Autumn 2006

A flickering streetlamp illuminated a blood-soaked patch of pavement in the cool fall evening. Litter was strewn across potholes and cracked earth, collecting around parking signs and natural barriers. Various brands of ground cigarette butts soaked with the deep red of a dying man. The tang of foul gore clung to the midnight air.

Although the night was proving to be cold with the impending winter, the man was shirtless and oblivious, his attentions drawn to a half-meter self inflicted laceration across his enormous abdomen. A sheen of perspiration glazed across his body as he plunged the silver knife again and again into his pale pimpled belly, cutting, dragging, tearing; yelling out a muffled word at the windshield of the idling ambulance that sat a few meters in front of him, headlights casting the scene in an eerie over saturation of fluorescence. He yelled it again, eyes casting blindly across the windshield.

“Shakes?” asked Abel from the safety of the passenger’s seat.

“Snakes.” Dave replied.

The man on the pavement held the knife in his right hand. He fed the fingers of his left into the newly created evisceration and gripped, pulling hard on the exposed blood-soaked tendrils of bowel. His right hand continued its motions, moving meters of intestines from the gaping wound on to the filthy ground.

Abel watched, mouth open, one hand on the passenger’s door, the other squeezing the armrest tight, “Shouldn’t we do something?”

“You bet. I’ll go and call ahead for a second trauma room just for you,” Dave said with a smirk. “What are you going to do? Whip out some karate moves and pull the knife from his hands? You’ll probably catch hepatitis just by stepping out the door,” Abel slowly moved his hand from the door, the tension releasing from his whitened knuckles. “Didn’t they have their share of crazy people where you’re from?”

“Yeah, but they normally weren’t swinging a knife around. Up north we normally had them strapped to a bed for transfers between hospitals.”

Dave chuckled behind his coffee, “Little bit of a learning curve down here in the big city, hey?”

As much as Abel felt the need to boast against his words, he had to admit that between this and the service he had worked prior, the city was a new type of beast. The pace, the acuity, the pressure for excellence was dripping from every call like the blood that soaked the pavement in front of him. It was stained into the fibers of the practitioners and their unconscious expectations of themselves; laying bare in the sweat and effort they put forth every day. It hadn’t hit him or affected him personally, but he had already managed to notice all this, and it was only night one.

The ambulance headlights laid vibrant upon the scene, enriching every terrible colour, emphasizing every grotesque movement the bloody man made. He was sitting cross-legged with wild eyes in various ecstatic torment, darting at every shadow and movement in the lot. The man made eye contact with Abel and shivers etched across his bones.

The call had originated from a person driving by who noticed ‘an angry homeless man rolling on the ground punching himself’. Dave and Abel had just been clearing from the Monarch hospital when the call had been dispatched, deciding to continue to scene without police aid. It had been a busy night and the cops liked to take their time. And, Dave had figured based on the description, this couldn’t be more than an easy offload to the hospital waiting room after a couple minutes of listening to a strung-out meth addict talk nonsense. Sometimes, reality was a cruel bitch.

“Looks like he’s at the end of his rope,” said Dave. Instead of staring at it, Abel had been coping with the trauma in front of him by envisioning the road ahead as nothing more than the set of a terribly shot movie. They could only show so much on TV, and in his mind that provided an ignorance that it couldn’t get any worse than it already had.

He was wrong.

The homeless man had a shiny pile of red entrails laid out in front of him, an unrealistic amount by Abel’s perspective, piled and spilling in a meter-wide heap of blood and bile. However, the man had finally reached a pause and the pulling stopped abruptly to his displayed confusion. He tugged once, twice without give. The string of intestines in his hand shook with each tremor like serpents, moving in a slithering orgy that coiled and twisted with the pavement’s filth. Dave gestured with his coffee towards the windshield, “Here it comes-”.

On the third attempt the bloody man tightened his grip and braced against the pavement with his free hand. Something was tearing from deep inside him. The muscles in his forearms protruded like vines as he drew back on the organ, pulling up and over his head in an arc as it released. The end of a coil of guts flecked through the light and the man cried out a deep, animalistic moan, followed by a spray of bright red arterial blood.

