Q&A with Joseph F. Clark, PhD

Excerpt from My Ambulance Education

Joseph F. Clark, PhD, has an impressive resume in the medical fields. He's a professor in the University of Cincinnati's Department of Neurology, and an adjunct prof in its Department of Molecular and Cellular Physiology. He's codirector of its Point of Care Center for Emerging Neurotechnologies, and chief scientific officer at Xanthostat Diagnostics, a local company working on technology to improve detection of bleeding in the brain. He has authored or coauthored more than 70 scientific journal articles and three scientific texts.

But in My Ambulance Education: Life & Death on the Streets of the City, published earlier this year by Firefly Books, what Clark recalls is his early career as an EMT. Clark joined the ambulance biz as a teenager to pay his way through college, and spent seven years working the mean streets of New York City. His resulting tome isn't for the faint of heart, but as Publishers Weekly concluded, "Readers with the stomach for it will be drawn in by this high-speed, adrenaline-powered ride-along."

Here Clark discusses the book's background, the accompanying excerpt and writing for publication.

How long have you been writing, and how did you come to publish My Ambulance Education?

I write for my work as a college professor doing stroke research, so I've been writing science books and research articles for over 20 years. While science writing and writing something like My Ambulance Education are quite different, there are some similarities. The first and foremost is that to write both, you need to write about what you know and have a focused point to make. Every word needs to build to answer a question and provide relevant information. In science we try to tell a story with data and hypotheses. Writing a book is definitely about writing a story with historical events and telling the story of the work that was done.

My Ambulance Education came about because I was encouraged to write down some of the stories I used to tell about working on the ambulance. This was true for the story about Bob the new guy, as well as Fritz and Alice. These events were told to my science colleagues when I tried to explain to them why I was so focused and driven on my scientific research. After I put some stories in print, they started to show a bigger theme of helping people. This theme remained throughout the book and is still a driving force in my current work. Eventually I added more and more stories and was fortunate to hook up with a professional editor, Carol Cartaino. She helped make the stories flow and be accessible to a broader audience, without losing the life-and-death aspects that make the book real. The more eyes that see a book, the better, and eventually it was picked up by Firefly.

Why will EMS providers be interested in this book?

I think there are multiple reasons that EMS providers and paramedical personnel will be interested in this book. First, Education is in the title for a reason. Working on the ambulance is an education, and it affects everyone in the field. I'm sure many people will nod knowingly at the tragedies that are recounted and feel the emotions I felt. How I tried to handle those events may or may not be the way a reader might manage their feelings; we all might use different techniques for handling the stress. Some people might be interested in reading about how I would go and visit the Labor and Delivery floor of the hospital to look at the babies if I was upset about a call. Others will see the gallows humor for what it is: a defense mechanism. Everyone in the field knows there are days or calls that change you. I tried very hard to portray how I was changed by a series of calls, which helped push me toward my career in medical research. For good or for bad, we are all changed by the job, and this is the story of how I changed and why.

You've said Fritz is a strong memory for you--why does he stand out?

The short answer is that Fritz died of a stroke while I watched helplessly, and I now do research on the diagnosis and treatment of stroke. While his death did not directly guide me into my current research, the experience did galvanize me in how I wanted to help people for a career. As my career took me into stroke research, I had a unique insight into the human component of stroke, having experienced the waxing and waning stroke with Fritz. To a certain extent, I am now a world's expert on what happens to the arteries during a stroke, and I can tell you with great scientific detail what was happening to Fritz and patients like him. However, not all scientists have a Fritz in their history. I am forever grateful for what Fritz and other patients have taught me.

You've now done some appearances and signings. How has the book been received by EMS/fire folks?

I absolutely love to talk to the people "in the trenches," and the book is being well received by these folks. One very kind EMT-P said he appreciated that an educated professor took the time to express, in depth, the environment that they work in daily. I think he knew I have tons of admiration for the EMS and prehospital care people. Every chance I get, I try to use the book as a platform for the research we're doing in neurologic emergencies. There are great new technologies I have the honor of seeing being developed for use in ambulances, and the book has become a kind of platform for priming ambulance personnel with what's on the horizon. The ambulance is a unique medical situation because most of the time you have two people tending to one patient. With the exception of the operating room, the rest of the medical system has one doctor or nurse to multiple patients. So the ability to treat the patient in an ambulance is in many ways greater than in other places in medicine. So what I ask people is, "If you're sitting next to a patient with a neurologic emergency and say to yourself, 'I wish I had a widget to diagnose or treat this patient,' and you have an idea how to do that, talk to me." I say this because I want to, and think I can, help get technologies into the ambulance.

