Some Thoughts on Leading Volunteers

I’m a member of a volunteer search & rescue (SAR) team and recently had the opportunity to speak to the annual retreat of the Appalachian Search & Rescue Conference on the topic of leading volunteers.  What follows is the script (loosely followed) for my remarks, and while applied primarily to volunteer leadership, the concepts and principles are, I think, more broadly applicable.

Introduction

I came to SAR following a combined commissioned and civilian career with Uncle Sam’s Air Force, in which I was fortunate to participate extensively in the Air Force’s leader development programs. My career included the opportunity to attend senior service school in residence, and spend about 20 of my 33+ years in first-, second-, and third-level leadership positions.  This commentary will offer up four vignettes on leadership derived from that background, extrapolated and applied to the slightly different challenge of leading volunteers. I say “slightly different” because, whereas the fact that our members are unpaid volunteers and not paid careerists does make some difference, ultimately people are people and when we talk about leadership, we’re really talking about people.

First, an important disclaimer: While this presentation is experiential, it is also aspirational. I’m not arrogant enough to stand in front of you and try to convince you that I always live up to these principles, but I assure you I try. It might be helpful to think of this as a vision for leadership – some goals we should aspire to, recognizing however that we are all flawed and will from time to time fall short. Also, this presentation focus more on organizational and strategic leadership than in-the-field tactical leadership, although there will be some references to the latter. Finally, we’ll be talking about leadership, not management – while complementary, they are most definitely not the same thing. Understanding the difference is something I think the military probably does as well or better than any other major segment of our society, an understanding I wish was better exported and applied in other endeavors.

 The Leadership Environment

For our first vignette, I want to talk about what I think of as the leadership environment. This is the “ecosystem,” if you will, in which leaders lead, and it’s composed of people, resources, the mission, and numerous other factors, all unique in some way to your organization.  Of these, the most important factor in leadership is people – leadership is fundamentally about getting other people to do certain things in certain ways to achieve specific goals.  First and foremost, to be a good leader it is essential to understand people, and especially so in a manpower-intensive activity like SAR.

Every individual is unique, so every SAR volunteer will be equally unique and uniquely motivated. When we talk of motivations, we often group them into bins of extrinsic, or external, motivations that come from outside the individual, and intrinsic, or internal, motivations that come from within. A common extrinsic motivation might be, “I need money to live, so I’m going to find a job that pays me a living wage.” On the other hand, intrinsic motivation might be more altruistic, like, “I feel good when I help other people, so I’m going to join my local SAR team.” It’s probably a good first order assumption that more SAR volunteers are intrinsically motivated than extrinsic, but that’s not necessarily so. What about the person who might be somewhat insecure and needs external positive reinforcement to bolster their self-esteem? Might someone like that also seek that by joining a SAR team? Or the opposite: Someone who needs to reinforce their ego by proving their superior outdoor knowledge, skills, and abilities to others, and needs to be recognized as such. Might someone like that also join a SAR team? Those would be examples of non-material but extrinsic motivation for getting involved in SAR. We’ll talk more about the importance of understanding motivation in a later vignette.

(You can read more about intrinsic versus extrinsic motivation at: https://www.verywell.com/differences-between-extrinsic-and-intrinsic-motivation-2795384 )

That leads us to leadership style. Lots of people have written lots of stuff on leadership styles over the last several decades, but a concept I like and would like to introduce here is the Transactional to Transformational leadership spectrum. I use the word spectrum because this isn’t a binary issue: It’s not about being either a “Transactional Leader” or “Transformational Leader,” it’s about understanding what they are and being able to lead from anywhere on the transactional to transformational spectrum as specific conditions require.

Transactional leadership is the world of carrots and sticks, rewards and punishment, “you scratch my back and I’ll scratch yours.” Transactional leadership operates on the lower levels of Maslow’s Hierarchy of Needs and gets people to do things by rewarding positive behavior and/or punishing bad. At a very basic level, paying an employee to do a job is transactional leadership: in exchange for coming to work and doing your assigned tasks, I will pay you wages. Bonuses and awards for exceptional performance are also transactional, as of course are punishments. Transactional leadership tactics can be very effective with people who are primarily extrinsically motivated, but can backfire badly if applied to more altruistic, intrinsically-motivated people (more on that later…).

