If There’s One Thing That Keeps Me Up at Night, It’s All the Ways What’s Inside Can Betray Us 

So, why EMS?

That question came up often in the first few months on the ambulance, and it was an understandable one. I worked part-time for the county’s 911 emergency response system while I completed a master’s degree in creative writing in Charleston, South Carolina. Every time that question came up, I gave a different answer—my thoughts ever-shifting. To be honest, I did not have a good enough answer at that time. I was an unpublished writer with a string of failed and abandoned careers behind me. What the hell was I doing on an ambulance?

I told them because of my time in the Marine Corps.

The Covid-19 pandemic made me want to help out.

My dad had a heart condition, and I wanted to understand how the heart worked.

I needed a way to pay the bills.

I said a lot of other things too, and I meant all of them. Ambulances held a unique and somewhat strange point of reference in the trajectory of my life. Distant and foreign and yet somehow poignantly relevant at particular moments.

The first dead body I ever witnessed was killed by an ambulance during rush hour on the shoulder of the Cross Island Parkway. The traffic gave way to flickering emergency lights and the inevitable rubbernecking.

My friend and I were chatting when we both looked over to see an old man supine on the shoulder of the highway. Dead. The first responders moved around him. He wore one of those Irish wool sweaters that old men over 65 all seem to inherit by birthright. They hadn’t even had time to cover the body. I had assumed it had been a hit-and-run until I found the headline the next day: “Ambulance fatally strikes an elderly man walking on the Cross Island Parkway.”

The first time I was ever inside an ambulance was the last night I drank. I started a fight with a complete stranger on the street as I wandered home from the last open bar in Bayside, Queens, around 4 a.m. Someone called the cops. I tried running. I learned a lesson. Don’t tempt cops. Especially the fluffy ones. They don’t chase. I was shot in the back with his taser, and I had a seizure. The night ended with a stay in the hospital, a court date, and several cracked teeth. But I haven’t had a drink since.

*  *  *

The scope of practice for an EMT basic seemed vast and daunting during my semester-long certification course. Initially, I wanted to volunteer with the student-run EMS group on campus, but I was turned away because I was not certified. I assumed an EMT certification was probably just a CPR class with a few extra things thrown in.

Within the first week, I quickly realized I grossly underestimated the commitment required. My time was filled with a full course load of writing workshops and craft and literature classes with my MFA program during the day. Then, at night, I had a three-hour lecture and a three-hour lab, each once a week, for the EMT course, which also required at least three 12-hour ride-alongs on an ambulance as an observer.

Within the first two weeks, I double-checked the refund policy several times and debated whether it was worth putting myself through the misery. Ultimately, the course material and my instructor’s passion helped me stick it out. When I passed both the psychomotor and written portions of the National Registry exam, I was elated. I felt a true sense of achievement, and I immediately applied for a position at a county just north of Charleston. Before the end of the summer, I was an EMT on the streets riding an ALS-capable Boo-Boo Bus responding to 911 emergency calls. But I soon discovered my abilities in the field were narrow.

Those first months were filled with a lot of doubt and confusion. I had no previous medical experience. Every call I went on, my head was clogged with acronyms, dosages, and so much information. Whenever I saw a patient, my mind went blank except for the NREMT assessment sheet used by the proctor during class: a blocky, grid-lined form that held the standard for patient care on paper but was an unrealistic approach in the field.

Part-timers were both loved and loathed by the full-time medics. One foot in the door, one foot out. Not enough experience a lot of the time. Often appearing on scene wearing a somewhat bewildered expression that only lost tourists and small, fury woodland critters caught in the headlights of an approaching vehicle possess. Part-timers didn’t have set partners. We filled the vacant slots on the full-time schedule. This meant that every shift I usually had someone different. In my first six months, I worked with more than 25 different medics. Different attitudes. Different styles. Different expectations.

