Krauts, Guns, and Hypoxia

We come across a variety of patients. We have our psychs, our pregos, our druggies, and we have our vets. These days, we usually deal a lot with post OIF and OEF vets, as well at Vietnam veterans. Some have flashbacks over fireworks, driving, or something as simple as a few words said to them. The Veterans Affairs hospital is very familiar with us, as well as the patients we bring them on a daily basis.
I was on duty one night with a guy named Steve. Steve was a part timer filling my partners slot for a shift. He hadn’t seen too much, and was a fairly new EMT. He was excited to work with me. It seems like when its just my regular partner and I, we dont get a whole lot of good runs. We do a lot of routine transfers, and on occasion we get someone with SI, that really just needs a place to sleep for the night, so they want to go to the psych hospital. When I get someone else on my shift, interesting things usually happen. Codes, wrecks, gsws, heart attacks, and more goodies. I would have never thought tho, that we would be in a situation where we were almost the patients, or doas for that matter.
It was around midnight and we got dispatched out to a “mental check”. Usually, for us, this is someone complaining that their loved one is “just not acting right”. Could be diabetic, could be schitzophrenic, just about anything. Seems with the way the world is now a days, there are a lot of mental checks needing to be done. Everyone lately has lost their mind.
We arrive on scene. I hop out and grab the bag, and make my way toward the house. The neighborhood is a nice neighborhood. Primarily elderly, with a few young married couples that just moved in for the quiet. The house is a nice ranch style home, with a professionally cut lawn and organized flower garden. Its quiet, and we hear some walking around the side of the house.
“Ill shoot you damnit, Im giving you a chance to get out of here.”

At this point, I am really not sure what I am hearing but I immediately hollered to dispatch to get PD in route for possible domestic. I saw the face of an old man peering around the corner of the house and tried to make verbal contact with him.
“Hello sir, did you call 911?”

“Damn Krauts, thats it, I warned you! Ill kill every single one of you!”
My partner and I made haste out of there back to the truck where we waited for PD. I updated PD by dispatch that the patient possibly had a weapon, and that we were back in our truck. We were unable to see the patient anymore and waited for clearance from law enforcement.
Several police showed up and I could hear them hollering for the man. Their hands were on their side arms, ready to take aim should something happen, and out walks this confused old man, with a lever action rifle and a small pistol on his hip. Police met with the man and confiscated the firearms. We were then advised to come evaluate the patient.
I began my trek again toward the house where the old man stood on his porch. Two of his sons just arrived by POV, and I started my assesment.

“Hello sir, what made you call us today?”
“Well, my wife came home and when I opened the door for her, I could hear em’ out there. I didnt want them hurting her or I, so I got my guns. I got my guns and I was going to kill every single one of them krauts!”

At this point I knew he was a WWII vet. He was 88 years old, and convinced that the Germans made it to America to get back at him for killing so many in the war. His sons stated that he had been acting strange the last few days, saying that there were helicopters flying over his house spying on him, and that they were mobilizing units on his street.

“Well, sir, the police are here and took care of those Germans out there. Can I check somethings with your health really quick like your blood pressure and blood sugar?”
He consented for the evaluation where I continued to talk to him about his time in the war as I checked him out. His blood pressure was fantastic for an 88 year old, his heart rate irregular from his a-fib. Skin was a little pale and his lips looks slightly tinged blue. I applied a pulse oximeter only to read it at 78%.
“Sir, are you having any trouble with your breathing?”
“Well, yeah I have emphysema and I take breathing treatments.”
“Do you have oxygen sir, that you wear daily?”
He pulls out a long oxygen hose where its hooked up to a powerless concentrator. “Yes, but the doctor says I only need to wear it 6 times a day.”

I walked into the back room where the hose led and powered on the oxygen concentrator. I attached a new nasal canula to it, and cranked up the liters to 4. My partner helped place the patient on it, and we continued to talk the patient into breathing through his nose.

The youngest son came in and began to give a history, stating his war experience, and the fact that their mother had been dead for over a year. So, he not only saw Germans outside in his yard, but he let his wife into the house. A simple man, with a plan to protect his house and loved ones. He was a very clean and neatly organized man, and we had no problem getting him to oxygenate himself.

