John Smith has been on the job 35 straight hours.
Thirty-five hours of tired eyes, tense moments and frustration. Thirty-five hours dealing with sick and wounded and out-of-sorts citizens from the Hollywood Hills to Boyle Heights to skid row.
A Los Angeles Fire Department paramedic, Smith is used to slogging through shifts like this. You clock in and you suck it up, often working days of forced overtime because there aren't enough paramedics to go around.
Sometimes you save a life. Sometimes, as is happening now, the thankless swirl takes a toll on your own.
Smith is riding shotgun in a boxy, red-and-white paramedic ambulance on the Eastside. He and his partner just resuscitated a man shot in the neck on a busy street. They had to jam a tube down his throat to get him to breathe--right there on the pavement.
They got the man to an emergency room, gave him a chance to live, then spent a half-hour wiping blood off their clothes and the back of the ambulance.
Now the paramedics are heading back to the downtown station house, Fire Engine Co. 9.
Suddenly, Smith is boiling. His stiff, blue uniform is soaked with sweat. His heart is thumping so loud that he swears he can hear it. His skull feels as if it has been pried open and scorched with a cattle prod.
Pull over, Smith says.
Smith stumbles out and tries to gulp down air. His partner checks his pulse; it has zoomed to more than 170, dangerously high. Smith starts vomiting and he doesn't let up. His partner shoves him into the truck and heads back to the emergency room.
Stress-related hypertension. That's the diagnosis doctors give Smith after running him through a series of tests. The doctors say what he has good reason to suspect: It's most likely job related.
"Guess I've been bottling up what I've been going through," observes Smith, a normally placid man of 37 years, as he recuperates at home. "I just feel worked."
John Smith is not alone.
There is a crisis among the 450 Fire Department paramedics serving the city's 3.8 million people.
These days, their ambulances feel more like bunkers, taking hits from every direction.
Recent studies by the Fire Department's psychologist found that more than half the city's paramedics are burned out and suffering from emotional exhaustion. About a third are dogged by extreme stress--the kind experienced by Vietnam vets who have seen and done too much.
They complain of being overworked and undervalued. They feel misunderstood and sometimes mistreated by the public. In much of the city they survive on torrents of adrenaline and caffeine. They tell stories of making rushed decisions because they want to get back to the station to get some rest, of falling asleep in front of patients, of relying on ambulance sirens to keep from dozing off.
Short-staffed and forced to go on record numbers of runs--roughly 200,000 in 1999--most are stretched so psychologically thin that it's not only hurting their job performance, it's damaging their lives, leaving them more vulnerable to family problems, susceptible to illness, causing scores to give up the job in recent years despite a base salary of slightly more than 10% more than what firefighters are paid.
"These are men and women who need help themselves," says Robert Scott, who wrote the studies. "Something needs to be done, and quickly."
The Fire Department, under increasing scrutiny after disclosures of serious breakdowns in the agency's emergency dispatch center, is scrambling for answers.
Backed by the mayor and City Council, the department hopes to hire 150 paramedics during the next year. However, many will be temporary, working on 8-month contracts. That means if they aren't hired at the end of their stints--and there's no guarantee they will--the bulge in numbers will be fleeting.
What's more, City Hall approval of an ambitious plan to train 500 paramedics over the next five years is far from certain. The proposal, announced Tuesday, was met with sharp criticism by the mayor's office, whose budget director said it was confusing and not based on clear goals.
"We're very aware of the problems," says Chief William Bamattre, who, like most of the department's leadership, has no paramedic training. "We feel we'll be able to handle the issue of stress and overwork by directly addressing the issue" of staffing levels.
Paramedics work a dizzying schedule, the bulk of it in 24-hour shifts alternated over five days, followed by four days off.
But because of shortages, the department also pressures paramedics into "volunteering" for four days of overtime each month. Those who fail to do so can be forced to work just about any time in the next month.
Planning on going to your daughter's wedding? Forget about it. A special dinner? Put it on hold. Tell the department you're not coming in? Expect a reprimand and a day off with no pay.
The overtime can boost a paramedic's salary into the six-figure range. But some paramedics don't want the money. They want rest from working 48 hours in a row, sometimes longer.
Everyone from the chief to the medics to the politicians agrees that the voluminous work and the shroud of sleep deprivation that comes with it pose serious risks.
Warns one paramedic: "If something isn't done, don't be surprised if you see a patient die in the field because a paramedic screws up. And don't be surprised if you see a paramedic go postal inside a station house. It's that bad out here."
Sleeping 6 Hours in 2 Days
A weary Bruce Liverpool is rubbing his eyes in the early morning glare pouring through the Hollywood station house. "God, I need a shower," he says.
This is the start of Liverpool's third consecutive 24-hour shift. Walking slowly and muttering, he is girding for another go-round.