Transformational leadership, on the other hand, tends to be more effective with the intrinsically motivated. Transformational leaders seek to inspire and motivate subordinates by linking them to a shared set of values and goals. Transformational leadership involves leading by example, modeling desired behaviors, and creating an environment that allows subordinates to achieve their own personal goals and self-actualization in ways that align with and support organizational success. The ultimate expression of transformational leadership is to be the kind of person others want to emulate. Transformational leadership can fail, however, when subordinates do not share the organization’s goals and vision. One of the best ways, then, to create a transformational leadership environment is to actively involve as many of the organization’s members as possible in developing goals and vision.

I’ll wrap up this first vignette with this: In my experience, most leadership failures occur when leaders do not accurately assess where on the transactional-to-transformation spectrum they need to be, and use leadership tactics that are misaligned with the attitudes, beliefs, values, goals, and motivations of their work force.

(More on transactional vs transformational leadership here:  https://courses.lumenlearning.com/boundless-management/chapter/types-of-leaders/ )

In the next three sections, I’m going to off up three guiding principles for your consideration and discussion. These are not the be-all and end-all of leadership, but they are three things I took from my education and experience that I think are especially important.  These statements are somewhat provocative (by intent), but I hope they will provoke deep thought and good discussion.

“If It Isn’t In Writing, It Isn’t Policy”

Harmonious, high-performing organizations, like harmonious, high-performing choirs, sing from the same sheet of music. In the previous section, we talked about the importance of transformational leaders inspiring and motivating team members by linking them to a shared set of values and goals. In addition to values and goals, establishing unity of purpose and unity of effort are also important to fostering fellow-feeling, a sense of belonging, and team harmony. In other words, ideally you will have everyone in your organization singing from the same sheet of music.  Achieving this can be challenging in any organization, but especially so in volunteer organizations where participation in meetings, training activities, and operations can be inconsistent and sporadic.

In order to sing from the same sheet of music, everyone on the team has to have the same sheet of music.  In organizations, that “sheet of music” is your constitution, by-laws, rules, standards, guidelines, expectations, goals, objectives, values, and vision – all of which need to be clearly understood by your team. For brevity, let’s call that collection of ideas your organizational policy[1] & doctrine.[2]  In the volunteer environment, with the aforementioned inconsistent participation, the best way you can facilitate that understanding is by putting your policy & doctrine in writing, making it readily available to your members (your web site is good for this), and doing your best to make your operations and training consistent with it. Verbal instructions, meeting minutes, power point presentations, etc., while useful tools are not enduring policy – policies need to be instantiated in by-laws, Standard Operating Guidelines (SOGs), manuals, or other formal documents to give your volunteers the best opportunity to sing from your organization’s sheet of music. Bottom Line: If it’s not written down, it’s not official policy. Getting your policy & doctrine in writing is challenging enough in full-time jobs, but even moreso for volunteer groups – but even more important.  Let me make one thing clear, though – I’m not advocating formal written policy for everything you do; there can be great value in leaving space for creativity, flexibility, adaptability, and improvisation, and over-scripting everything creates organizational rigidity that can be stifling. As organizational leaders, you’ll have to decide how much and for what issues you’ll need formal policy.

Let’s spend a moment on the possible effects of inadequate policy & doctrine on volunteers and volunteer organizations. A colonel I used to work with was fond of the phrase “juice to squeeze ratio,” an analogy for benefit versus cost. People generally prefer to do things where they perceive the “juice” (benefits) they receive is worth the “squeeze” (costs) they put into the activity. Benefits and costs can be tangible or intangible and are measured by each individual on his or her own scale.

