Dear Rutgers Chipie

By Steven P. Velasquez
September 6, 2010

This past weekend, as you were doing your daddy-funded, weekend bar crawl, you had occasion to actually look at me and acknowledge my existence (a rarity). You see, more than likely, you do not who I am, what I do or how my existence is actually of benefit to you, while the inverse is untrue. I am a Paramedic. The truck you see me in is a Mobile Intensive Care Unit; some say “a hospital on wheels.” That may be a little extreme and I won’t debate semantics but I’ll say I bring a very specialized part of the healthcare system to your doorstep, your college dorm or whatever bar you finally pass out in during your parentally unsupervised stay in my town.

My partner and I were parked in an empty lot when two of your fellow school mates lacked the intelligence to resolve their differences verbally. As they removed their shirts and assumed a combat stance, you looked to us in despair wondering if we were going to spring into action and save the day. Angrily you slurred “aren’t you going to do anything?” Sarcastically we replied; “We’re not cops. We don’t have guns.” Disinterested in their fighting or your frustration, we turned our attention back to my partner’s dinner and my paperwork. Again you opened your pretty, misinformed mouth and angrily shouted at us; “You’re just going to sit there while they kill each other, then take them to the hospital when it’s over?” (Truth be told, my partner did radio in the location and what was going on.)

Like any true NJ degenerate I did suddenly realize my lack of decorum and (to my partner) placed ten bucks on the taller of the two.

As the sound of slapping skin commenced, I began to really get annoyed at the commentary of the scantily clad, young chipie. “How dare you look down your nose at me?” I thought. Your parents send you from Ocean, Morris, Warren or Bergen Counties with a brand new car, a bottomless bank account, a six inch set of stiletto heels and you think you can sit here in judgment of me? You scoff at the fact that my partner and my personal safety supersedes that of these idiots?

Little girl, let me explain some of the facts of life to you. I don’t know where you come from or what you life has exposed you to. My life has exposed me to the harsh reality of what it is to be attacked, be injured, be overpowered and not have any backup coming. This issue was for the boys in blue (the police), trained in combat and the use of force. I’m trained in healing and the use of medicine. Your expectation, probably fed by some foolish TV show of Paramedics jumping into the fray and being decorated for “going above and beyond the call of duty,” is about somewhere else -- in some author’s imagination. We don’t get medals, recognition or even a simple accurate article in the newspaper. We get injured, maimed, shot (only a week ago for trying to help a motorist) and sometimes killed. We lose our ability to support our families. Our management turns their backs on us. Our hospitals discipline, fire or worse yet, write another inane policy like “there will be no parking anywhere near people under the influence of alcohol.” (That would basically put me in another town.) There is NO ONE to help me or my family when something happens to me. So who are you, my liquor-filled visitor in search of higher education, to expect me to put myself in harm’s way?

Only a few blocks away from where you saw me and only a few hours later, some young, muscular gladiator of your age who is a trained MMA (mixed martial arts) fighter got his head split open when it met the working end of a tire iron. So forgive me if it upset you that my partner and I didn’t tuck and roll like teenage mutant ninja medics and save these two clowns from themselves. Perhaps instead of pursuing another useless degree in sociology or linguistics, you can come do what we do. Unlike so many of your classmates, you’ll at least be employed and have a realistic view of the world around you.

Have fun.  Be safe. And if you aren't, my partner and I (who are still intact – and employed - for not engaging these mutts) will be there to assist you.

"Stay thirsty!"

For Bob's Kids

by Steven P. Velasquez
August 31, 2010 

This note was originally posted in a group of Jersey City Medical Center EMS employees.  Today, August 31 is the birthday of Robert Dominick Cirri of the Port Authority Police Department who was also a Mobile Intensive Care Paramedic here in NJ.  I offer this to Bob's family on his birthday to remind them of how loved he was/is and will continue to be.  Happy Birthday Bob!  May I look upon your countenance again some day.

****************************************************************************

Bob was one of the first Paramedics I had ever encountered. I was 18 when I got in the game and volunteered in Union City, NJ. I used to remember him as "the guy who looked like Sly Stallone." Sounds goofy but hey, it was the 80's and I don't think that was an insult. Of course Rambo XII and Rocky XXV hadn't been released yet. I guess we all need to make money right?