Dirty blood. Blood stained with years of chemicals and toxins and dirty needles; a pumping and inundating poison that represented what every practitioner craved and feared - life, mixed with mortality. It may be the six-sided star of life Abel and Dave wore on their uniforms but it was the blood they and all their fellow practitioners followed.

Dirty blood.

The man was weak now as death hung above him. He half-heartedly swung the dark blade down into the coiled organs laying in front of him again. The blade’s edge shuddering against the ground, cracking and braking off a long, sharp shard of metal from its blade. He continued yelling his one-word craze through cracked lips.

Snakes! Snakes! Snakes!

Abel’s focus on the scene was disrupted by a crisp sound to his left. Turning slowly with a fogged head full of shadow the first thing that entered his vision was a large white bite taken from the green skin of an apple. Dave gave him a wink and bit again. Abel’s dry mouth crept with the edge of sickness and he closed his eyes, resting his head forward against the dash in attempt to clear, make sense, move past, the snapping of fruit flesh ringing in his ears again and again; an overture to the witnessed torture.

It couldn’t last forever, that being said, Abel couldn’t believe it had lasted this long. How long could the human body put up with that much trauma? How long would a drug-addled mind last in keeping reality at bay? How long before he ran out of blood to spill? He didn’t know the answer and searched back to his classroom studies in search of one lingering in the void. Behind darkened lids, his vision moved from text book to slides in hope for some clarity. The order of words allowing him to slip into the calm of study; a place of relaxation and structure. In the textbook, every call had a purpose of study, and every patient had a diagnosis. There was always a treatment plan and answer. The questions would be presented, and with quick reference could be solved. The classroom was known territory and this, the real world, was nothing short of madness.

Abel had never seen a man die before.

“He’s running out of steam,” said Dave. Abel peered over the dash at the scene, relatively unchanged aside from the rapidly extending pool of blood moving out from the man’s body. The man looked deflated and hollow, pale in the throws of death. He moved in a slight sway, like a dry sapling tipping against the wind. His dirty hands were a mess of red and black, resting open in the collection of bowels as his heart struggled to continue supplying oxygen across his body. Abel knew the small amount of blood still left was pushing towards the brain in anxious panic, mixing with internal and external stimulants - the latter of which was probably the only reason he was still alive. The words exsanguination and hypovolemia came to Abel’s mind. And then, the man finally collapsed.

Abel quickly grabbed the door and pushed it open in haste, launching himself into the cool air, Dave’s gruff hand clasped around his arm as one boot touched the pavement.

“Not yet.”

Abel’s gaze jumped from his partner to the patient and back. Dave and the bloody man reflected each other’s stillness with the demeanor of graves. Abel stood with one foot on the asphalt. His legs shook with adrenaline and discomfort. Finally, Dave’s hand released and the driver’s door opened.

Tunnel vision took hold and Abel ran to the man in the parking lot, splashing a viscous mixture of fluids up his uniform, grabbing the patient’s shoulder and shaking. He screamed in the man’s ear without response, finding a slow pulse at the man’s carotid, his pupils sluggish and dilated. He looked back for Dave, finding him walking slowly towards the scene, the bed in tow, a collection of large wet abdominal pads laid out across it. Abel willed him to move faster. His partner’s pace reminding Abel more of a man on a weekend walk with his dog than a paramedic on a trauma scene. Dave moved around the edge of the red pool until the stretcher was directly behind the patient. He put the locks on and kicked the almost-forgotten knife from the patient’s reach. It disappeared into the darkness. Abel used the saline-soaked gauze to collect the intestines. He stuffed them back into the man’s torn wound with a squelch, his chest was hit with a small spray of dark arterial blood.

Dirty blood, Abel had to remember. Infected blood.

The tangle protruded slightly out of his gut and smeared a collection of smells and textures over Abel’s arms and chest. The two of them lifted the man onto the stretcher and swaddled him in a blanket, walking towards the ambulance. Abel latched the bed onto the back as his new partner raised the wheels. Abel jumped onto the tailgate to get into the back when he was stopped by Dave’s gloved hand against his stained uniform.

