The Toothache

“The Toothache” is excerpted from Marianne Paiva’s book Breathe: Essays from a Recovering Paramedic which tells of her life as a paramedic in rural areas of northern California in the 1990s. This particular story tells of the time she was called to take a man by ambulance with a toothache to the emergency room at 3 a.m. You’ll need to read the whole story to find out why this was the case! To understand the context for this story, you will need to read the whole book!

Marianne has since gone on to teach Sociology at California State University, Chico, and blog here at Copies of Breathe can be purchased for very reasonable prices at in both paper and Kindle versions.   TW


The Toothache

By Marianne Paiva

In paramedic school and in the field, instructors and veteran medics downplay the inherent stress of the job. Instructors will say, “As long as you know your job, you’ll do fine. Just always know your job,” and continue innocuous demonstrations such as how to stab an orange with a two-inch needle or how to start an IV on a life-sized plastic arm. And veterans, those people who have been in the field at least ten years or so, will laugh when you ask, “So, what’s the worst part of the job?” They don’t laugh because they think its funny; they laugh because if they knew, they wouldn’t be doing the job. But stress is the reason people leave so quickly, why the burnout rate for a paramedic is less than ten years. Why paramedics are more likely than the average person to have an affair, to commit suicide, and to use illicit drugs. It’s getting better; in the mid-1990s, the burnout rate stood right around four years.

 It comes from all sides in prehospital emergency medicine. The patient yells in pain; the family yells because you didn’t get there quick enough; doctors glare and occasionally, when you’ve really screwed up, they tell you to leave. “Get the hell out of my hospital before you kill someone!” Screaming doctors don’t cause the most stress; the most stress often comes from the unexpected and unlikely sources. When you are a paramedic, the most stress comes from the perfectly mundane. I often ask paramedics who have left the field, “why, why did you leave”? And they tell me stories of broken families, long hours, the managers who expected miracles all day, every day, and the one call—that final call—when they realized they were done.

The call came at 3:00 a.m. on a frigid winter morning in March 1997. A thirty-four-year-old man with an address just up the block from ambulance quarters, in run-down apartments we are all too familiar with, has a toothache. It’s my call and I wonder today, would this have been my breaking point if the call rotation had fallen to my partner? Would I still be working on the ambulance? But the rotation had fallen to me and the toothache was mine.

It takes only a minute from quarters to reach the low-income apartments where the man with the toothache lives. My eyes are still swollen with sleep and my boots are just barely zipped when I spot a Latino man standing on the sidewalk outside the apartments. The man, wearing a thin, worn multi-colored 1970s polyester coat, faded blue jeans, and work boots, bows his head as the lights of our ambulance flash in his dark brown eyes. A girl, no more than eight or nine years old, stands next to him. They are waiting for us, even though it’s nearly freezing and the girl is wearing only shorts, a thin shirt, and flip-flops. Her dark, wavy hair falls to her shoulders and makes a deep contrast to the pale pink t-shirt with the giant purple cartoon dinosaur on the front. The resemblance between the two is noticeable. She has his deep-set eyes and if the man ever let his hair grow out, it would be identical to his daughter’s.

I roll the window down as the ambulance nears the curb. “Did you call the ambulance?” I ask the father. He looks alarmed and glances at the girl.

“Yes, my papa. His tooth hurts.” The girl wraps her arms around her body and tries to capture some of the heat that escapes into the frigid air. The father nods quickly in confirmation.

“And you want to go to the hospital?” I can feel my partner, David, rustling behind the driver’s seat. He’s impatient and would rather be sleeping. And he forgot his Diet Coke. Before leaving quarters, on every call, David grabs a Diet Coke on his way out. On this call, he forgot.

The girl speaks quietly in Spanish to her father. He leans in to hear her, then straightens up and nods. Yes, he wants to go to the hospital.

An involuntary sigh escapes my lips as I open the passenger door and motion for them to follow me. Warm air and bright lights flood the girl as I open the double doors at the back of the ambulance. I wait for her to climb into the giant box, then over the gurney and onto a seat tucked away between the cabinets filled with blankets and medication and plastic tubing. Her father follows, taking his place on the gurney. He sits upright, with his feet still on the ambulance floor and his hands in the pockets of his coat. I pull the doors of the ambulance closed behind me and find the warm bench seat beside the gurney.

“Ready?” David calls from the cab of the ambulance. I look at the man and his daughter and wonder, can I ever be ready?

“Not yet, give me a few.” David turns to glance at me briefly and I shoot him a stare with one eyebrow raised, “Just wait, just wait.” I turn my attention to the girl and her father.

“Tell me what’s going on,” I ask the girl. I do not speak Spanish and my patient, her father, does not speak English. I know the routine better than I should; parents and grandparents, aunts and uncles rely on their children, often too young to read, to translate their pains and injuries to medical providers in emergencies. Children are kept from school to accompany their parents to doctor appointments and are allowed to see their mothers and fathers die because someone needs to translate from Spanish or Hmong (war refugees from mountain regions in Southeast Asia) or Laotian (war refugees from low-lying areas of Southeast Asia) to English and back again. When I was a rookie EMT, we responded to a medical aid for an elderly Hmong woman who spoke no English. Her husband and other adult family members who spoke no English surrounded the woman as she lay in pain, curled up on a couch in a small apartment. We relied on her grandson to translate. But it’s difficult to understand a five-year old whose second language is English and the paramedic didn’t know how to treat her. How do you treat a severe stomachache? We didn’t; we took her to the hospital and let them care for her. She died a few hours later. She had cancer of the stomach, but her grandson didn’t know how to say “cancer” and so she was in pain for longer than she should have been. If we had known, we could have requested morphine. We could have made her comfortable. Instead, she died in pain.

