Don't take it for granted

What I've learned from being an EMT

For the last six months, I've worked as an EMT (Emergency Medical Technician). I have now spent over 1,000 hours on an ambulance, and I want to share what I've learned from my experience.

But first, a bit of background. At my company, we primarily do inter-facility transfers, rather than respond to emergencies. As a result, our patients are relatively stable, meaning they probably won't die in the next hour or so. Probably. They are deemed sick enough to need to travel by ambulance, but not so sick that they need to go with the lights and sirens blazing.

Our patients are sick for a variety of reasons-- some are temporarily handicapped from injuries like an ankle fracture, and some are completely incapacitated from terminal illnesses like cancer. My partner and I alternate each call, so half the time I'm driving, and the other half of the time I'm in the back of the ambulance with the patient. Regardless, I interact with every one of our patients, and during our time together, however short or long, I get to know them and their condition.

Each of the hundreds of patients I've cared for is different, but they all have one thing in common -- it doesn't matter their genetics, their upbringing, or the choices they've made -- they are all sick.

As a result, the number number one thing I've learned from this experience is this:

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Don't take anything for granted.

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What follows are some anecdotes¹ from my time on the ambulance this year, which each remind me of one of the innumerable ways I am blessed. If it seems like a long list, that's because it is. I tried to be as concise as possible, but the truth is that there are too many things to count. If you need to take a break, feel free to come back at a later time. Some of these stories are pretty heavy, and take time to process, at least for me. I plan to come back to this list often, because it's something I need to constantly remind myself, because otherwise I take it for granted.

Alertness

Maria is 87 years old and is comatose. Two years ago, she had a severe stroke. A clot of blood formed in her brain, limiting oxygen to the area for about an hour, causing catastrophic damage. She survived, but is now permanently afflicted with several neurological deficiencies.

Maria's brain is only able to perform the most basic bodily functions. Her lungs spontaneously inflate and deflate, her heart still beats, and her digestive system processes food and water. But otherwise she is completely unresponsive. Maria does not open her eyes. She does not respond when you say her name. She does not respond when you pinch her.

The first test whenever I meet a patient (or a potential patient) is this: what is their responsiveness level?

Most people are alert, which means their eyes are generally open and will follow you around the room, and they will react in some way if you approach them.

But if someone is not alert, then their condition is abnormal. At best, they are merely asleep, and will respond to verbal stimuli ("Hello? Are you ok?"). At worst, they are suffering from a life-threatening injury or illness and need medical attention immediately.

However, more often than not, when I meet someone who is not alert, they are somewhere in between the extremes of asleep and about to die. Usually the issue can be traced to their brain, which for a variety of reasons, doesn't allow them to respond to sensory inputs. Sometimes people are merely intoxicated, and their central nervous system is depressed. But if so, they will still usually respond to painful stimuli (a firm pinch). Other times, they could be less than alert if they have suffered prior illnesses or injuries such as meningitis, a car accident, a heart attack, or a drug overdose.

We don't know how consciousness works for people in a coma. Experts think that the sense of hearing is the last one to go, so even when people cannot see you or feel you, they may still be able to hear you. When I cared for Maria, I still introduced myself to her, asked her how she was feeling, and explained to her what we were doing. I don't know if she noticed my voice, or if she understood me, but it doesn't matter. Perhaps on a deep subconscious level, she sensed that someone was taking care of her.

Maria is like many of my patients, who have an altered level of responsiveness. I take it for granted every day that I do not.

So, I am grateful that I am alert.

Sensation

Marcus is 56 and is deaf. He recently had a total knee replacement and is unable to walk for several months as he undergoes the slow and agonizing process of rehab. But otherwise, his outlook is good, as long as he is diligent with his therapy.

Marcus is alert and responsive to almost all stimuli, except for auditory. If Marcus is looking the other way, he may not notice your approach. Marcus cannot listen to music, in the traditional sense, although he can feel vibrations. All things considered, his handicap is a relatively minor inconvenience: Marcus can still see where he is going, he can watch TV, he look at flowers or paintings, and he can read and write.