Have you ever had the experience of being new to an organization and not learning the way they expect something to be done until you did it differently and someone corrected you? How did that feel? Did it make you feel motivated, inspired and a part of the team? Or was it discouraging or demoralizing? I’m betting on the latter. In a paid situation, organizations can survive occasional incidents like that because of the transactional nature of the employee/employer relationship – the juice (pay) employees get makes putting up with the squeeze (frustration, criticism, etc.) worthwhile. With intrinsically-motivated volunteers, however, it won’t take too many experiences like that to lead them to decide the juice isn’t worth the squeeze and they’ll find something more rewarding to do with their time, or at best reduce their participation. None of us are over-populated with volunteers, so we can’t afford to drive any away by frustrating them with a leadership environment characterized by “the-only-way-you-learn-the-right-way-is-to-do-it-wrong-and-get-corrected”.

The absence of official policy & doctrine leaves a vacuum that will be filled by personal preference, myth, and lore.  Leadership by personal preference, myth, and lore will at best be confusing and at worst demoralizing for new members.  It’s extremely important that, once you’ve established official policy & doctrine, all leaders commit to adhering to it and modelling it in their own behavior – failure to do so can lead to significant conflict within the team.

A related phenomenon to the myth & lore problem is that experienced and highly-competent practitioners of any activity tend, over time, to lose touch with how little beginners actually know. This can lead to assuming beginners know more than they do, creating unreasonable expectations possibly making beginners feel incompetent, clueless, or ineffective, leading in turn to diminished morale that decreases that juice-to-squeeze ratio. A thorough set of written policy & doctrine, made available to new members and followed by leaders, can help minimize this risk. A member handbook, issued to new members when they join, is a great way to begin the process of teaching and acculturating your members to your organization’s policy & doctrine.

My last point on this topic is that developing your written policy & doctrine does no good if they aren’t effectively deployed throughout the organization. That’s often the hardest part, and leads me to the topic we’ll discuss in the next session.

(You can read more about the importance of putting it in writing here: http://www.chiefexecutiveboards.com/briefings/briefing210.htm )

“If you’re not teaching, you’re not leading” 

We ended the last session talking about the importance of effectively deploying organizational policy and doctrine throughout your organization. While putting that policy & doctrine in writing and making it available to your members is necessary, it is not sufficient – no one would expect a choir to sing in perfect harmony just by handing them sheet music and having them perform the songs without rehearsal, and no one should expect an organization to function harmoniously without rehearsal. In addition to developing your policy & doctrine, you must teach it, rehearse it, model it, and reinforce it.

In the previous section we talked about the demoralizing effects of the “the-only-way-you-learn-the-right-way-is-to-do-it-wrong-and-get-corrected” effect. In my experience, adult learners do not like to feel clumsy, awkward, or incompetent, so it is incumbent on leaders to do their best to avoid situations where that can happen. While new members sometimes come with relevant experience and well-developed skills, often they do not – and it is the latter that in my view we are at most risk of alienating and driving away if leaders fail to also be teachers. Also, even with the former, we still must teach them our organizational policy & doctrine in order to fully assimilate them into our team and establish cohesiveness and harmony.

“Teaching” comes in many forms, and is not just the responsibility of official Training Officers and certificated instructors. All leaders have a responsibility to teach and mentor junior, less-experienced members, and it’s the informal, day-in, day-out mentor/mentee or peer-to-peer knowledge-sharing relationships that are perhaps the most effective teaching tools we have. Teaching comes in many forms, including but not limited to:

  • Formal, structured, didactic courses
  • Individual or small group sessions
  • Field and tabletop exercises and simulations
  • Modeling desired behaviors – there is no place in leadership for “do as I say, not as I do.” Followers emulate leaders.

Some key points I’d like to emphasize:

  • Know your policy & doctrine and adhere to it – don’t confuse beginners with personal preference, myth, and lore. Yes, there are many viable options for ways to do many tasks, but offering too many options too early can be overwhelming for new people. Give them effective tools they can master early, and allow their breadth of expertise to develop over time.
  • Empathize with your new people – experienced people who have attained a high degree of proficiency in any endeavor sometimes lose touch with how difficult basic tasks can be for beginners, fail to teach them adequately, and risk becoming frustrated with them.
  • Teach, don’t criticize – you cannot expect anyone to do anything they haven’t been taught, and criticizing behaviors you haven’t taught is unfair and demoralizing.
  • Re-teach and practice – you cannot expect learners to remember everything they’re taught only once, and psychomotor skills especially require frequent practice to maintain proficiency.
    • SAR is a “high acuity, low demand” (HALD) activity in comparison to other emergency services; we cannot count on frequent operations to keep us sharp.
    • Many SAR skills are perishable, even for avid recreational outdoorspersons – you’ve got to use ‘em or lose ‘em.