There was also boredom. Painful boredom. A busy day was 10, maybe 12 calls in a 12-hour shift. A slow day? A slow day could be one or two, maybe even none. There were BLS, “basic life support,” days. Lift assists and toe pain and back aches that started 15 years ago and “my kid ate a Tide Pod, are they going to die?” calls. These were the only kinds of calls I was qualified to run point on. We responded to everything and anything and a lot of nothing. In between calls, we relocated around the county to close the gaps as other medic units responded to calls. The slow days were always worse in those first few months. Twelve hours of sitting at the station and staring out into the abyss through the open bay doors. Waiting. Waiting. Waiting.

*  *  *

The world ends once a day in the low country during the summer. The wind picks up and clouds like slabs of raw granite roll across the sky, appearing from nowhere. There is that feeling that precedes a heavy storm: excitement, an electric giddiness, not quite being able to catch your breath. The skies open. The rain falls and it’s all the water in the world coming right down on our heads. And then it’s over. Aside from the wet asphalt and the sauna-quality humidity, you would never know that Armageddon had come and gone in less than 15 minutes.

Quiet fields of cotton left over from extinct plantations dot the landscape. Our ambulance wanders from station to station, and little bulbs of the crop blown loose by the wind softly bounce across our lane and into vacant church parking lots. Unending rows of bright orange traffic barrels line the roads wherever we drive. The whole county is in a perpetual state of road work. Manhattan has its scaffolding. Charleston has traffic barrels.

We weave in between the mammoth hulks of tractor-trailers and big rigs edging their way toward the interstate. They haul everything from freight to raw lumber. We haul people. The sick and dying, the unstable and the critical, the fakers and the lonely. We drop them off at the ER where patients are wheeled past us down corridors, wide-eyed and vacant as if they had stared into the face of some fierce and vengeful God for a moment too long. The rooms we pass are nickelodeons of people’s worst days. In one, the aftermath of an arrest. The paper and plastic wrappers of every single-use tool scattered across the floor. The flickering lights from the monitors. The dissonant beeps from the equipment. It is like Times Square after everyone has gone home in the predawn light of New Year’s Day. A nurse steps in the doorway and yanks the curtain divider in one swift motion, so smooth and confident it could have been choreographed on some Broadway stage.

Outside in the ambulance bay, we leave the back doors of our truck open and wipe down our equipment, place a new sheet over the stretcher. The surface of the ambulance bay tells a story without words. There are crushed catheters, spent and discarded like cigarette butts, in the crevices of the concrete. I can’t help but notice the particular rust-like way blood stains the pavement. A pearl earring. A reservoir bag from a non-rebreather. The garbage can by the entrance needs to be emptied; latex gloves and wrappers burst from under the lid. These items in the proper context are vital equipment for us to do our job, but singled out and dropped on the ground, they look like nothing but trash.

Back on the road, the day drags on. More calls, more driving. Blackened roadkill steams on the side of the road. This is the land of beehive boxes on front lawns and Hunt Brothers Pizza wedged in the back corner of nameless gas stations. Baseball diamonds with weed-infested infields beside brand-new county-funded parks with manicured lawns and shiny jungle gyms. Rows of assisted living facilities with handicap ramps. Shattered basketball hoops above garages and fractured pieces of crayons on the railings of front porches. Friendly one-eyed cats greet us on the front steps of apartment buildings while we wait for someone to answer the locked doors. Dried pools of blood in kitchens from mysterious half-remembered falls by elderly retirees who live alone.

The closer we get to the end of the shift, the harder it gets to watch the clock. We get off at seven, but if a call comes in and we are the closest available unit, we have to take it. Flinty cloud coverage forms a great dome over the suburban sprawl, illuminated by the holy neon lights of the Volvo dealership, the Quality Inn, the Cracker Barrel. We creep closer to our station, trying to make it back for crew change. Exhausted, quiet. I can’t wait to get out of this uniform. This is a job that clings to your skin. Every patient has left something of themselves on you, metaphorically and often physically. The suburbs give way to the rural. Derelict churches and abandoned auto body shops. Fluorescent crucifixes above the doors of single-level cinder block churches glow white-hot in the violet darkness.

Another slab of raw granite rolls across the sky, another storm rolls in.

