Author’s note: Names, places, and some details have been changed for story flow and to maintain the integrity of my patients and their families.

“Regret is the sound of the ghosts of our own making. I will live with mine until I die.” – T. A. Webb

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“Fine, I’ll sign it, but I don’t agree with it,” I told Matt as he laid out my write up.

Poor Matt just sat at the small round table in our station kitchen watching me fume, stuck between a rock and a hard place. On the one hand, I knew he understood my side. On the other I was mad and just fine with taking it out on the messenger. I’d never been written up before and I was not happy about receiving the corporate equivalent to being sent to the principal. And I was seven months pregnant – so my rage hormones were flying.

BEEP BEEP BEEP

Tones dropped around us just as I started to scribble my grievances on the “disputes” section of my write up. With hands shaking from fury, I hurriedly tried finished my sentence but Matt was already standing up.

“It’s ours. It’s a code at Marshall’s,” he said looking at his phone with the call information.

I stood up. “Wait, we just came from there. We’ll take it.”

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30 minutes earlier…

“I got a text from Matt, he’s going to meet us at the station,” I told Jase as we pulled away from our last call. I cradled my pregnant belly as Ollie did his hourly acrobatics on my bladder.

Jase gave me a knowing look. “I can try to drive slow,” he offered and I laughed.

It wasn’t that we didn’t want to see our supervisor. In fact, we loved him. But there were a few things funny with what Jase said: First of all, there was no use in delaying the inevitable. I was going to get in trouble even if I didn’t agree with the circumstances. Secondly, Jase was not usually one to drive below the speed limit. I never questioned my safety with him at the wheel, but a slow driver he was not. Finally, I had to pee.

BEEP BEEP BEEP

Our tones dropped right as we were about to pull into the station. Oh darn, my write up would have to wait.

“Medic 4, code three for unconscious person at Marshall’s Bar and Grill…” Dispatch continued with the call information as Jase pulled a u-turn in the parking lot, flipped the lights, and the sirens blared to life. “Patient will be located behind the bar.”

Marshall’s was the only restaurant – chain or otherwise – in our small horse-ranch town. That is, unless you count the Subway in the gas station about 5 miles southwest (but we didn’t). The large rodeo space with petting zoo was popular for travelers along the highway and locals alike. We’d dined there a few times ourselves and run the occasional call, so we were familiar with the layout.

Jase turned off the sirens as we pulled off the highway, into the dirt parking lot, and rolled around to the back of the bar. The patio seating area, covered by an overhang, hosted ten to fifteen people hanging around with beer glasses in hand. As we pulled up I looked around to see where our patient might be among them since I didn’t notice anyone on the ground or a group huddled around one person.

“The ambulance is here!” someone called as we jumped out and gathered our gear.

One of the women in the group branched off and waved us over to a man lying on one of the wooden picnic tables.

“Hi, sir,” I said to the man who everyone seemed to be watching anxiously. “Are we here for you?” Now listen, you’d think it was obvious that the man laying on the picnic bench was our patient, but I have assumed before and been wrong.

He shrugged and nodded. “Yeah, I guess. But it’s really no big deal.”

“Well, someone thought so. Do you mind if we check you out anyway?” I asked – a standard question I always pose when the patient doesn’t seem to be the person who dialed 911. We’d run into many calls where a wife would call because she’s worried about her husband and he’d say “Gladys, stop overreacting! I’m fine!” and it’d turn out he was having a major heart attack.

But this time the man shrugged again and sat down on the bench, removing his motorcycle jacket.

“So let’s start with your name,” I ventured as Jase and the firefighters started attaching the blood pressure cuff, pulse ox, and electrodes to him.

“Michael.” He gave me his full name and date of birth wile watching all of the wires and cords connect his body to our Lifepak.

I wrote his information down on my glove. “What’s going on today, Michael?”

He shook his head. “I don’t know, man. It’s probably nothing. We just rode out to High Desert Ridge starting from Apache this morning. We stopped here on our way back and I just starting feeling weird.”

“Weird, how?” I probed.

“Nothing crazy,” he shrugged again, “I just felt a little dizzy and was feeling soreness in my back and behind my arms.”

“Mind if i take a look?” Michael didn’t answer but turned so I could lift his shirt and look at his back. Nothing of note. “Have you ever felt this before?”

“No, I don’t think so.”

“Ok. Have you drank any water today?”

“No not really.”

I calculated the motorcycle trip in my head. Their trip would have taken about 3-4 hours depending on traffic and how often they stopped. Plus doubling back here added another hour.

“Ok, so you’ve been riding about five hours today?” I asked.

“Yeah, that sounds about right.” Michael said.

“I know when I ride that long I start to get sore. Does it feel like muscle fatigue or cramping?” Jase asked handing me the 4-lead EKG printout.