Final thought on this topic: Learn to Teach; Teach to Learn. The more you teach, the more you’ll learn yourself, both in lesson preparation and in the interaction with others – keep you receiver on with its gain high even while you’re transmitting. It’s amazing the things you can learn when you think you’re teaching.

(More on teaching here: https://www.linkedin.com/pulse/mentor-youre-teaching-leading-jon-aponte/ )

If you treat everyone the same, you’re not leading”

This is the principle that usually provokes the most negative initial response – some people immediately interpret this as advocating favoritism or unequal enforcement of rules. That’s understandable, but it’s absolutely not what I mean.

Let’s go back to the introduction, where we discussed the importance of transformational leadership that seeks to inspire and motivate subordinates by linking them to a shared set of values and goals. So how do you inspire and motivate people? We talked about intrinsic versus extrinsic motivation, and we discussed some of the reasons people might be motivated to join a SAR team. Most importantly, we talked about how we are all unique individuals, with our own set of beliefs, values, priorities, strengths, weaknesses, talents, and other personal attributes, and are uniquely motivated to do what we do. This principle speaks to that uniqueness, and the importance of leaders understanding their followers and interacting with each of them as individuals.  To be a good leader, you must understand people, and you must understand each person as an individual and interact with them in a uniquely individual way.  If you lead a group of 20, you have 20 separate and distinct interpersonal relationships to develop and nurture. All of us deserve to be treated as individuals – good leaders know this, and learn to motivate and inspire us by aligning organizational objectives and performance goals with our individual strengths, weaknesses, beliefs, and values.

In Senior Service School, I had the opportunity to listen to the late Dr Otto Krueger, an expert on the Myers-Briggs Type Indicator (MBTI).  Otto was talking about some of the differences between introverts and extroverts and differences in their motivations, and relayed a story (perhaps apocryphal) about an employee of one of the big-box retail stores. This lady had worked there for decades and had a perfect attendance record – she’d never called in sick or been tardy or otherwise missed a scheduled work shift. A new manager took over the store, full of business school ideas, and wanted to find ways to reward his top performers both to encourage their performance and perhaps motivate others. When he found out about this lady’s perfect attendance record he called a meeting of all the store employees, brought her up front, and presented her with an award and a bonus for her attendance record.  Sounds like a good thing, right? Well, it turns out this lady was a profound introvert, hated being the center of attention, and was intrinsically motivated to be a good worker.  For her, being placed in a spotlight like that in front of all her other co-workers was mortifying, so you know what she did?  On her next scheduled workday, she called in sick – she wanted to make sure nothing like that EVER happened to her again! The manager tried to do a good thing, but it backfired because he did not know this employee as an individual and treat her accordingly.

Another example – this one may be a bit of an over-generalization and sexist, but it does help illustrate the point: Mike Carey is the head coach of the West Virginia University women’s basketball team. Prior to taking the job, Mike had only coached men’s teams. A reporter once asked him about the differences between coaching men and women, and Mike replied that he had to learn to be very careful how he said things. If he had told a men’s team, “Some of you aren’t hustling enough,” he’d assume every guy on the team was thinking, “Man, coach sure is pissed at those other guys.” But if he said the same thing to a women’s team, they’d be more likely to think, “Oh, no, I know he’s talking about me and I’m going to be benched.” Like I said, it’s an over-generalization, but it is something Mike said that goes straight to the point of understanding people, understanding their differences, and interacting with them accordingly.