During the last two days, Liverpool has managed, in broken-up bits, to put together close to six hours of sleep.
He rattles off "a few of the highlights" from his last shift. How he tended to a pregnant teenager whose water broke. Calmed a boy who fell off a skateboard and broke his arm. Treated a stripper who crashed on the freeway. Went to an apartment and found an old man who had been dead for days. The heat was turned up; the place reeked.
"It was awful," says Liverpool, a 40-year-old with dark, deadpan eyes. "Just awful."
As he says this, Max Hengst enters the brick, two-story station, a quarter-mile north of Paramount Studios.
Hengst is Liverpool's partner today. The lack of manpower makes it common for paramedics to work with various partners. Medics get yanked all over the Fire Department's station houses, substituting for colleagues on sick days and vacations, filling in when there just aren't enough people to go around.
Los Angeles County, in contrast, has twice the paramedic staffing that the city does on a per capita basis.
The patchwork nature of city paramedics' scheduling is yet another gripe for many. Teamwork is of vital importance in the field: The more two partners know one another's strengths and weaknesses, the better they operate. These days, it is uncommon to find two paramedics working together for long stretches.
This was supposed to be Hengst's day off. He had planned to spend it helping his parents put on a roof. But because he didn't volunteer for overtime last month, he got nailed.
Hengst, resigned to his fate, laughs when he sees who he is paired with. He and Liverpool have similar reputations within the department: They are known as survivors, Hengst with 17 years as a medic, his partner with nine.
More than a quarter of the city's paramedics have 20 years or more on the job.
"After a while the job becomes a game," says Hengst. "You see who can last the longest. It's either gonna be you or the department. And hopefully, it's you."
It is 8 a.m. and the men inspect their ambulance, which from the inside has the look and feel of a huge Amana refrigerator: all gray and beige and vinyl, a few metal parts, the smell of plastic, a slight chill.
They stock it. They check the IV bags, the Valium and the morphine, which sit in a little combination locker. They line up rows of 2-inch boxes filled with dextrose for diabetics; Lidocaine for heart attacks, drugs that wake the nearly dead from heroin overdoses alongside drugs that would keep a person up for days.
"Looks like we're ready," says Hengst, 39, whose station house nickname--Bulldog--is an apt description of his stature.
"Maybe we'll get lucky today. Maybe it'll be quiet."
Spend any significant time with paramedics and you will find the pressure comes in unexpected ways. There are few "glamour calls," the as-seen-on-TV emergencies where women are trapped beneath steel girders and kids whisked to the hospital after gang fights.
Yes, moments like these happen. But more than anything, paramedics face an onslaught of daily small emergencies--so many coming so fast that these calls alone can make the job hell.
"We're dealing with a public that more often than not doesn't have health insurance, more often than not doesn't know how to use the medical system in this country, and we have become the doctors, the transport guys, even for minor problems that don't need emergency care," says Liverpool.
Hengst's and Liverpool's second run of the day is instructive.
They find themselves in a white bedroom decorated with a single gold crucifix. Hengst has his hands on the chest of a 72-year-old man whose family has called 911, saying he was having difficulty breathing.
As Hengst ministers to the man, Liverpool is trying to pry information out of his daughter.
"Ask him what is bothering him the most right now," Liverpool demands of the woman, an East European emigre who is translating for her father. Liverpool says this in the firm, no-nonsense tone he adopts on all calls to establish a sense of command and order so he can quickly assess the problem.
"He feels not well," says the daughter, caught off guard by Liverpool's cut-to-the-quick manner. He once had liver problems, she says. Now his stomach is sour. Her father, alert and unfazed, holds his shirt up as Hengst listens to his heart and lungs.
Hengst determines that there's nothing wrong. "Probably ate something that gave him an upset stomach," his partner says.
Liverpool tells the woman to keep an eye on her father, that she should give him water and let him rest. Her father doesn't need to go a hospital.
The woman won't listen. She insists that her father be taken to a hospital blocks from her home. She will follow, in her own car.
At first, Liverpool resists. Then he thinks better of it. He knows the Fire Department, leery of lawsuits for negligence, is pushing its medics to transport patients to hospitals. He knows that Chief Bamattre says he wants his medics to make "customer service" a priority and not to dissuade people from taking an ambulance to a hospital.
The result: Medics often transport and check in people they think shouldn't be going to a hospital. On the streets, many of them call these instances garbage calls. Garbage calls take precious time. Time that medics could use for rest. Time when medics can't respond to something more serious.
Hengst cannot contain his irritation as he finds himself in this position now. Heading to the hospital, his patient out of earshot in the back of the ambulance, Hengst says: "The city should educate the public about what we do.
"People aren't using common sense. Used to be if someone in the family wasn't feeling well and you had a car, you'd take them to the hospital and check 'em in. Now everybody is calling us; we're spent, we're frustrated."
And the worst part, he says, is that people who truly need hospitalization have to wait while another ambulance is sent from farther away.
"Someone could die because we're taking a person to the hospital when we shouldn't have to."
The two men are not happy, but they try not to show it. Medics learn to hide their frustration and anger behind what Liverpool calls "a Nordstrom's smile."
But many also roll their eyes when no one is looking. They sometimes yawn in front of patients. They work with slouched shoulders. On rare occasions, Hengst says, he has seen frazzled paramedics shout and swear at patients and worried families.
Trying to Conserve Energy
When paramedics aren't on the run, it's as if they are living a quarter-beat slower than the rest of us.
A matter of "conserving the energy," says Liverpool as he flops down on a Lazy-Boy recliner in the station's rec room during a short break. A very short one. The last for a while.
The day churns out a series of small emergencies. They scoot all over Hollywood, going from call to hospital to call and back.
They get dispatched out of their area to the San Fernando Valley to look for a car accident. They are sent to a guest house near the Beverly Center, where they treat a man who has had too much to drink and can't say his own name.
They treat a woman who suffered a seizure. They calm the woman's frail mother, stroking her hand, putting her in the front passenger seat, driving her to the hospital and making sure the nurses pay close attention.
On Hollywood Boulevard, in front of a shoe store, they try to help a drunken woman. She questions Liverpool's manhood, tries to fight him, throws up on his boots. Then she reaches out and touches his stomach, calling him a "fat-bellied [homosexual]."
They take a man complaining of stomach pain from a Sunset Avenue Arby's to Kaiser Permanente Hospital. The man bad-mouths them the whole way, calling Liverpool a "hateful, ugly jerk."
Through it all, the two paramedics absorb the insults like boxers accustomed to taking heavy punches. Frankly, they're more stunned by how little the public knows about their jobs: the volume of calls, the long distances they may have to drive to rescue someone having a heart attack.
"If the public was only aware of some of this," says Hengst, shaking his head. "Man."
The roughest part of their shift comes after midnight. They are sent on four runs--including a bogus call and one for two men who are sick and dazed from drinking too much.
At 1:45 a.m. they have returned to the station and are asleep.
Hengst is snoring, Liverpool is starting to dream.
"Rescue 27, Rescue 27 . . . " booms a computer-generated voice, accompanied by a humming bell. This starts a routine that is downright Pavlovian.
The two, sleeping in uniforms and boots, stumble out of bed. They have exactly 60 seconds to be out the bedroom door, down the stairs and into the ambulance. If they don't make it, they may get a reprimand.
In less than a minute, they're racing through the sparsely populated streets of Hollywood, stone-faced. They treat an old man whose stomach is so wracked by what the medics think is cancer that it feels like jello.
They put the white-haired man--mumbling Russian, his long fingers reaching out to touch Liverpool--into the ambulance. He is 82 and he has been in pain for hours, yet his wife waited until the early morning hours to call. "They always wait until we're just getting to sleep," says Liverpool. "It never fails."
When they show up at Cedars-Sinai Medical Center, the nurses do not look pleased: it is a tough night for them, too. Often, when paramedics need a hospital emergency room, they are all full. When this happens paramedics get to pick the nearest one, which is required by law to take the patient, like it or not.
Jamming down busy streets, sirens on, paramedics sometimes argue over their radios with nurses about whether they can take the patient. When they arrive, they are sometimes greeted with glares. "You sure you had to come here?" Even in front of patients.
"Just another stress," says Hengst.
In the hospital parking lot, Liverpool talks about the way the job is draining him, how his body hurts from it, how he worries about getting old before his time.
Hengst understands perfectly.
"I'm seeing a shrink, man," he says. "Nothing wrong with admitting that. A lot of paramedics are. If I don't end up seeing a shrink, the way I see it, I'm gonna end up screwing up on the job. Better to take your problems to the doctor than to take them out on the public."
Hengst started getting help about six years ago. Like many of his colleagues, he took the job home and it was ruining him there. Hengst was having trouble with his wife, partly because he was away at work so much they hardly saw one another. When they were together he'd start snapping at her, or he'd be remote.
He'd see friends and they'd tell him about their problems and he'd snap at them, too.
Hengst lives in Temple City. People in the suburbs don't have problems, he says, not compared with the population he deals with. "I've had friends start telling some sob story to me and the whole time I'm thinking of the calls I've had to go on, the problems I've had to see. My friends want me to listen but come on, I don't want to hear it."
Hengst carries the job with him every minute of every day.
Not long ago he was bitten on the back by a prostitute. Soon after, he was treating a homeless man who attacked him. With two fat and bloodied lips, the man spit into Hengst's mouth: blood and saliva, a straight shot.