Michael nodded slightly, “Yeah that’s probably it. I haven’t ridden in a while so this was a long trip.”

I considered the question and Michael’s response, but still wondered about the original dispatch information. Dispatch had been told that Michael passed out. I could reconcile the soreness with muscle fatigue, but the passing out didn’t add up. So I asked Jase to get me a 12-lead. “That’s definitely possible, but I’d like to be sure. We’re going to put a few more stickers on your chest to get a better look at what your heart is doing. Did you hit your head when you passed out?”

Michael looked up with furrowed brow. “I never passed out?”

One of the women in the group spoke up. “We called when he laid down. He never actually fainted. He just said he wasn’t feeling good and we told him to lay down. But we called because it just wasn’t like him.”

Jase printed out the 12-lead ekg and handed it to me. I glanced at the blood pressure and it read within normal limits. His oxygen was fine too. When I assessed his ekg, I couldn’t find anything abnormal.

“Do you mind if we take your blood pressure while you’re standing?” I asked. One way we can assess dehydration was if your blood pressure dropped and your heart rate increased once you stood up. I explained this assessment to Michael and told him that even though the weather had been nice, nixing the water intake plus exposure to the wind and sun could be a possible culprit.

Michael stood up and after a minute Jase pressed the buttons to obtain a new blood pressure and ekg. Both resulted within normal limits.

“Do you feel dizzy or lightheaded at all?” I asked. Michael shook his head. “Ok, why don’t you sit down anyway while we finish up here.” He did and I probed him for his medical history, allergies, and medications he takes. No falls or accidents recently? Have you seen your doctor in a while? No confusion or disorientation? Everything seemed to fall into normal categories.

Once I’d run through my arsenal of diagnostic questions, I folded the EKG into my pocket and shrugged. “Well,” I said, “Michael there’s nothing I can see on my end that explains this. What do you say we head down to the hospital so they can at least do some blood work and imaging and maybe find out why you’re feeling so cruddy?”

Jase had already started taking the leads and blood pressure cuff off. “Nah, I don’t think so. I’m probably just dehydrated.”

“Maybe,” I agreed, “But I can’t tell that for sure. We only get a glimpse at what might be going on. We can’t always see the whole picture in the fifteen to twenty minutes we spend with you.”

Michael shook his head and pulled on his motorcycle jacket again. The clouds above us had started forming, bringing a cool chill to the air. “Nah, I think I’ll be okay. It’s not like I’m going to die right?”

I smiled. “It’s not something I anticipate. I mean, we all gotta go at some point, but from what I’m seeing here it doesn’t look like it. But if you decide not to go to the hospital with me by ambulance I need ask you some simple questions and make sure you to understand a few things.” I asked him to repeat his name, date of birth, what town he was in, the current year, and his symptoms so I could document that he was fully alert and oriented to the situation.

Then I made sure one of his riding buddies was listening while I rambled off my usual refusal spiel: ” This might sound tedious but bear with me. I need you to understand that I recommend you to go to the hospital to get evaluated by a doctor. If for some reason you still don’t want to go to the hospital today, I want you to call your primary care as soon as possible to get an appointment. The closest hospital from here heading back toward Apache is Standard Hospital about fifteen miles southwest on the highway. Our local hospital is closer but it’s in the other direction. I don’t think you should do anymore riding today so maybe catch a ride with someone in your group that has a car.”

I turned to the friend as well, “If at any point he does lose consciousness or something doesn’t feel right, pull over and call 911.” And back to Michael: “Like I said, I don’t anticipate anyone here dying today, but that’s truly out of my power. So before I have you sign this refusal, I want you to understand you are taking all risks of refusal in your own hands up to and including the big three: stroke, heart attack, death.”

Micheal chuckled at my long-winded lecture and held his hand out for the pen to sign my chart, “Alright, okay, I understand I could die.”

He signed the refusal form and thanked us for showing up. I told him to drink some water and take it easy before asking his friend to sign as a witness to his refusal. “You’re not taking responsibility for him, just saying he was in his right mind to make decisions for himself, that we offered him transport but he didn’t want to go with us, and that I explained the risks of refusal.”

She signed it and I told her to call us back if they needed anything else. I headed back to the truck where Jase was already waiting in the driver’s seat. I hadn’t paid attention, but he’d already cleaned and packed everything up, ready for the next call.

“Ready?” He asked putting the truck into drive.

“Yes. Please. I’ve had to pee for like two hours and Ollie’s not going to let me hold it much longer. Plus, that write up is waiting for me.” I sighed.

As we pulled away I looked back at the group of people. But Micheal’s face caught my eye. To this day, with my memory clouded in hindsight of what had come next, his face was grayer than before. The look of a man who would not see tomorrow. A new ghost to haunt me.