My last example is personal: When I was a young analyst for the Air Force, I was pretty prolific and after a few successful early projects got pretty confident about what I was doing, especially my ability to write effective intelligence reports. OK, I was getting cocky – I admit it.  My first senior intelligence analyst was a man named Dave Ritchey, who understood and implemented the “individualness” of leadership very well. There was another analyst in a different shop that I worked with regularly, but she was much more uncertain about what she was doing than I, and lacked my confidence. One day she and I were talking to Dave about a recent report she had written that was very well done and impactful, and Dave just looked at her and said, “See, I knew you could write better than him” (nodding his head in my direction). I don’t normally advocate those kinds of comparisons, but in this case Dave knew that she needed positive encouragement and that I perhaps needed a little of the wind taken out of my sails and that one statement served as an effective motivator for us both. However, if he’d said exactly the same thing to me about her, the effect would’ve been the opposite.

So, don’t play favorites, don’t have different rules for different people, but don’t treat everyone the same, either – get to know those you lead as unique individuals, and interact with them uniquely… as they deserve.

(You can read more about this concept here:  https://www.bizjournals.com/bizjournals/how-to/growth-strategies/2014/02/treating-employees-fairly-not-the-same.html )

So here are my take-aways from all this; some concepts I think will serve us well:

  • Strive to be transformational
  • Put your policies & doctrine in writing
  • Teach
  • Know your people as individuals and treat them individually

 

[1] Policy is guidance that is directive or instructive, stating what is to be accomplished. http://www.doctrine.af.mil/Portals/61/documents/Volume_1/V1-D03-Policy-Strategy-Doctrine.pdf?ver=2017-09-13-150321-400

[2] Doctrine is authoritative, but unlike policy, is not directive; it is a storehouse of analyzed experience and wisdom. http://www.doctrine.af.mil/Portals/61/documents/Volume_1/V1-D03-Policy-Strategy-Doctrine.pdf?ver=2017-09-13-150321-400

 

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On Character and Resistance in the Face of Tyranny

My maternal grandfather was a racist. I can’t tell you how many times he referred to African-Americans as niggers and I distinctly remember him telling me they were an inferior race of human beings (giving him the benefit of the doubt, at least he conceded they were human).  He was an Alabama Conservation Officer, more commonly known as a game warden, who enforced hunting and fishing & wildlife laws in northeast Alabama.  Conservation Officers then as now were fully sworn law enforcement officers, empowered to enforce all laws, not just those concerning fish and wildlife.  He used to take me with him on patrol and I saw how gently he enforced the law, listening to him talk about how he would often give violators a break when they were illegally hunting or fishing for food they were too poor to buy.

In 1963, authorities violently suppressed civil rights demonstrations in Birmingham, Alabama, following the bombing of a predominately black church. This event became notorious in American history, with Birmingham police officers and firefighters violently suppressing demonstrators with clubs, dogs and fire hoses.  The state sent additional law enforcement officers to Birmingham to augment local forces, including State Troopers and Conservation Officers.  My grandfather was one of them.

I vaguely remember the night he came home from Birmingham, unexpected.  A state car stopped out front and he got out, bringing his helmet and nightstick in with him.  He never talked about why he was home early and neither did the rest of the family, but all of a sudden he was no longer an Alabama Conservation Officer.  He had served for 18 years and was closing in on retirement eligibility, but that was all gone now.  He spent the rest of his life working part time as a clerk for a local TV cable company and full time as a security guard for a private security company.  He never had the opportunity to enjoy retirement and died of heart failure in his early sixties.  An honor guard of Alabama Conservation Officers, organized unofficially on their own and not through any action by the state, carried his casket from the hearse to his grave.

Many years later, I learned that the reason he came home early from Birmingham, the reason he lost his 18 year career as a Conservation Officer, was because despite his racism he could not do what the state wanted him to do to protesters in Birmingham.  He signed up to enforce the law, not violently subdue women and children and other peaceful protesters.  What he saw in Birmingham disturbed him enough  cause him to turn in his badge and walk away from a career I knew he loved.  I wish I had known that when he lived so I could have told him how proud I was of what he had done.

His name was Carl Henry Lay, but everyone knew him as “Cotton” because even at a young age his hair was snow white.  Today, Birmingham is happening again at airports and other ports of entry across the country. I’m even seeing allegations that Customs & Border Protection officers are disobeying a federal court’s injunction against President Trump’s immigration ban.  These officers are today’s Birmingham police, and I can’t help but wonder if there are any Cotton Lays among them, men and women with the character to know this is wrong, who will comply with the court and refuse to obey this Executive Order that violates the very principles and history of our nation–men and women with the moral courage to be fired for their country like my grandfather was fired for his.  Are they out there? Or will they all try to fall back on this failed defense of the World War II German rank & file that they were “just following orders?”