Bob struck me as very competent, but then again, I didn't know what a Paramedic was or what they did. What I did learn over time was that when I was in front of a really sick patient and not yet able to comprehend what was before me, the door to the house would often open up and these towering, salty Paramedic types would come in with a box full of meds, a vocabulary I didn’t understand and they’d somehow make the patient better.

Over more time and with more experience, certain medics would evoke a feeling, not just of "thank God the Paramedics are here" but "thank God THAT Paramedic is here." Bob became one of those Paramedics for me. He inspired me to want to be like him though that kind of talent remained many years and hundreds of patient encounters away.

Fast forward to 1992, I returned home after two years in South Carolina and was now a Paramedic too. Bob had moved on to Hackensack University Medical Center's MICU and continued his admirable progress with the Port Authority Police. When I worked at Clara Maass Medical Center's MICU, I'd often meet up with Bob at the Colonial Diner in Lyndhurst. It was a nice neutral point between our primaries and didn't have a half bad cup of coffee. He'd always make me laugh and always had great stories to tell. He was like a big adolescent; but hey, aren't we all?

After a few short years, I had moved into computers and technology, gotten married and was immediately the father of a four year old and a year later the father of a newborn (both girls). My responsibilities at home and my new found passion with corporate America no longer left room for being a Paramedic. I felt like I had graduated - so to speak. I now had a "big person job" with real benefits, and an income (with one job) that had replaced my multiple EMS and teaching positions. My schedule had normalized and I was able to participate with my family instead of always being on a truck. My time as a Paramedic had ended and I let my number expire.

A few years and a few jobs later (it's normal to jump jobs in high-tech. You can average approx. a 15% increase from one job to the next or at least we could in the “dot com” 90's!), I was working in the corporate H.Q. of a major national retailer managing their email systems. An old partner of mine from the MC was having his (I believe) 30th birthday party at the Lyndhurst FD firehouse. My wife and I went and who was there but one joking, smiling, sometimes insulting and quite polluted Bob Cirri.

"Bro, you still a medic?""No Bob, I work in computers. I'm making good money and have a pretty good life.""Why don't you go get your number back?""It's too much work and I really don't have the time or the desire anymore Bob."He puts his arm around my wife and says: "tell this pussy to get his number back;" and proceeds to laugh at me. She was laughing too! She immediately fell in love with Bob, but then, didn't we all?

He'd disappear across the room for a while, drink some more and returned again. "Did you get your number back yet?""No Bob, I'm good. I'm not getting my number back.""Alright pussy. C'mon go get your number back. You know you miss this shit."

To & fro we went and what Bob didn’t know was that I was seriously hurting inside. 32 years old was way too young to be a "has been" at anything. Nobody ever wants to hear from someone who "used to be a Paramedic." Like Superman without his super-powers, you're no longer sexy or interesting. You're just another civilian.

I was still active on the fire side of the world and kept an EMT card; I just couldn't fly or leap tall buildings anymore.

My career goals had always included working somewhere in NYC. I mean, that's just the coolest place one can be, not to mention it's where all the best jobs were, particularly in hi-tech. After the fear of Y2K ending life as we knew it subsided, I modified my resume and began to look for new employment -- over there, in NYC.

I landed the best job I ever had, working with a great team of people and I was so proud to have the signature of all my emails proudly display the most popular business address in the world; 1 World Trade Center, NYC, NY. I landed a job with Empire Blue Cross Blue Shield. I was making more money than a person who never stepped foot in a computer class should ever make; more than an entry-level lawyer or accountant. Life was pretty good.

2000 gave way to 2001 and with that came the failing economy of that time. I was very aware of it because as an email administrator, I was the one that received the emails from the bosses saying delete the following people, managers or groups of consultants because we're cutting back. A few months later, my time came too as I took my last trip down the super elevators to the marble covered lobby. I bid farewell to the security guards that I had befriended and left the World Trade Center. Go turn in your ID's Steve. Your work is done here.

I couldn't breathe. I loved that job, that office, that lifestyle. I loved my boss particularly. Never have I worked for someone who inspired so much in me, who believed in me and expected of me. My marriage was failing at home and suddenly, it was hard to find hi-tech jobs anywhere, though anecdotally one head-hunter I was working with was trying to line up an interview with Marsh & McLennan Companies back in the WTC but on a higher floor if memory serves me correctly. I thank God now that never materialized.