“Lose the shirt. Bags are in the side compartment. Then get in here and get me a line,” said Dave. His eyes shifted a few shades darker, burrowing into Abel’s consciousness. “And remember this: If you want to continue working on this truck you will never, ever forget to put on your damn safety glasses again. One good spray from this waste of skin and you’d be in the ER drinking the HIV cocktail and getting blood tests into next year. Do you understand?”

The sudden change in demeanor caught Abel off guard and for a moment he was too scared to answer. It was then that he realized how much this man’s opinion meant to him; the value of his words. Why? He did not know, he had only just met him that week, and yet there was something more. But what? He flinched when Dave spoke again.

“I said, do you understand me?”

“Of course,” Abel managed to squeak out. He cleared his throat, “yes, completely.”

Dave closed the door and the ambulance’s scene lights turned off, leaving Abel in the darkness.

He exhaled sharply.

With a snap, Abel shed his blood-soaked gloves and dropped them to the ground where they floated among the evening debris. He took off his uniform shirt, putting it in a plastic bag. Pouring water from his bottle onto his arms, he scrubbed his hands and forearms to a pink froth. Abel rinsed but it appeared to cling to his skin, running across his hands and forearms like a pink tar. Abel cursed and rinsed with water again, following it up with a pump of sanitizer. Abel’s skin still felt sticky and tight with dried blood but he figured it was the best he could do.

Dropping his safety glasses over his eyes, Abel opened the side door of the ambulance and was met with the concentrated smell of gore. Much like his soiled uniform, the back of the ambulance hung with the taste of rust that was bitter on his tongue. A bag of IV saline with a primed line of tubing hung over the stretcher’s head like an incongruous mobile. Dave sat in the attendant’s chair with a small black bag on the floor beside him, a clear bag of D5W and a medication roll open across his legs. Dave was concentrating on the microscopic numbers on his syringe as he drew up a clear liquid from an large glass vial. His well-worn uniform was spotless among the carnage.

Abel moved around to the right side of the stretcher and found the supplies for an IV laid out along the adjacent counter. Abel gloved up and wrapped the bright blue tourniquet around the bleeding man’s bicep, searching for a vein. The man was still breathing, somehow, but his blood pressure was low and continued to drop as his body failed to compensate for the blood loss. They needed IV access to supplement fluid loss and provide what Abel assumed was in Dave’s over-sized vial, tranexamic acid. The TXA, for short, was an antifibrinolytic agent used specifically to combat a case of traumatic hemorrhage like this. It was to be diluted in the bag of D5W and given over ten minutes through an IV. That coupled with aggressive normal saline administration would hopefully stabilize the patient’s bleeding long enough for transport. It all came down to Abel getting the line.

He looked for a straight vein, clearing away grit and coagulated blood with an alcohol swab. The flip side of the patient having such a low pressure meant there was a limited amount of blood being pumped to the peripheral areas of the body; arms and legs. Less blood meant less pressure on the veins and less protracted blood vessels. The man’s mass also worked against him as subcutaneous tissue hid the majority of the vein choices from the naked eye. Abel resorted to moving his fingertips along the bruised, serrated skin for any natural knolls that would hint at access. It wasn’t looking good.

“Come on kid, we gotta move here.”

“Hand me a twenty gauge.”

“We need an eighteen or larger, sixteen would be best.”

“It’s not going to happen over here. Hand me a twenty.”

Extending the arm further, Abel nudged the yellow frame of the stretcher and a short length of the eviscerated man’s bowels slid over exposed forearm. Dave spoke, his voice steady as a snare while he unpackaged a sterile syringe from the cabinet.

“Well greenie, test time: what do we do about the wound?”

“I know the textbook states to drape the wound in sterile gauze or an ABDO-pad. I would consider a burn sheet for something this size. As for containing the intestines? We can’t stuff them back in and they’re getting increasingly unsterile falling on the floor so... damn,” Abel took a breath. “I’m not sure.”

“You’re not sure?” Dave reached down and placed a few unattached pieces of gut into a plastic bag. “Well how about just this once I’ll show you what I would do. But,” Dave’s eyes held on Abel’s like two cinders in their sockets, “just this once.” Dave stood and began unbuckling their patient on the stretcher. He motioned Abel over to the opposite side and forcefully slid the few protruding lengths of gut into the cramped wound. Dave grabbed the edge of the soaker sheet underneath the man - its normally green stitching drenched red - and met Abel’s eyes. “Now, on my count, shake him like a margarita.”