STUPID SH*T WE SAY IN EMS: “BLS BEFORE ALS”

A lot changed in my 30-year hiatus from emergency medical services (EMS), most for the better. However, since returning to the field one thing that has dismayed me is how despite increasing the training hours and expanding curricula required for certification, in some ways we’ve “dumbed down” EMS and replaced clinical judgement and critical thinking with trite sayings. These pithy little sound bites over-simplify what we do and in some cases may actually harm our patients by causing us to do the wrong thing by rote instead of the right thing by deliberate thought.  I call these sayings “Stupid Shit We Say in EMS.”

One that causes me to grind my teeth every time I hear it is “BLS before ALS.”[1]  I think this phrase is well intended, in the spirit that failure to get the basics right (controlling bleeding, opening airways, doing high quality compressions, etc.) can lead to a really bad outcome no matter what high-tech treatments us paragods might be able to provide.  However, the problem with these sound bites is they too often become dogma and cause us to fail to do what we’re really supposed to do: Provide the right intervention at the right time for the right reasons, whether it’s a “BLS” or “ALS” procedure (by the way, I consider “BLS” and “ALS” to be a false dichotomy and would like to expunge those terms from our lexicon, but that’s another rant for another blog post).

Let me give you an example: Our patient is a 65-year-old male with substernal chest pain, 8 on a scale of 10, radiating to his left arm and left jaw.  Vital signs are pulse 164, blood pressure 138/72, respirations 28, oxygen saturation 97% on room air, blood sugar 96, Glasgow Coma Scale 4/5/6.  Breath sounds are clear – no rales, ronchi or wheezing.  The pain began when the patient got out of bed 45 minutes ago; when he stood up he felt his heart begin to race and the pain began shortly thereafter at about a 4 of 10, becoming progressively worse.

If we follow the “BLS before ALS” mantra with this patient (using West Virginia BLS protocols), we would perhaps administer oxygen, give him 324mg aspirin (four baby aspirin) to chew, run a 12-lead EKG, send it to Medical Control and request an order for nitroglycerin SL.  So let’s say we run that 12-lead and it shows a regular supraventricular tachycardia (SVT) with no indications of an inferior myocardial infarction, so it’s theoretically OK for this patient to have nitroglycerin per protocol.

The problem here is that for this patient, none of those BLS interventions will help.  The reason he’s having chest pain is because his heart is beating too fast, increasing myocardial oxygen demand beyond what his circulation can deliver.  It’s ischemic chest pain, but it’s due to inadequate supply, not a blocked artery.  (Go do some wind sprints and get your heart rate up to close to its maximum; you’ll feel what this patient is feeling.) The difference is, when you stop running your heart will slow down on its own and that ischemic chest pain will go away.  His will not, due to accessory conduction pathways between his atria and ventricles or a re-entry loop in his AV node.

Increasing his oxygen saturation with supplemental O2 (BLS) might minimally increase oxygen delivery to the myocardium, but might also decrease it because high-flow O2 can cause arterial constriction and decreased blood flow to the heart muscle.  He’s already at 97% saturation, so raising that a couple of percentage points isn’t going to materially improve oxygen delivery to myocardial muscle.  OK, but nitroglycerin dilates the arteries, right? Yes, but the problem is that vasodilation effect is systemic.  This patient is at an un-sustainable heart rate and will soon go into cardiogenic shock due to inadequate preload of the ventricles if his heart isn’t slowed down.  Systemic vasodilation secondary to nitroglycerin administration might very well accelerate his decline.

This is a pretty classic “ALS before BLS” patient. What he needs is to have his heart rate slowed to a more normal level, in this case by a drug called adenosine (an ALS procedure).  If we don’t quickly establish IV access and push adenosine, this guy is going to crash and perhaps die.  If we don’t chemically convert his SVT and his blood pressure drops below 90 systolic and/or his mental status degrades, we’ll have to shock him out of his SVT with synchronized cardioversion (also an ALS procedure).  If we put BLS before ALS, we’ll be wasting time doing BLS things of little-to-no benefit (or that might actually hurt) when we should be doing ALS things that will actually help the patient.

