unconscious male out of his makeshift nook.

Upon rolling the male over we find he is indeed unconscious, with blue lips, cold hands and blue fingertips. I am counting his respirations as I survey the rest of his body - soiled wife beater, sweatpants, and white socks soiled green and brown from I don't know what. Instinctively I re-assess his arms and find a child's belt still tautly ratcheted around his bicep. Heavy tissue scarring and track marks are scrawled across his antecubital regions and forearms. On cue, an empty syringe is found gleaming in the periphery of my vision, it reflecting the only light entering the room through disheveled blinds.

The police officer is quickly relegated to watch over the tiny child in the crib and we hoist the unconscious, barely-alive male onto the stretcher. It would be my inclination right now to judge and condemn this man, and perhaps I should, but I resist. We secure the male with three seat belts across his legs waist and torso and lift the stretcher to its mobile position. I should curse the man for making me trek across a booby-trapped living room, over buckets of piss and shit, just to reach him, and yet I don't. Looking up I see pictures of the likeness of this man, and he's joyfully cradling what I identify to be the child in the crib, and there is also a female in the picture. A sign of better times, times not so riddled with demons.

There are so many avenues for suffering in this life, and so many ways to become apprehended by it, and by and large I find that the suffering my patients incur is of their own construction. With every avenue of suffering there is a healthy way to resolve it, but some people can't seem to find it.

We're quickly moving the patient out of the trailer, bumping across the broken concrete and gravel driveway and loading the male into the ambulance. A wooden sign hangs above the front door of the trailer which displays "A blessed family lives here." So many times we are trying to find ways to dehumanize the people who do wrong, in the face of abundant evidence of their humanity. Despite many wrong turns this man is made of the same flesh as me, created in the same way that I was, and he has smiled surely in ways that I have smiled, laughed as I have, and rejoiced in ways that I have. He has crumpled to his knees like me, and he has cried like me, but he has handled his problems differently. He has handled his problems in a human way, within the broad spectrum of human responses to a problem, and yet most would only judge him. It's so easy to do, and especially at this juncture he has allowed himself to be quite susceptible to it.

My partner makes a remark about this patient being a piece of trash. I tell him to hop up front and drive us to the hospital. It saves me from listening to judgmental racket. I need silence to operate.

The ambulance emerges from the driveway and claws toward the hospital ten minutes away. Back to the patient: he is breathing four times a minute and his heart rate is slowing. He is neatly packaged at death's doorstep and funeral arrangements are already being conceived in the cosmos without his knowing. Days from now he may say he saw a light.

I pop on medical gloves and set out IV supplies. I inspect the patient's arms for an IV site but nearly every go-to region is scarred to shit from years of IV drug abuse. Looking further up the arm, past the tattoo which says "LUV 4 MY BABY" I find a basilic vein on the underside of the crook of his left arm. Makes sense, it's hard to insert an IV on the underside of your own arm. Just inches away there's no good real estate at all for a suitable IV but this vein is pristine. I prep the site, prepare the IV catheter and look through the ambulance to the road ahead and see a straightaway ahead. Good, time to get this IV. I sink a twenty gauge catheter, twist on the adapter and secure the site with tape.

Maybe this guy wants to die. The panicked look on his friends' faces in that bedroom hint at otherwise. Most people cope with a bad day by having a few beers in the evening, perhaps he coped with a bad day by slamming two syringes of heroin into his circulation. The pictures hanging on his wall of his family tell of better times, of times that could be had again. Every day is a new day to rewrite all of the adulterated passages of our lives. Here lies a man with a muted plea for mercy. I can't judge him now.

I grab the vial of Narcan, an opiate-agonist antagonist. Basically it clogs up the opioid receptors in the brain so that no more true opiates can permeate, reversing the effects of whatever may be on board with this guy right now - which I'm pretty sure is a copious amount of heroin. I draw up the entirety of the vial and drop the empty vial into the sharps container. I slowly push the medication into the IV adapter followed by a flush of 10 mL of normal saline to ensure it circulates.

"Two minutes!" my partner yells back. The best case scenario is that I will be wrestling with a very angry and confused person for the next two minutes until hospital staff can help me. The worst case scenario is I've got the differential diagnosis all wrong and I'll be doing chest compressions soon.

The ambulance lopes onto the emergency room ramp and we back up to  the ER doors. The patient stirs, his eyes open and he strains to look all around him. I am seated behind him and he peers at me with a flash of anger. I ball my fists, ready to hold this guy down until help can arrive. He struggles briefly against the seat belt restrains, shuts his eyes tightly, and takes a deep breath.

I take a deep breath with him.

When his eyes are open again they are filled with tears.

"Where is my baby girl?! Did you leave her there all alone?!"

I calmly reply no, she is at home safe. A police officer is taking care of her.

Silence.

Tears are streaming. His voice creaks, "Thank you man..."

Once docility is ensured, we unload the patient, now pink warm and breathing normally, and wheel him into the emergency room. I turn him over to the nurses and physician and give my report. I don't bother explaining about the buckets of urine and feces, the trailer with more holes in the floor than intact surfaces, or the baby who was sitting in close proximity to her father as he injected a near-fatal amount of heroin. Not yet, anyway.

Some things are better left unsaid, for now. I return to my ambulance to complete the report, still sweating as much as I was before the call went out. My partner hops in the driver's seat. "What a piece of shit!" he exclaims. I look up, ready to say something, but I digress, and just breathe, and type my report. Still sweating, life goes on.