*  *  *

How do I tell an ambulance story? There’s certainly more than one way to do it. These stories come ready-made. There’s natural suspense and tension cooked in. But it takes some awareness. It depends on who I am telling it to. I might not include details that feel gratuitous or unnecessary, like how the first few compressions on the chest of a pulseless patient feel like crushing sea shells wrapped in gauze. Not everyone wants to know what it feels like when the cartilage of the sternum breaks away and allows for the chest wall to move freely, which in turn compresses a heart that is no longer effectively pumping blood. There’s vomit and blood and other fluids that most people are naturally repulsed by. I’ve stood over a patient when it appears the whole body is rejecting itself, unbecoming itself, and starting the process of decay right there in front of me. I’ve found that even the most curious of listeners can quickly disengage at the first mention of these aspects.

Television and film rarely, if ever, get it right. It’s all delicate chest compressions and cheap stethoscopes. Working on an ambulance is filled with clunky, awkward moments. It moves a lot slower than one might expect. Experienced paramedics are some of the calmest, most reserved people I have ever seen in emergency settings. There’s something about witnessing a person remain calm in the midst of chaos. The patient, supine, is at the medic’s feet while the firefighters work rounds of compression and I manage the airway. The medic stands over us calculating drug dosages, noting the vitals on the cardiac monitor propped on the bed, working through the algorithm for a cardiac arrest, and it’s all in their head. There’s a large pot simmering on the stove in the next room. The aroma is rich and savory, something Italian, and it fills the house. A dog barks endlessly. None of these people were expecting to be in this situation today. This family’s world is coming apart all around us, but the medic in charge is absolutely calm, and somehow this translates to a specific type of control. It is their scene.

Everyone is watching for your reaction. And if you break, if you crack, these strangers will never forget it. For the next 20 years, every time they tell this story at bars and church gatherings and holiday parties, they will focus on that specific moment, regardless of the outcome, and say, “And that’s when the medic said, ‘Oh shit’!”

If I have a really engaged audience, I might take some time to offer some real-world insight I’ve gained from entering people’s homes on their worst days. Such as the vast majority of the general public spends their time in the privacy of their own homes in the nude. It feels like almost every cardiac arrest I’ve been to at a residence, the patient was stark naked.

I’ll probably use some humor. Like the only time I ever greeted a patient with “How are you?” She stared at me for a moment, a frail, little old lady with chest pain. “I’m in the back of a fucking ambulance. How the fuck do you think I am?” she asked.

Oftentimes, people just want the wild stuff. They want the crazy stories. So maybe I just go straight for the sensationalism, the sort of details people expect from 911 calls. Like the time a guy got into a nasty argument with his girlfriend after drinking all Saturday night and then doused himself in lighter fluid and lit himself on fire. He greeted us at the door and walked right past our stretcher, waving it off and telling us he would just get into the ambulance himself.

Maybe I frame it as a moral tale. Why you should always wear your seatbelt or how there’s nothing to be gained from road rage. Or a “be careful what you wish for” type of story like the time my partner and I were cleaning our equipment after dropping a frequent flier off at the hospital while a no-shit shooting went off in our district. There we were, wiping down the stretcher and our blood pressure cuff with purple wipes, whining and complaining about how the one time we get a legit trauma call in our district, of course, we are stuck with a patient who refuses to take their insulin so they’re having a—

And at that moment a gunshot wound patient comes careening into the hospital parking lot. Turns out the patient’s wife had made the 911 call but then panicked and threw her husband, gunshot wound and all, into her minivan and hightailed it to the nearest hospital. Gunshot wounds are weird. I never expected it to be difficult to locate a gunshot wound. But the blood just seems to be nowhere and yet everywhere all at the same time.

But sometimes it is better to go for the quieter details. The ones that no one expects. When The Big One happens, it perfuses into reality as if we should have expected it all day. Tones drop. The notes appear on our screen. Echo response: unresponsive, unconscious, not breathing. We ride lights and sirens to the location, splitting the traffic right down the middle the whole way there, and when it goes right, it’s like Moses parting the Red Sea. It’s Saturday night, and we are heading into a bar where a patron has suddenly collapsed.