This girl speaks English well, though. Her father has been in pain all night and can’t stand it anymore. He needs a doctor.

“Why did you call the ambulance? Do you have anyone to drive you to the hospital?” Many people will call an ambulance instead of driving to the hospital themselves, thinking they will be treated faster. But if a patient can walk to the ambulance and gurney, like this man has, the triage nurse will escort him to the waiting room even though we delivered him through the back door.

“We don’t have a car,” she tells me. No car and I suspect, no friends they can wake up at 3:00 in the morning for a ride to the hospital, twenty miles away.

“If you go to the hospital, how will you get home?”

She shrugs her narrow shoulders. She speaks to her father in Spanish again. I pick up only a few words of the discussion, but enough to know that he doesn’t care how they will get home; he is in pain now, not later.

“The doctor will only give you aspirin, nothing else for the pain. Do you have any aspirin at home?”

“No”, she says, “We don’t have any money for aspirin.”

“Ok,” I say finally, “I need to see the tooth and call the hospital.” I snap on a pair of latex gloves and move toward the man. “Can you ask him to lay back so I can see his tooth?” The girl translates my question. I adjust the gurney into a reclined position and the father rests his head against the rough pillow. His tooth is abscessed beyond repair, the black shell of what it used to be hangs between other teeth that will see the same fate fairly soon. The stench—not morning breath stench but rotting flesh stench—knocks me back onto the bench. I wonder how he has been able to stand the pain until now.

The nurse on duty who answers my call is not happy. “A toothache?” she asks me, not believing what I have said. I called her so she will know I tried to convince the patient not to go to the hospital, because if I bring them a toothache at 3:00 in the morning, they will question everything I do later.

“Yes,” I confirm, “a toothache. I’ve advised the patient that treatment at the hospital will be equivalent to over the counter aspirin. He is adamant in his desire to be transported to the hospital.” She makes me wait for her reply.

“Copy Westside, ETA?”

“ETA twenty-five minutes. Do you have any orders for me?” Maybe she’ll let me give him a little morphine on the drive, but I don’t want to ask her for it directly. If anyone else is listening, I’ll be a laughingstock. But the nurse says “no, there are no orders,” and I am embarrassed to have asked, although I know my patient needs something for the pain. The nurse has obviously never had a toothache.

Since my patient cannot converse in English and his daughter has fallen asleep on his lap, and there is nothing I can do to treat him. I have time to think on the twenty miles to the hospital. I am surprisingly angry. Not at the patient or his daughter, but at the nurse, for not understanding a toothache and denying the man morphine. And at the way we treat undocumented workers in my town and country. The man refused to give me his name and wouldn’t provide any identification, a sure sign that he was undocumented and illegal. How desperate must we make another human before we break them? It is a long twenty miles. The father and I try not to stare at each other for too long but in the tiny ambulance, we catch each other’s eyes a few times. I try not to breathe through my nose, because the smell of the abscess is overpowering and makes my eyes water.

The nurses glare at me when I escort my patient and his daughter into the emergency department. “Take him to the waiting room,” the triage nurse tells me. “Couldn’t you do anything to persuade him not to come in?” The mild anger I felt in the ambulance flares and I walk back to my ambulance before I say something I will regret. I am done, I realize. I am done. I can’t take any more babies beaten and scalded with hot water. And mothers who extinguish cigarettes on their children and fathers who rape their sons and the people who cover it up. I can’t take the woman who goes back to the man who molested her children. I can’t take one more boy struck by a car on his way to school and my best friends being shot by their boyfriends. No more drug overdoses, suicides, and near misses. No more. No more nurses who turn their nose up as we walk into the department with a drunk transient. No more. And I can’t take any more toothaches in the middle of the night.

The next morning, as I am driving to school, just at the city limits entering Chico maybe two miles from the hospital, I see two figures walking on the side of the road toward me. One is small, dressed in shorts, a light shirt, and flip-flops. Her father’s polyester coat hangs around her shoulders, draping her like a dress. The other is a slightly built Latino man in his thirties. The man with the toothache and his daughter, who should be home in her warm bed, just waking up to get ready to go to school, are walking the twenty miles back home.

The girl shivers as she climbs into the front seat of my SUV; her father takes a seat in the back. He doesn’t say anything when he closes the door, but pulls the seatbelt across his shoulder and tightens it as I shift into gear. I glance at the girl; her pink cheeks warmed in the stream of heat from my dashboard.

“You’re not working?” the girl asks.

“Nope, not today,” I confirm. I wait while she settles into the seat. “Buckle up,” I instruct gently. She pulls the belt tightly and snuggles deeper into the coat. We drive in silence back the way we had come just a few hours earlier. Their little apartment appears even more run-down in the daylight. I wait as the girl’s father gets out of the car and scoops his daughter from the front seat. She has fallen asleep somewhere along the way. He looks slightly embarrassed at the situation. I smile, trying to tell him it is okay; she’s a kid, she should sleep. I shift into gear as he moves away but then he steps back toward me and I think maybe he has forgotten something. I wait.

“Thank you,” he nods slightly. Holding his daughter in his arms, he nudges the car door closed and carries her home.