After about 25 minutes of oxygen therapy, we was back to normal. He knew his wife was dead, and was not really sure why we were all there. We began explaining to him what had happened, and he admitted that sometimes he feels like the Germans are coming back to get him. He is paranoid on occasion, and lonely. He misses his wife, and feels like there is really nothing left to lice for. He was a retired and decorated WWII vet with the Navy.
He refused to go to the hospital for evaluation, and his sons agreed to stay the night to keep an eye on him, and schedule a doctors appointment in the morning. This lead me back to thinkin, if we would have went any closer, we may have gotten shot. That poor man thought we were Krauts, and that we were going to kill him. It could have turned into something a lot worse than a call for mental status changes.

Relationships – The Ins and Outs

It didn’t take me long at all to realize that this was the career that I wanted to progress in.  I remember from day one, how crazy I was about starting this job, and I was hoping that I wouldn’t get burnt out too soon.  Some people get burnt out quickly, yet I have remained loyal for 11 years to this field.  I still love it as I did on day one.
                It’s like the relationship you have always wanted.  We know that in EMS, relationships come by the numbers, and so do divorces.  This field is demanding, sexy, addictive.  People can become so attached to your passion that they think you can have the same passion towards them.  In some cases, they can be so focused on your passion, that they think they can displace your passion for this field, to have only passion for them.  Some people are snakes like that, and believe me I know.
                Our jobs are stressful; they bring a lot of tension to a household.  It’s very hard to explain to someone how you’re supposed to feel when you have worked a pediatric code and were unsuccessful at a save.  It’s hard for your significant others to understand what you’re going through, and it makes communication difficult too.  Along with that, it complicates a lot of things.  A lot of us seek counsel to try and make things better, but it never seems to work.  We are told we need medication therapy, when the only true therapy is more work.  Maybe this is why most of us hold more than one job.
                I had a significant other once tell me that this job was easy, and that anyone could do it.  She would say that it was no different than a clerk at a gas station, and that my position was nothing special.  It would make me upset to no end and I was constantly starting arguments based on this accusations.  I would say, if she could go work a baby code, tell mom there was nothing more you could do, go to your truck, crack a joke, and eat a sandwich as though nothing happened, then she could do this job. 
                I would explain how paramedic school was.  I sold everything I loved to pay for a deposit just to take the class, then it was 8 hour classes twice a week for 9 months during the day, when at nights I would work, and on off days I was doing clinicals.  I took a two year program in less than a year. I was never home, hardly slept, had tests, exams, practicals, clinicals, bills, worked three jobs just to support myself, and had to deal with the emotional stress and abuse by my significant other.  Of course all this was after I had finished a two year college degree for fire.
                To this day I still attend classes to make myself that paramedic I want to be.  The one who is very knowledgable in the field and can address my patients problems quickly, diagnose them early, and treat them to the best of my ability with what I have to work with.  This is a very young field with advancements everyday, and its important I keep up with everything.  This is another thing that makes relationships so hard.
                So many medics try to alleviate the potential for problems by dating within the field.  Nurses, doctors, emts, other paramedics, etc.  Sometimes this goes by well, other times it ends up becoming a battle.  Paragod mode kicks in, and then it’s a battle as to who is the best in the relationship.  Im really not too interested in this route either.
                My job means everything to me.  Without it, I have no place to live.  Without the education, I am uneducated.  This job is what will put a roof over my future children’s heads, foot in their mouths, and clothes on their backs.  People dont realize that some of us do this job because it’s a job, and it supports our families.  I do this job because I enjoy helping people.  The rest are just perks of the job.  With the salary we make, no one does it for the money.  I am completely satisfied if I know that I made a difference in one person or child life.
                I believe our passion and dedication is what drives us to do this, day in and day out.  If someone can’t see that, and look beyond that to the person we are inside, then no one deserves us.  My family are my brothers and sisters that I spend 2/3 of my life with doing this job.  My romance is the duties I perform everyday to the patients I encounter.  My happiness is the outcome of us making a difference.  Like I said, everything else is just a perk.

People Die

                We have all been over the “graying” of America.  It’s true.  Most of our runs consist of the elderly.  The falls, the diabetics, the chest pains, the altered metal status.  Just about anything and everything, we deal with from the elderly.  We can thank a lot of our medical skills on them from how often we are presented with their situations.
                The elderly also bring several other factors into play with our job.  DNRs, powers of attorney, health care delegate, and so on.  Nursing homes are usually where we see or hear about these quite often, and we are all too familiar with the nursing home issues delt with on the runs.  The lack of information, or help for that matter, when dealing with a true emergency.  Nursing homes make some of our jobs harder than they really are, and put us in awkward situations at times.

