We have little voices in our heads. They say things like, "Hey - this injury couldn't have happened the way the parents say," or, "The drunk with the head lac says he was home drinking all day - why isn't there any snow on his car in the driveway? - check the front bumper."

The voices pipe up in the back - "Patient is going to vomit in 4.7 seconds, grab a basin" - and we're glad to have them.

Sometimes, though, the voices want to get out. Sometimes they try to come out of our mouths, and, professionals that we are, we simply have to place both hands over our mouths and hold them in.

Our mid-twenties patient states, "I swallowed a balloon filled with meth, and it got stuck going down. I did some research on the Internet and found out that this could be bad for me."

DTs' Inside Voice wanted out. It wanted to say, "Ya THINK SO? Jesus Effing... Man, what... You've GOT to be kidding me." I mean, it's a balloon, okay, which the patient voluntarily swallowed. It got stuck going down, partially occluding the airway. Bonus: The balloon is filled with a very toxic drug.

And the guy now has to *research this predicament on the internet* to see if maybe, just maybe, this is a bad situation to be in.

wheezy186: Cant breath lol NEbodE know WTF 2 do?

einstein01: DooD just breeth

wheezy186: Got 4G ice stuck in baloon

einstein01: $4 grand wow DooD

wheezy186: nooB 4 gramz

einstein01: DooD not cool GTF to the ER

wheezy186: ...

wheezy186: ...

wheezy186: yeah ok

Shhh. Shhhhhhhhhhhhh. It's okay. This is just a warmup for the upcoming "I didn't think the fuse would burn so fast" Festival.

I don't travel much, so I don't know a lot about other parts of the country. I would guess though, that Northern Virginia probably has a population with a diversity of languages greater almost than anyplace but New York. I try therefore to be able to speak at least a few words in a language my patient understands. Doing so really seems to set them at ease. In some cases, though, I get chewed out.

For instance, we entered the ED and saw a rather flustered and grumpy 98 year old female patient, glaring at everyone around her. The nurse said, "Here's Mrs. X, but she only speaks Ukranian. Her daughter was translating but she had to leave."

"Privet! May nya za voot DTs", Hello! My name is DTs says I (yeah, it's grammatically piss-poor Russian, but they're close enough). Our patient's face lights up and she's the nicest, least-grumpy patient one could wish for. When we leave her at the receiving facility she calls down God and all the saints to watch over us and our children to the thirtieth generation or some such thing.

So we got that going for us, which is nice.

We leave our Korean patient at the rest home. "Hang-uun-ule peem-nee dah!" says DTs,bowing out. I hope and sincerely pray it means, "Goodbye and good luck!", at least I think it does. The patient stares intently for a few moments and releases a spate of rapid-fire Korean back at me. I don't know if I just told her off, or she's saying, "If you speak Korean, why didn't you before?", but it's time to go...

Spanish is one we deal with so routinely that, well, I have a routine. In very poor Spanish I can tell my patient, or his family, "Before we go I need to get your signature on this form. When you sign this form, you're giving us permission to take you in the ambulance; to care for you during the ride, and to send the bill for the ride to the insurance company so you don't have to worry about it."

I have to be careful to say this slower than I'm able. When I speak too quickly the patient gets the impression I speak fluent Spanish. A pediatric patient's mom signed the form and, probably thought, "Finally! Someone who speaks Spanish! I can at last tell the story!" Faster than an auctioneer, she starts: "My daughter first began having this difficulty about three days ago, no, it was four days ago and..." I had to do the "whoa whoa" hand motions and apologize for the misunderstanding.

Now, DTs speaks none of these, but rather carries a somewhat extensive electronic phrase book so I may ask "Chest pain?", "Allergies?", "Nausea?" and such. Since I put it together myself I try and verify it when I can.

I just don't get Chinese, though. I'm considering just leaving that one alone.

Our patient spoke only Chinese, but his wife spoke very good English. "If I wanted to say, "Hello, my name is DTs", would it be: Wo shee DTs yee sheng? I'm just checking..."

"Oh, yes!" said the wife. "That's exactly right. You would say: " and here she said something completely different. Not even a good pronunciation of what I tried, but completely and utterly different syllables.

I stared at her for a second, then asked, "So... I'd say...?"

And she said something else, different from the first thing she said.

Richard Feynman, in his autobiography Surely You're Joking, Mr. Feynman, relates the following:

"When I was in Brazil I had struggled to learn the local language, and decided to give my physics lectures in Portuguese. Soon after I came to Caltech, I was invited to a party hosted by Professor Bacher. Before I arrived at the party, Bacher told the guests, "This guy Feynman thinks he's smart because he learned a little Portuguese, so let's fix him good: Mrs Smith, here (she's completely Caucasian), grew up in China. Let's have her greet Feynman in Chinese."

"I walk into the party innocently, and Bacher introduces me to all these people: "Mr. Feynman, this is Mr. So-and-so."

"Pleased to meet you, Mr. Feynman."

"And this is Mr. Such-and-such."

"My pleasure, Mr. Feynman."

"And this is Mrs. Smith."

"Ai, choong, ngong jia!" she says, bowing.

This is such a surprise to me that I figure the only thing to do is to reply in the same spirit. I bow politely to her, and with complete confidence I say, "Ah ching, jong jien!"

"Oh, my God!" she exclaims, losing her own composure. "I knew this would happen - I speak Mandarin and he speaks Cantonese!"

The dispatch information said the kid weighed about 3kg. I see a teensy little one under a french-fry lamp, extremely jaundiced, see-saw respirations, weak cry. The kid weighed 2lbs at birth, along with her twin. Being premature by 9 weeks didn't help. I noticed scars across the abdomen and sternum from two separate operations conducted just after birth.

Ooookay.

Mom says the sleep apnea monitor kept going off at home - eg., the tyke's breathing kept stopping. "This is just what happened to her sister last week; she had to be intubated and flown. And (the sister) has RSV".

Ooookay.

The RN pops in. "She's really very stable. You can go ahead and take her."

Something about this isn't filling me with confidence. Just the other week an entire Pediatric ICU team was needed for a 2-year old with respiratory distress. We played Glove Balloon Volleyball with him all the way to the ICU. This kid looks nowhere near as good. I'm thinking more hands in the back would be nice if the kid crumps and I have to intubate, pump and blow, that sort of thing.

"You know," says DTs, "Just to err on the side of caution, she looks like a really good candidate for a PICU team transport. Let me contact those guys and get an ETA for you."

"Why?" asks the nurse. "She's really stable."

"Yeah, well, call me careful..."

The doc walks in. "Good news! The chest x-ray confirms the pneumonia is mostly cleared up."

"She has pneumonia?" asks mom.

"Well, not a lot, it's mostly cleared up."

"But she was just in the NICU two days ago and they didn't say anything about that."

Say WHAT? thinks DTs. This is just getting better and better.

The doc turns to me. "So, ready to go?"

"I'm thinking PICU team here, or at the very least getting another unit of ours for extra hands in the back."

"Why?" asks the doc. "She's really very stable. You should just go."

And this, Gentle Reader, is where I have noticed that a little more communication might help.

We have here a doc - many, many years of school; more years in the trenches. Highly educated.

Doc is talking to "the ambulance driver" - who probably had a couple of weekend classes and watches House, ER, and Scrubs to supplement his training.

In doc's mind: "I am a doc, and I tell you three times the patient is cool. When you don't believe me, Ambulance Driver Guy with a little bit of knowledge, I get exasperated." And that's completely understandable. If you think that way.

But some docs use the same reasoning for Good. I don't mean that they're condescending, although those guys exist. I mean the docs who take the time to address any concerns we have. The kind who understand that yeah, if the shitstorm arrives, it will be ME, thank you, in the back of the unit, with far less help on call, far fewer resources, and yes, I admit it, far less training - although what I do have is the same as you where it counts. These are the docs who are willing to address your concerns.

And they're certainly not the docs who say, "Yes, well, very good, all is well, off you go, no problems here, don't worry about a thing, see you, bye-bye, hit the road-"

That just sends the wrong message.

We're hauling ass down the road, blinkies and woo-woos. This is not unusual.

There are the regular Virginia players before us -

We avoid the JAMs - "Jesus! It's A Medic"s, who jam on their brakes. They are expected.

We slip by the Tweaks - they're the ones who see us in the rear-view mirror and immediately swing left/right/left until the other drivers back off to avoid getting hit, making a space; par for the drive;

We get the attention of the Blaupunks (rhymes with "wow" punks) - whose blaring Blaupunkt or analog stereos mask our sirens. Wouldn't be a response without 'em.

There's the Gold Star Gang, least represented of all. These are the folks who will: Use their turn signal; actually move into the lane they signalled for (left blinky, move to the left); move into the nearest out-of-the-way shoulder (the right-hand shoulder is not always the most appropriate, and this is actually taught in Driver's Ed class); and slow down after completely vacating the lane we need. We love seeing these guys and they get a wave, a nod, and a smile as we flare by in lieu of a Gold Star.

And then - there's really no other word for it - there's the Dumbass.

This is the guy talking on the cell phone, or TEXTING, while driving.

This is the chap who, when he finally moves languidly into another lane, has the audacity to give you the Stink Eye because your siren is interrupting his Important Phone Call.

It's just unusual for this fella to be in full uniform and driving a marked "Sherriff" vehicle.

Just sayin'.