There are other pathologies where “BLS before ALS” is a bad guideline, such as symptomatic bradycardia, some overdoses, or any significant fracture where the patient is hemodynamically stable and in a safe location (pain medication before straightening, splinting and moving, please!).  If we must have simplified rules of thumb to follow, I’d much prefer “Don’t forget the basics” because BLS procedures are important and meaningful and must be done well (and sometimes, as in cardiac arrest, more important than ALS), but they do not always come first!

[1] For any non-EMS readers, there are basically two tiers of emergency medical service in the USA: Basic Life Support (BLS) provided by Emergency Medical Technician-Basics (EMT-B) and Advanced Life Support (ALS), provided by Advanced EMTs and paramedics.

To An Addict

You are blue from the neck up, lying there on your back half in the bathroom, half in the hall.  Your body fights to live; gulping for air about six times a minute. You snore, but it is not the snore of a deep and peaceful sleep. The people who love you despite your flaws are there; either stunned and silent or frantically yelling at us to hurry and at you to breathe.  Your carotid artery thumps against my fingertips as I check to see if your heart still beats.  I peel back your half-open eyelids and despite the gloom of the poorly-lit hallway see your pupils constricted to the size of pinpoints. Heroin does that.

Head-tilt chin-lift; bag valve mask. C-grip; squeeze-release-wait-squeeze-release-wait. The pulse oximeter I’ve slipped on your finger says 31; it should be in the 90s. Your body reacts to each squeeze with a convulsive gasp for air, trying to help me help you. My partner arrives behind me with the rest of our gear and takes over breathing for you as I slide past your head.  Trauma shears – sorry about your t-shirt, man, but I need room to work. The blue numbers on the oximeter are getting bigger – a good thing- but are still too low.

Blue tourniquet around your biceps; looking for a vein.  No track marks – you’re one of the lucky ones… so far.  No big blue bulging pipes, but my fingertips probe inside of your elbow and feel a change; a slight bulge my eyes can’t see but is there nonetheless. Alcohol swab; left fingers on the vein to mark it, catheter in my right hand.  I stab and – whew – blood fills the flash chamber. Advance the catheter; withdraw the needle; attach the extension; release the tourniquet; flush. The saline flows easily through the 18-gauge and I secure it in place.  There may come a day when the poison you shoot into yourself will kill you, but it is not this day.

Naloxone prefill in my hand; pop the caps, screw the ampule into the injector, push a drop out the tip to make sure it flows. Connect to the IV; push sloooooowwwwwwly until 0.4 milligrams of second chance (Or third? Or fourth? Who knows?) flow into your veins.  Partner still squeezing, I flush the line and watch your chest and face for response. Not much. I let the sweep second hand of my watch make a trip around the dial then do it again. Now your belly begins to jerk as you gasp for air and your face pinks up. The blue numbers are much bigger, and we slap a green transparent mask on your face to help them grow even faster.

Your eyes open and we sit you up. You’re groggy and confused but alive. The police officer finds your empty heroin packets in the unflushed toilet and your spoon on the bathroom counter.  The people who love you seem lost, not knowing what to do, answering our questions with dazed expressions.  We get you up from the floor and my partner, the firefighters and I walk you to the ambulance.  On the way to the hospital, you repeatedly apologize to me.  You don’t know it because I don’t show it, but this makes me angry – the people you need to apologize to are not here, they are back in that gloomy apartment we brought you out of. You thank me, which is fine, but if you really want to thank me you’ll get into a treatment program and get off that shit you shoot into your veins.  I’m just doing my job, man – I don’t want your appreciation or your apologies, I just want to never see you standing on death’s doorstep again. You bought yourself a ticket with two destinations, and today it was a hospital. Tomorrow it might be the morgue.

My partner and I clean and re-stock the truck to get ready for the next one.  As we pull away from the emergency department entrance, he looks over at me and says, “I went to high school with him.”