                We had just clocked in for shift on this Friday evening, and things were calm for the moment.  My partner was extremely tired and decided to grab a nap, as I made sure our truck was checked off.  Afterwards, I decided to chat with a close friend, and clean the car that I was borrowing from my roommate.  I must say, I was motivated to do something productive tonight.  After cleaning the car, I began to search the station for something I could do that would tidy up the place.  I was still trying to stay busy as I watched my partner come out of the day room.

                                                “We got a run?” I asked.
                                “Yeah, priority two at Pine Creek for a fall.” She replied.

                So, we loaded up in the buggy and off we went to Pine Creek.  Most of the falls that we do at nursing homes end up being minor injuries, or “protocols” for a CT at en emergency care facility to rule out hidden injuries.  In these cases, we roll in with everything but a backboard, and if we determine that in fact it is a spinal injury, or hip injury, we go back out and grab the needed immobilization device, to properly package the patient in, to avoid further injury.
                We arrived at Pine Creek, grabbed the cardiac monitor, bag, and rolled in.  A tech showed us to the patients room, where in the bathroom, lie a 96 year old man, in no distress, with only his night pants on.  I jumped in and began an assessment.

                                                “Well how on earth did you get down here?” I said.
                                “I was watching the Louisville basketball game, and I had to use to the restroom.                              I got my walker, and I came in here, and suddenly felt weak and fell.  I don’t need to go                                                 to the hospital.”

                The man’s glascow coma scale (GCS) was a 15.  He was completely alert and oriented, denying pain.  All his vitals were in normal limits, his blood sugar 136.  No spinal deformities, though he did have a small knot by his temple.  His abdomen was slightly distended and rigid which made me suspect a bowel obstruction, but other than that, the man was sound.

                                                “Sir, you hit your head, and your belly looks like your having some trouble using the bathroom.  I think we should take you across the street to get checked out at the hospital to make sure you didn’t do anything when you fell.” Said my partner.
                                “I’m not going to the hospital.  If my body was as good as my mind, I would be great.  I am 96 damn years old, I’ve lived my life, and don’t need to die in no hospital.  I want to watch my games in peace, and die here when I’m ready to go.”

                Despite our efforts to take him for an evaluation, he refused, and like any refusal, if they are alert and oriented, we do not have to take them.  Unfortunately, the nursing facility thought otherwise.  They were very persistent that he go, and were even trying coming up with reasons to take him.  We argued forever with the nurse.

                                                “He has slurred speech, and his stomach don’t look right.  That’s new to us.  He                                                 has to go to the hospital.  You have to take him.”
                                                “Well miss, the man is completely coherent, and legally we cannot take                                                                 someone against their will that is.  It would be considered kidnapping, and we cannot do                             that.  It sets us up for a lawsuit.”
                                                “You can’t take him?  You have to, he has to go, we can’t keep him.  Anyone                                      who falls has to get cleared before they can continue to stay here.”
                                                “Again, we are sorry but we cant take him if he is refusing.”

                This carried on for about 30 minutes.  The nursing home called the son, and the son came with the same demands, that he needed to get checked out.  He started going on about how he is the power of attorney, and of course we advised him that the POA does not have any legal say for us if they are completely coherent.  So, what does the son do?  He goes to his father, lying on the bathroom floor, and begins to ask him questions.  Surprised, the old man answered them all right up to the very hour that the time was.  I must say, for 96 years old, the man had his mind!
                Time was ticking by, and I was starting to get concerned about the patient being on the floor of the bathroom for so long.  My partner covered him up with a blanket while she was still trying to explain that we could not take him if he didn’t want to go.  Then the nurse comes in again, and goes up to the patient and begins trying to con the patient into going.  My partner and I were both disgusted with the things she said.

                                                “Sir, look, you can go and get checked out and come right back to watch the                                       game.  You won’t be there long at all, and you will be right back.”

                We knew that what she was doing was wrong.  What if the man had a bleed?  What if they decided to keep him overnight for observation?  He don’t want treatment anyways, he has chosen that option in his living will.  So, waste time sending him to the hospital to get diagnosed with or without something that ultimately will not get treated anyways.  The dude in 96!  Respect his wishes and let him die!  I hoped we would take him and he would be admitted over night, just so he would come back angry, but I knew the man didn’t want to go.