“Take your fuckin’ time,” a man grumbles at us as we pass him on the patio of the bar, leaning over a beer and a cigarette.

Or maybe it is a residence we are heading to and when we arrive, we park, get our gear out, and walk to the front door. To stand outside on the corner, you would have no idea someone was dying inside the house we are about to pull up to. It is an unremarkable suburban house. The sun has just set and the heat is still radiating from the asphalt in that soft and comforting way it does late in the summer. Even the first steps through the front door do not reveal anything abnormal other than some indistinct commotion coming from a room deeper inside the house. You could tell a family had lived there. We pass worn-in sofas that hold bodily impressions in their cushions like molds for forming future generations.

It is in the things on the walls: the photos, the paintings, the memorabilia, and souvenirs, all slightly out of date and coated in a thin film of dust. There are things forgotten in the corners too. A display of fine china. A collection of porcelain dolls. A crystal bowl. All of these items left so long that they become a permanent part of the house. So familiar that it becomes unseen. But then a wife or a husband or a child comes rushing around the corner to meet us and any semblance of a normal home is shattered.

If I really trust the person, I might get candid, even a little vulnerable.

My first serious trauma alert involved a young woman who had crashed her car while arguing with her boyfriend on a narrow back road. She clipped another car while trying to pass and sent the other car into the woods. Her vehicle rolled and came to a stop on someone’s front lawn. The boyfriend left the scene with only a few scratches. She was ejected and then her vehicle rolled over her. By the time we got to her, she was turning blue and did not appear to be breathing.

We get her in the back and my partner is asking me for an OPA and I know exactly what an OPA is. An oral pharynx adjunct, a curved piece of plastic inserted into the mouth to keep the tongue from blocking the airway. That’s day one stuff. But I can’t find it. Or rather, I can’t recognize it. I have the airway bag open in front of me, the cover is completely peeled back and I am staring down into it. All of the instruments are right there in front of me, but they’re just objects. They have as much meaning to me as a child’s set of blocks: a collection of solid, primary colors. Red, yellow, green. Smooth and shiny.

My partner is still asking for an OPA, just the slightest hint of frustration on the edge of his tone. He masks it well. The sign of a truly gifted medic. Calm, deliberate, refraining from shouting at me.

Finally, he reaches past me and grabs it, and I am relegated to the BVM, which I use to breathe for the patient until we reach the hospital. Quite a lot is happening around me; meds are being administered, a flurry of different hands, competing voices, but I focus on keeping the mask sealed to her face and squeezing the bag every six seconds. Images lodge in my memory. Shattered glass and bits of brown leaves in her hair. A faded tattoo of a butterfly on her hip. Despite our efforts, she is fading quickly. The trauma bay is prepped and waiting to receive us when we arrive at the hospital.

Things move quickly. We roll her in, transfer her to the bed and the trauma team takes over. There’s a lot of space in a trauma bay and the whole operation has the feel of a NASCAR race pit. My partner lets me stay in the room. I never take my eyes off her, and yet I don’t even notice the surgeon perform an emergency thoracotomy. They cut open her chest cavity to massage her heart. It sits there like a pearl in an oyster.

Resuscitation is violent. There’s a narrow window to bring someone back after they’ve gone over that cliff. To do it correctly requires violence. But I’ve never felt more alive than when I am kneeling over the body of an unconscious patient using my own body weight to compress their chest wall with the chance of bringing them back from the dead. There’s no sadness. No regret. Even if you do this job completely right, and execute every skill with absolute perfection, it can still result in the worst possible outcome.

If it’s at the end of a particularly long shift, I probably won’t tell any stories at all. I’m tired and it’s time to go home. Who wants to talk about work?