Anyway, long story short, a few months passed and the unspeakable horrors of September 11th 2001 had transpired. The buildings that I once loved so much, photographed, admired and proudly took my children to, had fallen upon and consumed my friend and co-worker, my inspiration.

There were so many things left unsaid. So many things I would have told Bob if I knew back in April of 2000 that that would be the last time I'd look upon his countenance. What I thought was him just fucking with me and joking was more prophesy than jest. I still wonder today if perhaps, somehow he knew and thus planted the seed within me?

In 2004, after much struggle and having to go through the entire EMS cycle again, working BLS transport, 911, taking all my classes again (ACLS, PALS, PHTLS etc...) and facing a Paramedic manual that grew to twice the size of the one I originally learned in, without preceptors, study groups or classmates, I did it. I passed the National Registry Exam and I got my old number reinstated and was once again a Paramedic.

Today, I'm on a truck every night, have no money few assets, and very little time with my now three children who I love so much. But I'm no longer a has-been; I'm not ashamed of who I am or what I do.

I'm back Bob. I got my number back just like you said. And now with your guiding hand, I can fly and leap tall buildings again.

Your friend always,

1 6 8 8

Hackensack Medical Center MICU

Bob's co-workers from UMDNJ EMS

The flag that was retrieved from Ground Zero

Planting Seeds

by Steven P. Velasquez, NREMTP
June 10, 2010

A four year-old boy in the 1970’s visits the Asbury Park boardwalk with his parents. A day of rides, games and salt-water taffy turns sour when the boy gets a splinter in his foot and is in terrible pain. The parents, not knowing where to go, take the crying tyke to a local firehouse and seek the help of the brave. Doing the best they can with what they have, which is what these people do daily, the firefighters remove the splinter, clean the wound and dry the boy’s tears. To speed the process, they let the little boy wear their turnout gear and helmet as he lives out a childhood fantasy and proudly rings the polished bell mounted upon the front bumper.

Ten years later, on a cool October’s afternoon, the growing boy is on the phone with a friend. The cord (wired device used to connect the receiver to the telephone back then) wraps from the hallway to the living room where the boy is perched upon a chair when his best friend in the whole world, his grandmother, develops agonizing chest pain. The boy’s aunt (sister of the grandmother) runs to him and frantically interrupts his phone call – much to his frustration – as she yells at him in Spanish “something is wrong with your grandmother, come quickly!” As the boy rounds the hallway and looks toward the kitchen, his best friend, the woman who raised him, is gasping for air and writhing in pain.

He calls the local police department (no 911 back then) and asks that they dispatch an ambulance to the address for a heart attack. Within moments, several people clad in white jumpsuits arrive; provide care and transportation of the boy’s ailing grandmother to an area hospital. He notices that one of the crew members is someone he knows from school. He’s a member of the ambulance corps’ youth squad and even if he didn’t know everything, he knew more than the boy did. And on that day, he was part of the solution which in the boy’s eyes – made him a hero.

Four years later, that boy became a man, joined the fire department and later became an EMT and a Paramedic. Twenty plus years later, he sits at his laptop reflecting on the seeds that may have been planted by these seemingly insignificant moments in his past. Do the random gestures we perform daily plant seeds for generations to come? I pray they do and look forward to reading others similar experiences.

For now though, I thank the people who planted this man’s seeds, the Asbury Park Fire Department and Ken Arnold, of the Rutherford Volunteer First Aid Squad, who today continues to serve people in a uniform of a different color, but of no less importance. I found Ken on FaceBook June 9th 2010, decades after not seeing him. No longer a youth squad member, Kenny now wears the distinguished uniform of the U.S. Navy. Though I found him on Facebook which continues to shrink the size of the Earth, Kenny is on the other side of it (the Earth), serving in Afghanistan. Anonymously and courageously he protects my family still and in this man’s eyes, that makes him – still a hero

What I Like About Him

Photo by: Diane Velasquez

May 23, 2010

I was cleaning out my desk this morning when I happened upon a crumpled piece of paper covered with light pencil markings. Fortunately, a scrutinizing eye and attention to detail helped me realize that this was not another of my voluminous unpaid bills but a note of some sort from my daughter Nicolette. The paper was yellowed from age and exposure to light. It surprised me that the paper had survived previous cleanings. By the contents, I estimated this was written in the summer of 2006 as we were all anxiously awaiting the arrival of my youngest daughter Brianna Elizabeth.