However, Marcus is closed off from the world in a fundamental way-- it is very difficult for him to interact with others. Unless they know sign language, or have the time and patience to write things out to him, Marcus is unable to communicate. Marcus's own daughter only knows a few words of sign language. No one else in the hospital knows sign language. We have to use a video screen to call an interpreter in order to explain to Marcus where he is going, and why.

When I cared for Marcus, it was awkward and difficult. I was unable to explain to him why I needed to touch certain parts of his body. We weren't able to make any small talk, which always eases those embarrassing moments of close physical contact. I couldn't ask him if he was in pain, or whether he needed any medications, or a host of other things I was concerned about. In the hour I was with Marcus, things were difficult for me, but I can't begin to imagine how difficult it is for him on a daily basis.

While brain damage is the most common way that we lose responsiveness to our environment, sometimes our organs lack the capacity to receive inputs at all. Some people are born blind, or deaf, or mute. Others acquire these handicaps from an injury or illness. Sometimes these handicaps are temporary, and sometimes they are permanent. Many of my patients are paraplegic (unable to move/sense anything from the waist down), and many are hemiplegic (unable to move/sense anything on either the left or the right side of the body). Some patients have similar symptoms as a result of third-degree burns, which not only affect their sensation, but also their appearance.

I take for granted how often I rely on my basic senses to interact with the world and the people around me. To give a small example, when I first contracted Covid, I lost my sense of taste and smell for several months. It was a huge tragedy, radically altering my relationship with food, my appetite, and my overall mood. But that experience does even come close to what many people face from the impairments mentioned above.

A nurse explained to me the depth of Marcus's hardship: "When you are blind, you lose the ability to interact with things, but when you are deaf, you lose the ability to interact with people."

So, I am grateful that I have sensation.

Orientation

Clara is 63 years old and has Alzheimer's disease. It is the most common form of dementia, which is an abnormal degeneration of the brain. We all lose some size and elasticity of our brains as we age, but this is an accelerated process, caused by a disease we do not fully understand.

Clara acts much older than her age would indicate. She gets confused often when I am talking to her. She knows her full name, and that she was born on March 2nd, 1960 in El Paso, Texas to her parents Margaret and John. She remembers much of her childhood. However, she thinks the current year is 1994. She thinks George W. Bush is the president. When I tell her it's actually 2023, she says "Oh, I see."

Clara doesn't know where she is. When I ask her what city and state where are in, she doesn't even guess. She simply says, "I don't know." When I ask her how she got into the hospital, she doesn't remember either. The nurse told me she fell two weeks ago in her home, and has been in the hospital since. When I tell her this, Clara accepts it, without question. "Oh," she says. "That's right."

The second test, once I determine that my patient is alert, is this: what is their orientation?

Clara is alert and oriented times one. She is oriented to self, but not to time, place, or event. Most people are oriented times four, as they understand all of those things. Unless, of course, they have suffered an illness or injury to the brain.

It was shocking to me how little Clara knows about the world around her, and more importantly, how little this bothers her. She sort of floats around the world, not knowing where she is or why, with people she does not recognize taking care of her, similarly floating in and out of her life, like ships meeting in the ocean. When we brought Clara home, she didn't recognize her husband or her daughter, but she did recognize her daughter's dog, Fifi. How do you think that made her family feel?

In my life, I've experienced disorientation, but only in the briefest of moments. It usually happens when I wake up in an unfamiliar bed, and still think that I'm in my own home, only to realize that my surroundings are different from what I remember. But this feeling lasts only a few seconds at most. Imagine if it was your everyday reality.

Clara is relatively high-functioning; she is alert and able-bodied. It's just that her memories seem to stop at around age 30. She remembers some things after that, but pretty much all new information seems to be forgotten immediately. That makes it hard to make plans and navigate the world on her own.