Now, every month for the next year, Hengst has to take an HIV test. Many other paramedics are in the same boat, exposed to HIV, tuberculosis and every other contagious disease you can think of on a daily basis.
Some are so frightened of diseases that when patients hand back pens they've used to fill out medical forms, the paramedics carefully wipe them down with disinfectant.
Liverpool wears wraparound sunglasses on almost every call, day or night, to protect his eyes from getting splashed with body fluids. The glasses give him the look of someone on his way to a very intense game of racquetball.
Hengst tries to laugh off the dangers, but you can sense a sad bitterness in his voice. "This is a job that's gonna follow you, on the job, off the job, at home." It's so bad, he says, that he has to wear a condom now to protect his wife.
"That's how close it hits. That's too close."
Firefighters, Medics Differ in Images
There are few who understand the pressures that paramedics face better than Capt. Bill Wells, 46, a man regarded within the Fire Department as a living, breathing history book, a man able to put the current troubles in perspective.
Wells arrived in 1973, right after high school, and was among the first department employees to be trained solely as a paramedic. Back then they were a separate group, not trained to fight fires.
As a result, the paramedics, although stationed in firehouses, felt alienated from the department, Wells says.
Partly to boost cohesion and allow Fire Department personnel more career options, the agency in 1990 mandated that paramedic recruits also be trained as firefighters. It also allowed firefighters to train and work as medics. The idea was that firefighters and paramedics would bond.
That hasn't exactly happened.
Both groups still tend to view each other in stereotypical ways. In station houses, firefighters are known as ultra-aggressive warriors, more oriented toward pouncing on disaster and solving problems with brawn.
The medics, although most are trained firefighters, are regarded as the brainy bunch. They stand back and assess, then rush in, always with control.
Fueling the resentment of many paramedics is the fact that 80% of the department's emergency calls are for medical help. So while they are ping-ponging around the city, their firefighting counterparts are often relaxing at the station.
"The paramedics are gone so much for their runs that they just aren't in the station house," Wells says. "So they tend not to be part of the everyday station life: the cooking, the eating and talking together. . . . When you aren't around, you get talked about."
The Fire Department is trying to deal head-on with these clashing cultures, says Bamattre, who acknowledges that there needs to be a departmentwide change in attitude.
"Whenever you have a working environment with two disparate types of people, two different types of work, it's going to be a struggle," he says.
Bothered By Memories
Just hours before he got sick--before his partner took him back to an Eastside emergency room and the doctors told him the job was stealing his health--John Smith sat in the sparse kitchen of Hollywood's Fire Engine Co. 27. He was eating a bowl of spaghetti.
It was about 8:30 p.m. and he had been on the job since early morning. He had nearly a day more to go before he could go home, and he was in a reflective mood.
"There are so many things we have to deal with," said Smith, lifting his fork slowly and heavily. "It's different layers" of trouble.
Memories are the deepest layer. The sights and sounds, even the smells of the most horrific calls. Most try to keep them at arm's length. Most admit, there's no running away.
"Every time I hear someone talking about Disneyland," Smith said, "I think of this one particular call."
Smith remembered a family that drove home in a minivan from Disneyland a few years back. The mother held her baby in her arms in the front seat. The father drove, but fell asleep and slammed into a freeway guardrail.
Smith got there first. One image haunts him: The mother, rocking back and forth.
She had been holding her baby when the crash happened. The baby flew into the windshield, then bounced back into her arms. When Smith arrived the baby was mangled, bloody, dead. He tried to pry the mother out of the van but she wouldn't move, wouldn't let go of her dead infant.
Wake up, wake up, she whispered to her baby.
There are as many similar horror stories as there are paramedics. Stories of finding children who have just committed suicide--with shotguns, or ropes or knives. Stories of plane crashes, of driving down airport tarmacs and taking in the acidic stench of gas mixed with blood mixed with flames. What it's like to see body parts in the moonlight.
It is Sunday morning at 7. Liverpool is finally getting his shower. He will be off soon. He will drive to his Thousand Oaks home. He'll be tired but his wife and two children will be waiting. They won't see much of him. He plans to sleep.
As for Hengst, he's standing by the ambulance, thinking about what he has been through in the last 24 hours.
The women he helped and the woman who laughed at his gut. The runaway he gave some pocket change to and the old man who stood like a statue on a sidewalk and refused any help. How he was so tired on a 4 a.m. call that while Liverpool worked, he stood on a corner, eyes closed, nearly asleep.
Hengst is eager to go home too, but he's not going soon.
A paramedic scheduled to take over for him is sick, leaving a vacancy that his supervisors are scrambling to fill. Hengst must stay until another can be found.
The man who is too sick to show up is John Smith. The 11-year veteran is at home, resting, unable to work and not sure he really wants to go back to work at all.