*  *  *

Another night of nothing. Boo-boos and bullshit. It’s near the end of another shift and I’m working in one of the isolated stations in the upper part of the county. Time in the upper county is always a little warped. An hour passes slowly, with a dilated feel to it. My contribution for the day? I accidentally hit the wrong button on the garage door opener as we left the bay to respond to a call and the door came down and knocked our antenna off, rendering our ambulance invisible to GPS. We had to go out of service to write an incident report and then switch to a vanbulance; a smaller, compact little thing that projected about as much authority on the road as a clown car. The firefighters make sure that we are aware of it. Some days were like that.

Despite my error with the garage door opener, I am beginning to sense a certain level of comfort with the job. I know what I know and I don’t know what I don’t know. I’m comfortable with this fact.

I’ve got teeth on the brain. Our first call of the shift was for a fall. An elderly lady in a church parking lot. We lifted her onto our stretcher and loaded her into the ambulance for transport. She had banged herself up pretty good despite only falling out of the passenger seat of her car. I took lead. As we were getting ready to leave, she became irritated and motioned to her mouth. I held my gloved hand out, open and willing, and she spat shards of a tooth into my palm. The last one clung to her bottom lip, not ready to leave.

I wrapped the shards in some gauze and asked if I could place it inside her purse.

“Go ahead, I’m not hiding anything in there. I don’t have any secrets. Unfortunately,” she said through a bloody mouth.

But that wasn’t entirely true. We all have secrets. Our bodies are full of secrets. Our bodies are filled with crevices and hollow places that we never really consider. They’re filled with latent defects and deficiencies that come out in the form of tumors, aneurysms, clots, and embolisms. If there is one thing that keeps me up at night after working in this field, it’s not the outside world and the variety of ways it can harm us, but all the things brewing inside we have no control over.

We qualify our time in EMS by our “yets.” Generally speaking, we are more concerned by what we have yet to do or witness rather than what we already have experienced.

I haven’t placed a tourniquet yet. I haven’t seen a decapitation yet. I haven’t cardioverted a patient yet. I haven’t performed a field delivery yet.

Despite the “yets,” I learned quite a lot in less than a year. There are the things you learn slowly, things that take practice and repetition. Like how to work a code together as a team. And things you learn quickly. Like how people actually change colors when they begin to die. And how you never—ever—say the Q word.

I spent six years in the Marine Corps as a machine gunner preparing for a job I never even had the opportunity to do in real life. No deployments. No combat. No war. I’m not saying I wished for war. I’m not saying I wish I had gotten a chance to do my job or I would give anything to have done my job. My job was to kill people. Bad guys. All of my friends who have been there and done that have very complicated feelings toward the experience. All I know of war is what I’ve read about and what my friends have told me, which is to say, I know nothing.

But EMS gave me the chance to actually do my job. In six months, I had done almost everything in my scope of practice. It wasn’t always smooth, but the confidence and the proficiency came in short order. I’m coming up on a year and thinking about going full-time.

There’s one call from that first year that I am genuinely proud of. A psych patient who was hearing voices that told her to stab her dog with a kitchen knife. I wasn’t even supposed to be there. It was the end of shift, and, of course, my relief was late. Goddamn part-timers.

We arrived at the residence, a dilapidated trailer tucked away in the rear of a trailer park, staged the ambulance, and got out. A police officer approached me.

“Ever transported her before?”

“No, never been here,” I told him.

“All right, well, she’s the real deal. If you can find it in the DSM-5, she’s got it. Schizo, multiple personalities, history of violence, hears voices, self-mutilation. You have to be careful with her.”

The door to the mobile home opened and a woman emerged. She was around six foot five inches and maybe 285 pounds. She had to duck to avoid hitting her head on the door frame when she walked outside.

My partner looked at me.

“Looks BLS to me. All you, man,” he said.

Great. Just how I want to end my day.

Psych patients are a topic of contention in the EMS community. There has long been debate about whether 911 ambulances are truly the best resource to use for such cases. Psych patients can be unpredictable and even dangerous to providers, and we often have very limited training and tools to deal with them. But the fact of the matter is this is one of those medical professions where you are expected to be something of a jack-of-all-trades.