So, I am grateful I am fully oriented to the world.

Sanity

Kelly is 36 years old and has schizophrenia. She sometimes hears voices that no one else can hear, and is visited by people that no one else can see. Her doctors call them auditory and visual hallucinations, but to her, they seem just as real as regular voices and people.

Kelly believes that her ex-husband is a drug runner for the Colombian government. Whenever she tells people about this, they tell her that can't be true. Kelly believes otherwise, as the pattern of coat hangers in her closet are too irregular to be simply coincidental. Someone is moving them, somehow, and they are trying to tell her something. She believes she has recently decoded the message, which says that the biggest drug run yet will occur in two weeks, and that only she can stop it.

When I met Kelly, she was on a 72-hour mental health hold, during which many of her rights were revoked. She was brought into the emergency room the night before by her friends, who said she was acting more strangely "than usual." A doctor then prescribed the hold, and it was my job to transfer her to a mental health facility for diagnosis and treatment.

Kelly seemed to be totally normal. A bit anxious and prone to crying, but who wouldn't be in that situation? She was alert and oriented times four. Her stories about what happened to her seemed valid. She claimed her friends were overreacting, and that they were just jealous, trying to get back at her for something. At first, I believed her that her husband is a drug runner. He was a Colombian immigrant, after all. He was often staying out late and acting oddly, after all.

But when she told me about the coat hangers, I started to doubt. Although it's still possible, I find that part of the story very unlikely. It's not my responsibility to decide whether she is telling the truth or not, but I still have my own opinions (which I keep to myself). Perhaps this part of the story is a paranoid delusion, a classic hallmark of schizophrenia. It called into question everything else she had told me so far. But for her, the details about the coat hangers seemed just as valid and reasonable as the other details of her story.

I've taken other patients on mental health holds for a variety of reasons. Some of them are depressed, and have expressed the desire to hurt themselves (or have actually attempted to do so). Some have diagnosable mental illnesses, such as schizo-affective disorder, bipolar disorder, psychotic disorder, or borderline personality disorder, all of which can cause erratic behavior that puts themselves or others at risk.

Regardless, these patients may be alert and oriented times four, but their mental status is still altered. They have been deemed unsafe, at least temporarily, and therefore have their most fundamental rights revoked. It may not be fair to call them insane, but there really is not proper word to describe their relationship with the world and others.

The proper definition of insanity is "repeatedly doing the same thing and expecting different results." I've definitely been there, and there were times in my life where I was so stuck in my bad habits for so long that I wondered if I wasn't losing my mind. But I thank God that I've been able to move past those times.

The outcomes for these mental health patients also vary. Sometimes they just need to go home after they've calmed down, and they've realized how terrible it is to be in a mental health facility for three full days. They get shook up enough to seek the help they need. At other times, they need further medical intervention, such as prescription medication(s), or therapy with a counselor, or both. Sometimes they need to be committed to a facility for longer, for months or even years. All of these outcomes are challenging.

So, I am grateful I have my sanity.

Condition

Kevin is 58 years old and has a long list of medical conditions:

• Type II Diabetes: he must monitor his blood sugar levels by pricking his finger every few hours to draw blood. He must avoid sweets and sugary drinks, take insulin as necessary, and be careful not to wait too long between meals.

• Morbid Obesity: his BMI is over 40%, which adds additional burdens to his organs and bodily systems. Most obviously it is difficult for him to walk; he needs two people to help him stand.

• Neuropathy: because of his sedentary lifestyle, and the pressure of his weight upon his spine, he has chronic lower back pain, sometimes with uncontrollable spasms.

• Chronic Obstructive Pulmonary Disease: his lungs have a difficult time getting enough air, making him short of breath, so he must have high-flow oxygen through his nose at all times, wherever he goes.

• Several other related issues, including Hypertension (high blood pressure), Hyperlipidemia (high cholesterol), Obstructive Sleep Apnea (difficult to breathe while sleeping), GERD (recurrent heartburn), Gout, and Depression.