What advice would you give others in the emergency fields who consider writing for publication?

Do it. For me the writing became cathartic. Do not be afraid to express emotions. When I started writing, the stories were more like run sheets, which by their nature do not express the human tragedy. Eventually I learned to express more of the emotion that needed to be told. Finally expressing those emotions was quite gratifying, even though I was digging up old memories.

For more, see www.josephfclark.com.

 

Excerpt from My Ambulance Education

Bob the New Guy

Chapter 8 of My Ambulance Education: Life & Death on the Streets of the City, available from Firefly Books

New York is a great place to gain experience--notoriously busy, lots of action all the time. I had been on the job for several years and been given the job of training a new partner named Bob. New guys had lots of nicknames, like probies, newbies and FNGs (fucking new guys). It had taken two weeks of night shifts to break in this particular new guy. Nights were the best times to break them in: their mistakes and sometimes glaring incompetence were easier to cover in the darkness.

Bob was a very big and heavy guy with a pale, freckle-faced complexion and the reddest red hair I'd ever seen--it looked like he was bleeding hair out of his scalp. For some reason, when he was in his civvies he always wore green shirts and sweaters that clashed with his hair. Bob was a quick learner, though. He had finished the training program for emergency medical technicians with low marks, but still wanted to work on an ambulance and continue on to become a paramedic. If he had had higher marks he would have gone to a nicer neighborhood. But this was the heart of the city. This place was so full of guns that we called the police station the DMZ (demilitarized zone).

You can always rely on a new guy to bring up all those nifty facts that they make you memorize in school, like that brain damage can start within one minute of a person suffering cardiac arrest. While this is an important fact, we will be working hard to save the victim at 59 seconds as well as 61 seconds. Another thing he reminded me of was that there are seven layers of skin. I, however, am not going to pull on someone's cut wrists to count how many layers of skin have been penetrated. I generally operated on the assumption that a laceration had four layers to cut into: Skin, fat, muscle and bone.

Bob the new guy was very informative and surprisingly competent despite those low grades in the EMT course. He was also very gung-ho. While diligently listening to the radio, he would hear another ambulance getting a call and he would want to take it if we were closer to the address. This is called jumping a call, and it's a major no-no. First, it means more work for us. Second, he would want to do this even when the call was a no-brainer. If you are going to jump a call, pick an interesting one.

There are only two people on an ambulance crew, so you had to have confidence in your partner.

Fortunately, Bob did well with the patients. He could tie more knots in a bandage than emergency room nurses had scissors. That made life easier for me, because I left him with the patient most of the time while I drove. It's true that, being the new guy, he could have killed our patient. But someone in control of three tons of ambulance going 60 mph down city streets can kill a carload of people, not to mention the ambulance crew.

It was the beginning of my third shift with Bob, and one of the emergency room staff was having a party to celebrate a promotion. We stopped by the party to get some free food--no drinks while on duty. All the cops and emergency staff would socialize and hang out together, since normal people would not put up with us. You simply cannot have a conversation with someone who is "on the job" without hearing about blood, guts, vomit or death. Which is probably why we were not usually invited to other peoples' parties.

Only five minutes after arriving at the party and before getting any food, we got a call. All other units were out and the call was in the center of our region, not far from the hospital. We didn't get any details on the type of problem. The dispatcher only said, "officer requests an ambulance for an injured man." We went up there 10-17 (as fast as possible, with lights and sirens) and met two police cars at the scene. This was a bad sign, because if they felt they needed extra help, it usually meant a violent or seriously injured patient--or a slow night for the PD. As we pulled up in front of the apartment building, a cop came running out and breathlessly summarized the situation: "Man... hand... severed..."

A totally severed hand is not something an emergency service worker encounters every day. Hanging by a thread, yes--that happens a lot. I have seen some very big "threads," including some that looked more like an arm with a bad cut. Such exaggerations by bystanders were common. But I was made nervous by the cop's description of the hand as "severed." Bob, however, was ready to save the whole world. Out of the ambulance went 250 pounds of new guy--but with no equipment. He was followed by the cop, who began directing the new guy to our patient and our patient's hand.