Some providers take a very authoritative approach by immediately asserting dominance and control with their tone and actions while others try to show radical empathy and use soft voices. I know some medics who immediately reach for the ketamine and restraints at the slightest sign of aggression. Many just don’t have the patience to do anything other than buckle them into the captain’s chair and get to the hospital as quickly as possible. My own approach? I don’t have any drugs that would help, so I do my best to keep the environment calm and stay out of arm’s reach.

Initially, everything was fine. The woman was more than willing to come with us. She was much larger than me, but her disposition was the kind of docile reserve that an elementary student displays the first few weeks of school while they are still getting to know their teacher. I started my assessment by asking her some questions to get a feel for her orientation and state of mind.

She told me all about the voices and how they were demanding she stab her dog, a tiny Maltese named Luna. I told her she had done the right thing by calling us. She calmly sat herself on the stretcher and allowed me to secure the seatbelts around her legs, waist, and chest. I sat in the captain’s chair behind her so I could still see her but keep a comfortable distance—as much as possible in an ambulance.

We made it onto the interstate. No problems, nice and easy. The truck gained speed. Between 65 and 75 mph. Ten minutes out from the hospital.

This was when her breathing quickened. She mumbled something.

“What was that? Everything okay?” I asked.

More mumbling. Heavier breathing.

“Did you say something? I didn’t catch that.”

I stood up and carefully maneuvered my way to the side of the stretcher. She was definitely breathing more heavily. She was wide-eyed and crying too. Fat tears were rolling down her cheeks, and she had a look of abject horror on her face.

“Hey, what’s the matter?” I said in a soft and concerned tone.

“They’re mad! They’re mad at me for coming with you! They say I need to get out of here!”

Every sentence was louder than the last and I could sense the panic rising inside of her.

“You did the right thing,” I said, calling her by name. “We are going to take good care—”

She unclipped her waist and chest belts in one attempt. Her feet slipped out from under the belt at her ankles. “I need to get out of here! Let me out of here!”

Is this real? Is she just faking it? Does it matter? In that moment none of those questions seemed relevant. The facts were simple: I was in a tiny metal box on wheels now more akin to the Thunderdome than a place for medical aid that was careening down a major highway, and my patient, who had a documented history of psychotic episodes and was significantly larger than me, was reaching for the handle of the back doors. I was on my own. No amount of training or knowledge learned in any classroom could have prepared me for it.

For a moment, the entire universe could be seen through the back windows of that ambulance. Cars raced around us and the concrete highway spooled out from underneath like an infinite silver ribbon. I reached out and gently placed a hand on her arm.

“Do you want to try something together?” I asked her. I kept my tone gentle and as calm as I could.

She paused. I had her attention and, more importantly, her trust for a moment. But probably only a moment. There was no time to waste. I kept my hand on her arm, and she remained frozen, one foot on the floor, the other midair hanging off the stretcher, a hand gripping its side.

“Just follow along with me. I want you to breathe in, hold it for a few seconds, and then let it out slowly. Now, breathe in, one … two … three … four. … Hold it, one … two … three … four. … And release one … two … three … four. … Great, let’s do it again.”

I couldn’t believe it. Not only was she listening and following along, it actually appeared to be working. I could feel the tension in her arm relaxing, and then she settled back down. We continued this way for a few rounds, and with each exhale the pressure in our little box released a bit too as if some unseen hand was turning a knob. Finally, she picked her foot up and placed herself back on the stretcher.

“Will you take my blood sugar? I just don’t feel good.”

“Of course. Just let me buckle you back in.”

When we got to the hospital, she calmly stood up and walked herself off the ambulance and right to the charge station like she had been riding the local bus to the grocery store. My partner gave me a look.

“How did you pull that one off? Sounded like it was about to get pretty hairy back there.”

Breathe.

That’s it.

Breathe.

---

This War Horse reflection was written by Michael Jerome Plunkett, edited by Kristin Davis, fact-checked by Jess Rohan, and copy-edited by Mitchell Hansen-Dewar. Abbie Bennett wrote the headlines.

The War Horse