When I read Kevin's medical chart, I rolled my eyes. I have had patients like him before, and sometimes they complain a lot. And for good reason, as they are dealing with a lot of difficulties. I was expecting it to be be frustrating to deal with Kevin.

However, I was surprised when I met Kevin; all of my prejudices and stereotypes evaporated, as he was extremely pleasant. Kevin did not complain once during our time together, even though I know that every bump in the road caused him a lot of pain. I learned another important lesson from Kevin, something I probably knew but had since forgotten: never judge a book by its cover.

Some of Kevin's medical conditions are called co-morbidities, as they can contribute to his death. In fact, almost all illnesses are co-morbidities, in the strict sense of the word. Even something as lethal as cancer is not actually the utlimate cause of death. When we die, it's because our organs fail, which happens when their cells are no longer able to receive nutrients and surrender waste. The primary systems in charge of this process are the brain, the lungs, and the heart. But we also need all the other organs to assist in this process (such as the liver, kidneys, stomach, and even the skin). If any of those organ systems fail, the rest of the body does too. Cancers, like all other co-morbidities, bring death by interrupting these processes.

But although not all of Kevin's conditions are deadly, all of them make his life more difficult. Few people die from heartburn, and his diabetes is manageable with the proper attention, but for both of these reasons Kevin still has to monitor what he eats. In some ways this is like a food allergy, which are common these days-- whether to gluten, nuts, shellfish, or onions. Sometimes these allergies merely cause discomfort, and sometimes they cause anaphylaxis (a life-threatening reaction requiring immediate intervention). But regardless, they completely change the way people approach their meals. And not just the food, but the social situations surrounding them.

And there millions of other conditions that can affect each part of the body, making life more difficult for us. To give a simple example, I've had Achilles tendonitis for the past five months. I didn't realize it at the beginning; I thought it was just soreness that would go away eventually. But it never got better; in fact, it got worse. Now, I realize I have to do serious rehab every day to restore my functionality, or else lose the ability to walk comfortably for the rest of my life, unless I want to get surgery, and even that doesn't always succeed. Still, I am very fortunate to not have many medical issues, and any co-morbidities (at least, none that I know of).

So, I am grateful for my condition.

Mobility

Thelma is 96 years old and is bedbound. Thelma fractured her hip last month when she tripped over the carpet in her home. She was lying on the floor for six hours before her daughter found her. Luckily, she didn't sustain any significant damage from lying on the ground for so long. However, she won't walk again. She is simply too old for the doctors to operate on her hip, without risking further complications during the surgery.

Otherwise, Thelma is extremely health for her age. Most people never live as long as her, and those who do usually suffer one of the illnesses mentioned above, such as dementia or cancer. Moreover, Thelma is mentally "with it." She is as sharp as a tack, making jokes with me and my partner.

However, Thelma cannot take care of herself, due to her injury, so she now lives full-time in a skilled nursing facility. She cannot use the restroom without assistance, so she has a permanent catheter that drains her urine into a bag, which a nurse has to empty about once a day into a bucket. When Thelma needs to go #2, she just goes into her bed, and has to call for a nurse to help her get cleaned and changed. Thelma cannot get her own meals, so she has to wait for a nurse to deliver them three times a day.

Thelma doesn't get any exercise, unless a team of nurses moves her into a wheelchair and one of them pushes her around outside. Due to the demands on the nurses, this only happens about once a week. Needless to say, Thelma doesn't travel much anywhere. She doesn't go shopping, she doesn't go to the movies, she doesn't go to the park.

My patients have a variety of mobility levels. At best, they can stand and walk around on their own. Actually, some of them can run (which presents a real risk in the case of my mental health patients). At worst, they are bedbound, whether due to a musculoskeletal injury, or brain damage as mentioned above. But most are somewhere in between. Some patients can use a wheelchair (or a power chair), as long as someone moves them into it. Some patients can stand, but need to use a walker to avoid falling.