“What-?”

“One, two, shake!”

Dave began vigorously pushing and pulling the sheet across the stretcher with the man moving on top. The bloodied man’s movement was violent and jarring, sending his limp body back and forth across the stretcher with each push and pull. Abel, with his hands limply holding the opposite side almost lost his grip, but the nature of the movement passed to him and he followed Dave’s direction. His hands tightened on the man’s clothing, blood bubbling in between gloved fists. They shook the man for ten seconds, the vitals on the monitor churning out artifact with the movement and masking the true mortal numbers beneath.

They stopped and Dave nodded towards the man’s belly. Where the protrusion of intestines had previously been amassed was the gaping wound. The wound, but not the organs. The bowels were inside and settled, slightly protected from the outside world. Bleeding had slowly restarted around the wound with dark spoils dripping along the carved gape but, once the man was covered again with a moist sheet it was almost impossible to tell.

“Learned it from the O.R.,” Dave said. “It’s the organ’s muscle memory, everything just settles back into place. If the damn guy hadn’t torn a few lengths off himself he’d be all set to walk on out of here. Now,” he handed Abel a green-tipped eighteen gauge IV, “get me that damn line or get out of the truck.”

With shaking fingers, Abel took the uncapped needle and leaned over the bloody man’s arm. He had unintentionally left the tourniquet on but no veins had shown themselves in the few seconds between this and his last glance. It wasn’t possible, there was simply no way to tell where this guy’s veins were around the bruising and- wait, the bruising. They weren’t normal contusions, they were pin-point and concentrated in linear patters. They were track marks from IV drug use. So long as this guy had been a pretty good shot he may have just offered a blueprint to his entire peripheral vascular system.

Abel opened his mouth to tell Dave about this revelation as a ‘click’ sounded from across the ambulance. Dave undid his tourniquet and attached a second line that had been hung from the ceiling. The IV catheter was a bright green; an eighteen. He started another bag and got access in the time I had found a vein. Great first impression, Abel.

He dropped his eyes and uncapped a pink needle - twenty gauge. It may not have been what Dave wanted but it was as large as Abel considered possible with his limited options. He swabbed the site again, the ambulance dipping into a palpable silence. A pair of eyes watched on.

The tip of the needle punctured the man’s skin and Abel dropped it into the vein, the needle’s hub filling slowly with dark red blood. The track marks had been good, he was in.

Abel breathed out slowly and quelled an itching smile that was creeping across his face. Silence persisted around the ambulance. He just had to advance the catheter, secure it, and they would be set. He advanced the needle one millimetre further.

Under his fingers Abel felt a release as subtle as the single beat of a butterfly’s wings. It may as well have been an earthquake. A dark purple bruise creeped slowly around Abel’s injection site and swelled.

He had blown it. Gone in one side of the vein and out the other.

“Well thanks for your contribution, but I think that will be enough for this evening.”

“I have another site to try, I’ll go for a twenty-two.”

“No you won’t. This is a trauma patient. I asked for at least an eighteen. You didn’t listen and you fucked up a smaller gauge than that. I’ll get one on the way.”

“Let me go for an eighteen than-”

“Abel,” Dave said, a vibration of fury imitating around him. “Now is the time to get out of the truck.”

He was right, Abel had missed his chance. This was not the time to try and win his reputation back, no matter how hard it stung. He lowered his eyes, nodded, stripped off the latest set of gloves and left the back of the ambulance.

In the front cab he turned on the emergency lights and a stream of white and red cut through the vacant lot. Until that moment, Abel hadn’t noticed the rain. Small concussions hit the glass at a gathering pace, giving a soundtrack to the night’s tiny flashing prisms that fell from the clouds. Momentarily caught in the refractory lights, they mimicked diamonds among the abyss of night. Stars morphed and drifted over the sleeping city as their light was caught in the falling rain that cascaded across the city.

He left the scene in a scream; sirens bouncing off of abandoned buildings and derelict vehicles left to rest in the autumn evening.