Being older and slower, it fell upon me to bring the necessary equipment: the trauma kit, a specialized first aid kit for just such an adventure. For a heart attack, I would have brought our medical kit. To the untrained eye, the trauma kit and medical kit may look much the same, but to the professional there is a big difference. When we use the medical kit, which has medications and drugs, it costs big bucks. The trauma kit just contains lots of bandages in various sizes. By the time I got inside with the low-budget kit, the new guy had already taken control of the scene and assessed the situation by saying, "My God, what happened?"

Our patient looked like a Jackson Pollock painting. He was a heavyset white male dressed in bright white overalls, with shocking bright red splatters all over his body and topped by neatly coiffed blonde hair and sky blue eyes. He was standing in the middle of the room holding his arm in the air--sans hand. Nothing was hanging on by a thread. Bob, always the professional, informed me that the hand was in the trash. That seemed about right for the surreal scene in front of us.

The victim was a maintenance man, and his hand was severed at the wrist while he was loading trash into the compactor. The maintenance man's name was also Bob. So Bob the new guy took care of Bob the maintenance guy while I searched the trash for the missing hand. I had searched toilets for aborted fetuses, scanned the highway for lost fingers and toes and scoured car interiors for stray teeth, but after years of ambulance work, rummaging through freshly compacted trash in search of a severed hand was a new one for me.

There was a large collection of cheap wine bottles, lots of newspaper, fish heads, fish guts, soiled diapers, at least a dozen tampons and too many sanitary napkins, but no hand or fingers. Undaunted, I dug further. Two fingers finally came into view amongst what looked like a large blob of fish guts partially wrapped in newspaper. With a gloved hand, I tugged the ashen gray fingers toward me--and the fish guts moved with them. They weren't fish guts, they were long, stringy bits of muscle and tendon dangling from what was left of four fingers. The length of the sinews suggested that they came from well up the arm. As the trash compactor's massive piston came down on Bob's trapped hand, he must have pulled fiercely to get out of its grip. So forceful were his frantic pulls that he severed the muscles and tendons before the compactor pulled his hand off. With the skill and care of a surgeon, I peeled off the pages of newspaper from the spaghetti, packed the hand in sterile saline and put it in ice. I then gave the whole mess to one of the cops with instructions for the emergency room staff. Cop and hand were off to the ER.

My next concern was the two Bobs. Bob the new guy had Bob the maintenance guy all bandaged and in the stretcher. The wounded stump was elevated to pre- vent further blood loss and our patient was sitting up comfortably. But something was wrong. I had pulled out four fingers, but no thumb. It did not take a great knowledge of anatomy to see that something was missing from Bob the maintenance guy's bandaged stump. I pointed to the stump and quietly asked Bob the new guy, "Is his thumb in there?"

"No. Wasn't it with the hand?"

"Shit."

I awkwardly turned to Bob the maintenance guy, who was dutifully elevating what remained of his limb. "Excuse me, sir, but before this, did you have a thumb?"

"Are you kidding? Before this I had a whole fucking hand!" he said, as he waved his bloody and bandaged stump at me.

I told Bob the new guy to get our patient into the ambulance with the help of the remaining cop and shout for me when he was ready. I went back to look for the missing thumb. Time was now crucial. The hand had been severely damaged by the compactor, and hope of reattachment was fading. I tried to recreate the accident in my mind as I searched the trash. This time I avoided the allure of bloody tampons and focused on fishier things. But no luck in retrieving a thumb. Then I reasoned that if I had my hand stuck in a trash compactor I would try to pull it out very forcefully. If the thumb was still attached to the arm--say, by a thread as the maintenance guy pulled his arm free, the thumb could have been flung a good distance. Sure enough, I found the thumb across the room, on the floor next to a broken dishwasher.

Just then, Bob the new guy started yelling for me. Ignoring proper medical procedure, I picked the thumb up off of the floor and shoved it in my pocket. Both Bobs were in the back of the ambulance looking equally pale as I hopped into the driver's seat for the short drive to the hospital. "Any luck?" Bob the new guy asked. I responded with, "Everything is in hand." I then radioed this simple message to the hospital, "We are en route with the rest of that patient from South Parks apartments." The hospital didn't bother to respond and I didn't blame them.

When we arrived in the ER, the surgical team was gowned and gloved, hovering around four digits and gently peeling pieces of newspaper loose from a spiderweb of tendons and muscles. Everyone was using the utmost care to maintain sterility to prevent infection. They were working like a well-oiled machine to save our maintenance man's hand, ignoring us even though we had the rightful owner of the hand with us. They didn't give me a second look until I said, "Are you guys missing something?"

All I got were blank looks. When I dropped the thumb in the middle of their sterile prep I was suddenly very popular: now their inventory added up. I walked away, deaf to their shouts and reprimands for my unorthodox transport of the missing digit. (Bob the maintenance guy did end up having his hand and thumb reattached.)

Bob the new guy and I went back to the party to boast of our accomplishments. I ate a large bowl of cold chili as my partner told everyone how he did all the work. My friend Steve asked me later that night if I had bothered to get out of the ambulance. "I drove," is all I said.

Bob the new guy and I worked together again the very next day. We were working 3 p.m. to 11 p.m., or sec- ond shift. Second shift can be problematic, because it includes the dreaded 5 p.m. rush hour, when all the lights and sirens in the world mean nothing to the slow-moving traffic. At 5:27, Bob and I got a call of "man down" in the park. Traffic was a nightmare, so it took a while to get there. I knew that the trip to the hospital after the pick-up would be worse, so I hoped for a simple knock-on-the-nut type of call. Anything that would need urgent treatment would be bad news.

We arrived to find an elderly man with severely slurred speech and pupils that were unequal and sluggish to respond to stimuli. His right arm flailed wildly when he talked and he couldn't move his left arm. Witnesses said he was walking around unassisted and then just fell to the ground in this condition. The diagnosis was easy: it was a stroke. There was a blockage in one of the arteries to his brain, and he needed blood flow now. We could do very little for him, however, except to "swoop and scoop." We got him to the emergency room immediately.

I sat with our patient, Fritz Miller, and monitored his vital signs on the long ride to the hospital. Bob drove this time, because the heavy traffic made speeding impossible and I was concerned that Fritz might crash (which means blood pressure and respirations suddenly decreasing or stopping) and need me to keep him alive. We had him on oxygen, but oxygen to his lungs was of little use--what he needed was oxygen to his brain. He needed blood to critical parts of his brain and all I could do was hold his hand as we made our slow way to the ER. This type of call was known as a "hand job," because that was all I could really do for Fritz.

He did have periods where he seemed lucid. So when he was with it, we made small talk. He had a very weathered-looking tattoo on his right arm and I asked him what it was.

"It's a football crest," he said.

"What's a football crest?"

"Oh, sorry--soccer. It is the crest of my favorite soccer team from when I was a kid."

Now that Fritz was speaking more clearly, I noticed that he had a German accent.

"When did you get the tattoo?"

"When I was eight, after the team won the championship."

"Eight?"

"Yeah, and boy, were my parents mad. You could not remove these things in those days, so I have had this for 83 years."

"Wow!'

"The football club does not exist anymore, though. Even the town where I grew up is no longer. The whole town was lost during the war, and many of our friends and relatives were killed then."

"How did you survive?"

"We escaped to America, changed our name from Muller to Miller and hid our German heritage. I had to tell people the tattoo was a family crest or other convenient lies. I loved that team and my family made me hide it and hide my German ancestry," Fritz said ruefully.

Those were the last words Mr. Muller said. He lapsed into a coma and died while I held his hand. Of course, I told Bob to radio the hospital that we were bringing in a cardiac arrest and worked hard to try to keep Fritz alive, but with no success. His brain was dying and I was powerless to help. I wanted to ask him the name of the town he came from and the name of the soccer team. Why couldn't I give him something to save his brain? I was incredibly frustrated. Fritz needed a definitive diagnosis and quick treatment. My hands were tied and I didn't like the feeling.

That call marked a turning point in my career. It started me thinking that I might be more effective at helping people like Fritz Muller if I were better trained--possibly trained as a physician. Maybe medical school was the way for me. I was a chemistry major in a college class full of pre-med students and I could run rings around them because I was on the job and had medical experience that they did not. Medical school meant a lot more college, but it would enable me to help lots of people in a way that a paramedic never could.

The university guidance counselors were surprised when I went to the office to announce my decision to change to pre-med--surprised because they'd assumed I was pre-med already! I hesitated at joining the cutthroat ranks of the pre-med students because this was not really my style. But maybe those competitive pre-ed people were not so bad after all--maybe they really wanted to help people, too.

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