When I was a freshman in college, I rolled my ankle playing basketball. The injury was so bad that I was on crutches for the entire Spring semester. This was even more difficult in Virginia, where snow, ice, and frost cover the ground for the first several months of the year. Getting to class was always difficult, especially if the building didn't have an elevator. It was also a huge social inconvenience, as I attended a couple of dances, but as you might imagine, not many girls wanted to dance with me.

I eventually healed and was able to walk and run again, until my senior year, when I injured myself while weight lifting. I ruptured one of my discs. For a long time after that, the only thing I could do was walk: I couldn't lift weights any more, I couldn't play frisbee, I couldn't run. As a 22 year-old, I lived at home with my parents, and I walked the neighborhood just like all the other old folks that lived nearby. Eventually, I found a physical therapist who restored my back, and I thank God every day for that. It still becomes an issue every now and then, but it's much better than it once was.

In both of these injuries, I lost my mobility, and I was miserable. Over the years, I've recovered, and have again taken it for granted. That is, until I developed Achilles tendonitis, and now I have to learn the lesson once more.

So, I am grateful I have mobility.

Pain

Luis is 45 and has fibromyalgia. His condition is not well understood, but he suffers from chronic pain throughout his body. Luis takes heavy narcotics every four hours to help him deal with the pain, but they only reduce it, not eliminate it.

Another important test whenever I meet a patient is this: what is their pain level?

A patient who is complaining of abdominal pain could have a wide spectrum of illnesses, and my response is dictated by their level of pain. If the pain is mild, it could just be a stomachache, which will go away on its own. If the pain is severe, it could be appendicitis, or some other internal bleeding, which can cause death in minutes if not treated.

I usually ask people, "On a scale of 0-10, with 0 being no pain at all, and 10 being unbearable pain, what is your pain level?" You might be surprised how many people will calmly tell me, "10 out of 10."

Most people don't know true pain. And thank God for that. 10/10 pain is screaming your head off in unspeakable agony. 10/10 pain is you would rather die right this instant than last another second. Most people never experience that kind of pain, unless they survive a fall from very high up, or a high speed car accident, or a gunshot wound.

Usually, when the pain is that intense, the brain shuts down automatically, and people pass out. They may feel the pain for a moment, but then are unconscious for most of it. But the real pain from those injuries comes afterwards, when the body is healing over the following weeks, months, and even years.

Eventually, most people feel less pain as they recover, even from traumatic injuries like the above. But some people never fully recover from whatever illness brings them pain. Luis, for example, will never be cured, unless by some miracle. Many of my patients who have terminal cancer or organ failure are in a similar situation. Narcotics (like Morphine, Fentanyl, Oxycodone) can alleviate the pain, but they also induce numbness and stupor, so giving too much can cause unconscious. As a result, these people often live with some level of chronic pain, 24 hours a day, seven days a week.

I've shared in the past about a back injury I incurred while cliff jumping. About six years ago, I leapt from pillar in the sea that was about 90 feet tall, or nine stories. I didn't hit the water quite right, and as a result I fractured one of my vertebrae. Stupid, I know. I'm reminded of that every day, as I feel pain in that area no matter what I do. I'm fortunate that my pain level is nowhere near that of some of my patients mentioned above, but it's still there. All I can do is live with it, and do the best I can to not let it bother me.

I am grateful that I am not in too much pain.

Youth

Kara is 14 and has anorexia nervosa. Her parents sent her away from her home in Florida to come to an eating recovery center here in Colorado. She has to wear a hospital gown every day, and have a feeding tube permanently affixed to her nose, so that they can force-feed her every meal. She doesn't get to use her phone, or talk to her friends, or even exercise (which would cause her to lose weight again).

Although Kara's daily life sucks right now, it won't always be that way. She is young, and will likely recover. Her outcome is optimistic. I've written about Kara before,² but in short, I think her illness is mostly caused by the pressure her parents and coaches put on her. Once she gets older and has more independence, she will probably be just fine.