After washing away a face full of tears, I had to assure my now two year old that Daddy is ok. Many of us place pictures here on "face" book and that is one of the many reasons behind its enormous success. It's one of the reasons we don't have a social networking site called "word" book. It was Confucius that once said "a picture is worth a thousand words," yet, ironically enough, when we think of Confucius, we think not of a picture of the old sage, but of his words (Paul Harvey). So, I present to you a daughter's love for her Daddy in her words. She was 10 when she authored this.

The paper was titled What I Like About Him.

My dad is very important to me. I love my dad because, well he's my dad. He is very nice to my sis and I. We always go places and have fun.

One place we go to a lot is New York. My dad worked in tower one of the twin towers. We would go all the time. It was tons of fun. New York is like a backyard to us.

Another thing is my parents have been divorced for half my life. So now he has a girlfriend, her name is Michelle. She is pregnant with my new half sister! She's due in October. I can't wait! We will have so much fun with Brianna Elizabeth Velasquez

My dad is my best friend ever. If I ever don't feel good he's a paramedic. So, he comes and helps me. Soon he'll be helping Michelle and Brianna. My sis and I will be helping him.

In other words my dad is super special to me, I love my dad. I'd do anything for him. I wish he couldn't die ever.

And so, my friends (wiping a tear from his eye) I share with you the words of a ten year old (spelling and grammatical errors included) to her Daddy. Unscripted, without prompting -- from her little heart to your eyes.

Let Me Die

By Steven P. Velasquez - NREMTP, MICP 
April 4, 2010 

A team of paramedics are dispatched to a nursing home for a person with respiratory distress. Upon arrival, they find a BLS crew moving the patient over to their stretcher. The patient is barely breathing on their own and is showing signs of poor perfusion as evidenced by their mottled, diaphoretic skin, their rapid pulse and extremely labored breathing where they employ all their accessory muscles to breathe.

The paramedics prepare their advanced airway equipment and instruct the EMT's to begin bag-mask ventilations with supplementary 02. The patient's chart has yet to make its way into the room, so nothing is known about the patient or their history. A nurse walks in and states "this patient is here for hospice and has a DNR." After a deep collective sigh, the paramedic uncrosses their eyes and withholds the next logical question ("then why are we here lady?"). The nurse vanishes from the room and the paramedics are left with this critically ill patient with an unstable airway (pooling secretions in the pharynx), severe dyspnea / respiratory failure, sepsis (106 degree fever) and his / her life hanging in their hands.

The nurse returns with all the paperwork except (drum roll please) the DNR (Do Not Resuscitate) form. They can't seem to find it and subsequently, if they don't present it, the paramedic's can't honor it. So, this patient who's body is riddled with cancer and has other co-morbidity's is intubated, suctioned, ventilated and a detailed secondary exam is performed including an ECG (electrocardiogram) which now reveals a life-threatening arrhythmia -- Ventricular Tachycardia (with pulses). The patient has a blood pressure of 160/110, a heart rate in the 180's and is being ventilated with oxygen. The DNR form finally arrives and states the exact instances when it is to be observed. It states that if either the breathing or heart beat stop, no extraordinary measures are to be performed. Currently, NONE of these factors are present, so the form is equally as null as when it wasn't there. The paramedics proceed.

IV access is established and large amounts of Normal Saline are infused to combat the fluid loss (hypovolemia) associated with the patient's wide-spread infection (sepsis). An anti-arrhythmic (Amiodorone) is drawn up and infused slowly. After only a few minutes, the v-tach is resolved and the patient's ECG returns to a normal sinus rhythm (the rhythm we all want!). Unfortunately, with the correction of the patients' lethal condition, their natural compensatory mechanisms begin to fail and their blood pressure falls to 50/30 (not enough to sustain human life).

The paramedics call their telemetry physician and receive orders on how to proceed including accessing the patient's port (device beneath the skin for IV access) and large volume hydration but no more medications. The patient is transported to a local hospital where the EMS crew is "greeted" by the charge nurse. As they roll the critically-ill patient down the hallway she yells:

"Is this the DNR that you intubated?" The paramedic tries to demonstrate diplomacy while correcting the inappropriate nurse and counters: "No, this is the patient, who is critical and needs your care, is intubated and has a DNR." She rolls her eyes, sucks her teeth and proceeds to bad-mouth the paramedics in front of the mini-chorus of young ER nurses (who all look barely old enough to be there). "Then why did you intubate him?" she sarcastically asks. "We're just going to extubate him and send him back to the nursing home -- like the family wanted." All of this is transpiring over the patient and in plain view of the entire emergency room, the other patients and their families looking on. The patient is moved over to the hospital bed and care is transferred to the staff. Finally, the patient's family arrives and initially inquires with the nurse why the patient is intubated. The nurse rolls her eyes in my direction and says "go ask him."

By this point anyone reading this is probably ready to shoot the charge nurse right? Trust me, I was too. She embarrassed me personally (more than once). She embarrassed herself and really showed gross apathy and disregard for her profession as a whole. I collected myself and consulted with some trusted RN's and believe I have discovered the disconnect.



The nurses have a very different understanding of DNR's, according to their education, than EMS providers. The one's I've spoken to have stated that they were unaware of how EMS providers have very specific instructions (inclusions / exclusions, parameters) to follow pertaining to DNR forms. Some are written where we can give fluids but no medications, provide oxygen but no intubation, jump on one leg rubbing our belly with our left hand and... you get the idea. Their (the nurses) interpretation is something akin to a "Let Me Die" form. This fictional form would be a blanket form that is A: easily understood and B: universally applicable. Once signed, it wouldn't matter what the hell was wrong with the patient, "Let Me Die." If my heart or breathing stops, "Let Me Die." If my blood pressure or heart rate are too fast or slow, "Let Me Die." If I cough, have a fever, vomit, am shot, catch fire or fall off a building -- "Let Me Die." This would make everyone's life much easier with the very sticky topic of preserving human life when there is no promise of quality of life.

In summary, this could all have been avoided if the nursing home had followed the instructions regarding hospice patients. The patients are in their care for comfort and palliative care only. They are there to prepare for death. By being in a hospice program, they are fully aware that the end is near and their family's wishes are that they not be intervened with. Yet, this call happens all to often, trapping EMS providers right in the middle of these conundrums.

The nurse should have accepted the patient, taken over his / her care and interviewed the paramedics as allies and professionals in health care. Any questions she may have had could be easily, courteously and professionally answered but she chose her way.

I'll be introducing proposed legislation to my congressman to abolish the complex DNR forms and all their rules and change them to the new streamlined "Let Me Die" form or better yet, a wrist band, perhaps black in color indicating to providers "Let Me Die." No more lost forms, no more questions whether to proceed or stop just Let Me Die.

Mind If We Pray?

By Steven P. Velasquez
Jan. 3, 2010

A few years ago, we responded to a ninety something year old female that had become unresponsive during a Catholic mass. Upon our arrival, BLS had gotten the patient out to the ambulance and were treating her appropriately. We began our assessment and treatment when through the side door, there appeared a priest. He asked: "Would you mind if we pray for her? We'll stay out of your way." My partners and I took a collective glance around the ambulance and could find no objection. He wasn't hysterical or obstructing care, so we let the priest and his partner climb in.

Silently but audibly, the two gave the patient "Last Rites" (the last of the Catholic sacraments, necessary for salvation, before moving into the hereafter) and began reciting the "Lord's Prayer." "Our father, who art in Heaven..."

The prayer began with the ceremony of the silent priests. My partner's voice suddenly joined, soon the EMT's voices were present. Then, as if absorbed, though not involuntarily, into a whirlpool of spirituality, I echoed completing the caretaker's chorus. Albeit a little

Last Rites

unorthodox and I'm sure could, in certain circumstances, cause a variety of conflicts, it was beautiful. This occasion was moving to say the least! I felt the hair on the nape of my neck stand at attention. The voices seemed to roll around the ambulance like a round robin. A chorus of bellowing baritones resonated and reflected off the walls and provided a soothing environment for us all.

Patient care was never interrupted. Everything went as it should, it just felt a little less repetitive than the usual call. We felt uniquely attached to each other, to the patient and to the two clergy. The patient seemed more human and we seemed to be more than just clinicians. I actually felt as though I was an instrument of God, channeling His good will, working with and praying over one of his elder children.

No father. We don't mind if you pray.