                                                “Ok”, he said.  “Fine, Ill go, but get me up and get me dressed damnit.  I don’t want to miss tomorrow’s games!”

                My partner and I were slightly pissed.  For 45 minutes we were tossed back and forth.  Told we had to take the patient against their will, told that they will get a doctors order requiring we take him.  Badgering with the family, and yet telling everyone that we cannot take anyone against their will, then having a nurse aid lie and con the poor man into getting on our cot, going to the hospital, being stuck for labs and put through CT.  I mean, really?  Our jobs as professionals are to give care, yes, but it is also accident prevention and positive customer relations.  This does not include conning people to go to the hospital when they have made it a point not to go.
                We loaded him onto the cot, I obtained vitals, which were all within normal limits. And then we began our trek to the hospital which was literally across the street.  Way to talk about a short transport.  He was evaluated at the hospital, and stayed for quite some time, with nothing found.  He was then taken back to Pine Creek without any problems, but was extremely pissed he missed the basketball game.
               

Using Your Head

                In this field of work, everyone has their weaknesses.  Vomit, shit, kids, elderly, and even blood!  Yes, we all have some strange weakness that we learn about sometime in our career.  I have a few that I have found in the many years that I have been involved in this field, but one incident stands out in my head the most, and is the reason for this specific weakness today.
                We got snow.  Snow, snow, snow, and more snow.  Weather anticipated eighteen inches of snowfall this evening, and I was for certain we got two feet.  Snow days are usually rough.  There are a ton of wrecks on I-95, and while on shift during a noreaster, I usually work about ten of them, my unit alone, and transport maybe two to Maine Medical Center.
                The snow had calmed down a bit, and we had returned to the station to grab a nap.  I had volunteered for 72 hours anyways, so a nap is always nice when you know you’re working three days straight.  I climbed up the stairs to meet my friend rescue Randy in the mezzanine, and tuck myself into the small camping cot above the department.  Most people slept in the bunk room, however working with grown men who snore exceptionally loud makes for a hard nights rest.
                I had just shut my eyes, and, well, you guessed it.  The tones dropped for a roll over on the city line.  I sat up, took a deep breath, ran downstairs, threw on my turnout gear, and on the buggy I went with an engine ahead of us.  Police had arrived prior and radioed “possible entrapment”.  It would have been the first time tonight to actually break out the extrication equipment.
                We pulled on scene with mutual aid fire responding, police on scene, and our engine unit.  We found a new 2004 Jetta crumpled and on its roof.  It easily rolled over three or four times and you could see where it skidded.  Fire checked the scene out and suggested we “come check out the patient.”

                                “Yeah, I think he’s dead.  There’s an awful lot of blood, and a limp body.”

                My partner Greg looked into the smashed window to a lifeless body lying on its back along the windshield of the upside-down vehicle, with various broken items around it.  All the windows were broken except for the rear.  You could smell fuel and cigarettes.  Yes cigarettes.  Apparently our victim was a smoker, and an unrestrained one at that.  Greg called for me.

                “Parker, hey this dude is missing a body part so can you look around for random body parts?”

                I had yet to be at a scene with anything other than a missing finger or toe, and Greg was displaying behavior that may indicate a larger item, like a leg or arm, so I surveyed the area for anything out of the ordinary.  There was debris everywhere.  A headlight lens here, a spoiler there, part of a tire, and various other broken items scattered across about thirty five yards of field.  Then I saw something different.  I wasn’t really quite sure what I was looking for but it appeared round, distorted, and dark.  I could see where it had slid, or rolled for that matter and it lay not more than about fifteen feet from the car.
                I yelled to Greg, asking what he was looking for.  His response was not what I expected.
                                “The guys head is gone, ripped from his shoulders, so we need to make sure it’s here                                    somewhere and cover it up for the coroner.”
                I nearly puked, knowing exactly what it was and relaying my finding to Greg.  He insisted I grab a sheet or towel from the truck and place it over the distorted body part.  It took me every ounce of effort to even agree to do such a thing, but I thought to myself that this wouldn’t be the only time I saw a gross disfigurement, so I needed to carry on with my duties.
                I walked to the truck, popped open the linen cabinet and grabbed a sheet.  I began to walk toward the head, making sure I didn’t disturb any other items that may be in the way.  I would continuously turn my head, as to avoid having to actually look at it, and proceed one step at a time.  By the time I reached the decapitated head, I had glanced down long enough to place the towel on it and peer into his green eyes.  I dropped the towel and swiftly made it back to the truck, where I hid myself on the wheel well of one side and proceeded to vomit.
                The only thing that was going through my head was that he could actually see every move I was making, and in his little head thinking, “oh shit what did I do to myself.”  It’s just not right seeing a dead man’s eyes, and one that’s been decapitated for that matter!
                Greg was making fun of me.  Mr. I puke anytime someone else pukes!  I was so angry and disgusted at the same time.  Greg couldn’t stop laughing.  I was getting extremely fed up.
                                “What the fuck is so funny Greg?”
                His reply, along with the details of this scene, are the reasons why one of my weaknesses are open eyes at a DOA (dead on arrival) run.
                                “Did he ask you for directions Parker, cause I think he was going the wrong way.”

The Beer Bandit

         We have all been on our fair share of drunk calls.  Three in the morning dispatches, your sound asleep in your bed, only to be awoken by the tones for the same idiot that called you two shifts ago.  You head code to the scene, only to determine that the patient needs no medical intervention, as police handcuff him and take him to the “drunk tank” to sober up.  Yeah, we are all too familiar with this one.  So routine, and not out of the unordinary.
          I was a freshie.  Straight out of EMT school and onto the streets in Lewiston, Maine.  The population consists of a variety of people.  Different backgrounds.  For the state of Maine, you would think that there is not a lot of crime, and generally there is not.  However, we have a very dim population of blacks, and a huge population of white people who really want act all brody and tough, like a blood or crypt.
          It was cold outside, late December.  My blood was pumping, for I had worked my first code prior.   We were dispatched out on an unconscious unknown.  PD was already on scene and requested our assistance.  On our arrival, we were greeted by one of the police officers.  “You guys are gunna love this I tell yah!”
          The officer guides us up the stairs of a very nice residence.  Elegant artwork on the walls, extremely clean carpets, and an overall well kept quarters.  We come to the doorway of what appears to be a master bedroom filled with police officers.  Jim, my partner, a seasoned paramedic says, “Ok? So I see a bunch of police officers standing in a room and wonder to myself what could be going on… there seems to be no obvious distress going on in here!”
          As Jim’s face begins turning red in agitation, one of the officers points toward the bottom of the bed.  I get down on my hands and knees after dropping my bag, to peer under the neatly made bed. 
“Is he dead”, I asked.
“Not yet.”
          According to the police, the gentleman had been dumped recently and he wanted revenge.  He broke into his ex girlfriends house, decided to drink all her beer and planned on attacking her when she got home from work.  However, his plans changed when his drunk ass decided to try to crawl under the bed with an open knife and a beer can.  He somehow managed to stab himself in the chest while maneuvering under the bed.  When the woman arrived home, she heard him crying for help and complaining of respiratory difficulty, only to find him under the bed.  Afraid, she called for the police, and in turn we got called for his injuries.
          Police were able to con the man out of his knife, and my partner and I grabbed his legs to pull him out from under the bed.  Surely enough, he still had a beer in his hand that he had stolen from the fridge, slurred words and the smell of beer on his breath.  He was obviously in distress.  Who knows how long he had been down prior to our arrival.We flipped him over on his back, exposed his chest and applied high flow oxygen.  He had stabbed himself in the right side of his chest,  mid clavicular.  Text book sucking chest would.  I sized out and lubed up a nasal airway and inserted it into his left nare.  As my partner placed him on the monitor and established an IV, I placed an occlusive dressing on the wound and taped down three sides.  We had police escort us to the hospital.
          When we arrived at CMMC, the doc received the report.  After hearing the story behind the injury, the doc leaned over to the patient and said, “Didn’t your mother teach you not to play with knives?”  The patient looked up at the doctor and said, “I just wanted some beer.”

Double Medic Diabetic

                In paramedic school, you learn the necessary things to perform invasive procedures in an emergency.  One of the other things you learn is that you always start with your basic skills.  You were an EMT before you got the “P” behind it.  Some people in this job fail to realize that.  They get their medic, and they think they are on top of the world.  Paragods, we like to call them.  Some paramedics have doubts in EMTs.  Why?  I am not sure, considering they too were once an EMT.  Some EMTs have saved a paramedics ass.  Some paramedics just don’t need to be paramedics.
                I had been out of class for some time.  I was waiting to test out for my license, anxious of course, and excited for the new chapter to begin.  The good thing about having done your ride time at a place you work at is that your always there to help your partner, and ultimately are a double medic truck.  One day, it turned out that I was the only medic on.
                My partner had called in sick, and was relieved by a new medic, licensed and fresh out of school.  I had seen Craig practice before and was not too friendly with him.  I doubted his diagnosis’s and treatments.  His skills were horrible, and I began to believe he cheated his way through paramedic school.  However, I was with him this shift, and needed to accept that.
                Craig is always sleeping.  First in on shift, he heads straight to the bed.  I kept hoping for a run, as hours passed without a tone.  I finally decided it was time to take a nap as well, but of course once you settle in, the runs come, and that is what they did.  They came.
                We got an emergency run to a residence where there was said to be an unconscious diabetic.  Upon arrival, we were rushed in by a family member, stating the patient was barely breathing and “wouldn’t wake up”.   Craig stood there like a deer in headlights.  I was getting extremely agitated.
                                “Hello!  Earth to Craig, lets go!”
Craig and I made our way in the room, to see a middle aged female, pale, diaphoretic, and breathing around 8 times a minute.  I quickly grabbed the glucometer, prepped the finger, and attempted a reading.  While I was waiting for the reading to come up on the screen, I looked over to see Craig hooking the patient up to the monitor.
                                “Craig!  Get a damn IV in the patient, her sugar is 28!  Ill get the monitor and vitals.”
                As Craig grabbed an alcohol swab and the IV kit, I spiked a bag, and plugged up the D50 prefill.  While Craig was attempting an IV, I had obtained a strip, and vitals.  She was sinus at 68 with occasional PVCs, blood pressure 98/54.  Pulse ox was 95% on room air.  I applied high flow oxgen and I was ready to get her loaded and on the road.
                                “Craig, you got that IV yet?”
                                “No dude, Ive tried three times, I cant find a good vein”, as he is trying a fourth time with a 22g IV needle.
                                “WHAT?!  You will never get D50 through a 22g man, let’s get her on the cot and load her.  Ill look for an IV site in the truck.”
                I quickly drew up a milligram of glucogen and gave her an IM injection to buy a couple of extra minutes.  It brought her sugar up to 45 and we were able to load her into the truck without any further complication.
                Once in the truck, I quickly opened the cabinet for the IV supplies, grabbed a 16 gauge needle, and an alcohol prep, and looked for a vein.  This woman was fairly large and had poor iv access visably, but I was determined. I couldn’t find a tourniquet, so I grabbed a nitrle glove and tied it around the patients arm.  I felt around and was able to feel a deep AC.  I prepped it up, and popped the needle in.  Kaboom!  Good flash, I advanced with care, popped the glove off and flushed the line for good flow.  It flew like a champ.  Craig stood next to me silent and still.
                                “Give me the D50 man!  Lets get this done!”
                Craig handed me the D50, I pinched off the IV tubing, intermittingly allowing saline to flush it into the veins until the entire amp had been emptied.  I said, “Ok, Its in, we got everything completed, get another sugar in a few minutes, Im heading code to the ER… want me to call the report too?”
                Craig insisted he call the report and I headed up to the cab to drive us in.  Half way to the hospital, I heard the patient talking, asking where I was.  I asked Craig if he obtained a sugar, and he was able to get a reading of 530.  Mission accomplished.
                Upon arrival at the emergency department, the patient looked at me and thanked me.  I asked her if she was able to hear everything we were saying despite her unconsciousness, and she replied with a yes.  The report was given to the hospital and the patient was monitored, fed, and released that same night.
                I had hoped that Craig would have learned from this run.  Learned how to take control of a scene, and delegate certain skills to me, and others to him.  Prioritize his patients and their needs.  That didn’t happen here, and I had to step in and take his role.  This lady was knocking on deaths doorstep, looking as Jesus holding a piece of cake and saying, “Come here and eat this cake.”  I was not going to let that happen.  I did my job, and it was doing everything I could to make that patient say, “Thank you.”