Working with young patients is great, because no matter their illness or injury, they have a good chance of recovering. Moreover, I can make a big impact on their lives, just by talking with them. Young people are malleable, which is both a blessing and a curse, depending on who influences them. At the end of our ambulance ride, Kara told me that it was the best conversation she's had in several months, better than any she's had with the several medical professionals who talk to her every day.

In contrast, some of my patients have had longstanding issues, and there's not much I can do to reverse the damage. Some of my patients have been smokers for decades, and now live with emphysema or lung cancer. I can still make an impact in their lives by caring for them and being kind to them and listening to them. But I can make an even bigger impact in the life of someone like Kara if I can help her make decisions like avoiding smoking in the first place. Or having a healthy perspective about herself.

Young people are also resilient. I've seen them recover from all kinds of injuries and illnesses. Diseases like Covid are much more deadly for older populations, and for those with multiple co-morbidities. A pelvic fracture may be inoperable for someone like Thelma, but a doctor wouldn't even think twice about going into surgery for someone like Kara.

I'm not as young as Kara; I'm 31. But I still feel young. I know I can recover from my tendonitis. I tear muscles all the time in Jiu Jitsu, and every time, I come back. It won't always be that easy. Perhaps I may even one day heal from my back pain. My outlook is likewise optimistic.

From a career perspective, I still don't know what I'm going to do when I grow up. I want to be a writer, and I also want to be a paramedic. I want to be a fighter, and a dancer, and a reader, and a gamer, and a hiker, and many more things. Because I'm young, I still have options. And if I want to learn something new, I can learn it quickly. I readily accept new technologies and techniques, while older generations tend to be more conservative.

If I'm really lucky. I may live into my 90s like Thelma, and I may even be healthy for many of those latter years.

So, I am grateful I am young.

Access

Carter is 65 years old and is in remission. Three months ago, during his annual checkup, his doctor ordered a lab test. Carter's blood was drawn through an IV, placed in a centrifuge to separate its components, then tested with various reactants, observed under a microscope, and tested with a statistical analysis software. The lab test revealed abnormal values for some of his blood proteins, and the doctor was concerned.

A couple weeks after that, he underwent an MRI scan, during which he drank a magnetic fluid, and a machine that costs about $2 million rotated sensors around his body to create a three-dimensional picture of his groin region. The results of that test prompted the doctors to order a biopsy, during which they took a sample of his body tissue and analyzed it through a complex series of laboratory procedures.

The result? After all these tests, the doctors determined that Carter has prostate cancer. Fortunately, because of the routine check-up, the cancer was detected early, is still in its early stage, and is limited in size. If left untreated, this cancer would likely metastasize and spread throughout his body, killing him anywhere from 2-10 years from now.

Or, they could operate on him using state-of-the-art technology, and the relative survival rate for that procedure is 100%. Difficult choice.

Carter opted for the surgery, during which a doctor (who specializes in this specific procedure) used a robot to drill three micro-holes in his abdomen, and then direct the robot to the prostate gland, and remove it entirely. The procedure was so non-invasive that Carter was back on his feet in a couple of days, and running his morning the following week. The cancer is now completely gone and will not return (at least to that site).

100 years ago, this surgery would still have been possible, but the survival rate would have been much lower. The surgery might not have been completely effective at removing all the cancer, or the patient might have died from unstoppable hemorrhage from cutting him open. They might not have even detected the cancer in the first place, or they may have found it too late to do anything about it.

300 years ago, the illness would not have even been identifiable as cancer. There was no medical understanding of such a thing. Carter would have died a pretty painful death. He may have even been accused of sexual sins, and told that the sickness around his groin region was God's punishment for his wrongdoing. Medicine has changed a lot since then.

We are fortunate in the 21st century, and in developed countries, to have access to unfathomable technology and medical understanding. To someone living in the 1700s, everything in Carter's procedure was pure magic, and yet to the medical professionals who actually performed it, everything was so routine as to be boring.

One of my instructors in EMT school was apt to remark, "I know it's crazy that we all decided to work in the worst medical system in the world, but hey, we just have to deal with it." He would usually say this in regard to some inefficiency in the system.

And I have many complaints about the medical system in the United States, but it is definitely not the worst in the world. I have been to Zambia, where the only ambulance in a major city was sitting on concrete blocks in the parking lot of the hospital. If you have a medical emergency there, you cannot call 911, even if you do have a cell phone. There aren't any EMTs, and even if there were, they would not have any equipment to help you. Needless to say, they do not have MRI machines or surgical robots, nor do they have the medical professionals to operate them.

So, I am grateful I have access to advanced medical professionals and technology.

Life

Timothy is 23 and has a rash. He is concerned about it, and so he came in to the urgent care clinic to get an STD test. He didn't want to find out later that he had contracted HIV, which later leads to AIDS, which is deadly. The former is treatable, while the later is not. Even if it wasn't HIV, but something less lethal like Herpes, Timothy didn't want to spread any dangerous diseases to future sexual partners.

But his insurance wouldn't cover the test. As a result, the hospital wanted to charge him $3,000 out-of-pocket. Timothy still doesn't know if he is infected.

One of the biggest controversies in our medical system is the default imperative to save lives, no matter the cost. In cases like those of Maria, who are kept alive for years in a vegetative state, at the cost of millions of dollars, this imperative may seem unwieldy. There are other inefficiencies too, as in the case of someone like Thelma or Marcus, who merely have musculoskeletal injuries, could probably be transported by a family member, a wheelchair taxi, even an uber driver. But Medicare will happily pay for them to go by ambulance, with two EMTs attached to keep them alive, and the doctors will gladly prescribe it.

As a result, for young people like me, the cost of healthcare is nearly prohibitive, because insurance companies have to pay for patients like the above, keeping them alive and well for decades. As a result they decide that we young people are resilient enough to be ok without treatment. At least, until it's too late. Insurance companies would rather pay for a expensive surgery than the preventative healthcare that would avoid it in the first place. It doesn't make a lot of sense, I know.

Still, the default imperative to save lives cuts both ways. Everyone is shown mercy in an emergency, no matter their condition or ability to pay. I have seen homeless people revived from drug overdoses, week after week, and unable to pay a dime each time. Perhaps they won't learn from their mistakes. Perhaps the next time will be the last. But I also met a man once who was previously homeless, and had turned his life around after a near-death experience. The man now works in street ministries, helping the homeless by serving food, educating them, and sharing his story of recovery.

It's not for me to decide who gets treatment.. All I can do is my job, which requires me to help anyone who is in an emergency, or to care for whomever I am charged with during my shift. What happens after that is in the realm of physicians, administrators, bureaucrats, and politicians.

Still, deep down, I think there is a wisdom in the imperative to sustain life. It's something I don't fully understand, and I don't think the decision-makers above do either. It's something even more primal and indescribable.

Some of my patients are suffering from the worst illnesses and injuries imaginable, in all sorts of agony and confusion and delirium. And yet, they are still alive. There's something precious about that.

I don't know what comes after death. Maybe there is heaven. Maybe there is absolutely nothingness and total annihilation. Maybe there is reincarnation. Regardless, I'll only get to live this life once, and heaven isn't going anywhere. Shouldn't I try my best to get the most out of it?

There's one last thing I'm grateful for: no matter how bad things get, no matter how much pain and suffering I undergo, at least I am alive. Not everyone will agree with me here, but I still believe it's true. Life, no matter how awful, is still life, and worth preserving.

So, I am grateful I am alive.

1.

All the details of each of these stories have been changed. The names are made up, and so are the years, and so are the specifics of each story. But they are based on things that happened to me, and people that I met.

2. Where I wrote about “Kara” before: