Silent Siren, page 10
The radio on my belt chirps: “Aid 14, Attack 6, Medic 1, 23 Avenue South and South Holgate Street.” Jules and I weave our way through the ER to the medic unit bay. The dispatcher continues: “Seventy-two-year-old male unconscious, unresponsive. Ongoing CPR.”
Our senior paramedics that day couldn’t be more different. The more experienced of the two frequently looks like she’s about to explode and often does. She’s distractingly attractive, but her propensity for loudly correcting malfunctioning students is probably what she is better known for. Her partner is a much newer paramedic. She has short, gray-streaked hair and a calm demeanor. Still open to learning, she seems to accentuate the positive more so than many of the other seniors.
It’s my turn to run the resuscitation and Jules’s turn on intubation. An elderly Vietnamese man lies unconscious on the living room floor, his family crying hysterically. He’s a kidney failure patient and had been dialyzed earlier that day. Patients in kidney failure are prone to abnormal heart rhythms brought on by high or low potassium levels. Attack Unit 6 has started CPR and attached the automatic defibrillator, though they haven’t had a shock-able rhythm yet.
I attach the four leads for our monitor and search for an IV site on the man’s left hand as Jules prepares to intubate. The monitor shows asystole without the slightest undulation to it. I wrap the rubber tourniquet around the man’s upper arm and slide an 18G catheter in his hand.
Jules is having some trouble with her intubation. I’m not paying close attention as I’m concentrating on my next move with this patient. She is still fumbling around with her equipment and, since the man has no teeth, the firefighters are having some difficulty getting a good mask seal on his face.
I slam a milligram of epinephrine into my IV line and wait a couple minutes for it to circulate with CPR. Jules has finally, after much difficulty, managed to get her tube in the right place.
Two minutes goes by. The seniors stand back and watch. I tell the firefighter to stop compressions and turn my attention to the monitor. Regular spikes at about 140 a minute have now replaced the slightly undulating flat line on the oscilloscope. I check for a pulse in the man’s groin. It’s bounding. The man’s heart is beating again.
We roll him onto a backboard and get him out to Medic One. Jules wraps a blood pressure cuff around the man’s left arm. That is when the more edgy of the two senior paramedics flips her lid.
“Get that blood pressure cuff off his arm right now!” she screeches.
Rattled, Jules removes the cuff and announces the blood pressure. It is well over 200 systolic. The epinephrine did the trick and then some.
I’m still mystified as to what’s gotten the senior so excited. I won’t have to wait long for the answer.
“His dialysis shunt is on that arm! And Jules, pay attention to your tube!”
I hadn’t noticed when I placed the IV that the man had a dialysis shunt, a surgical connection between his artery and vein, in the crook of his left arm. Back pressure from either a blood pressure cuff or tourniquet could theoretically cause the shunt to burst, resulting in uncontrolled hemorrhage and possibly death.
The ride to the hospital is uneventful after that. The man maintains his very high blood pressure and pulse the whole way to Virginia Mason ER. I imagine he probably survived his cardiac arrest because of our interventions.
As Jules and I clean up the rig, the two medics get in back with us and shut the door.
The quiet one says, “So, what went right on that call?” I can tell she’s trying to accentuate the positive, and I appreciate that.
“Um…he lived?” I offer.
Without missing a beat, Edgy Medic launches into a rant involving shunts, the importance of paying attention to your tube, and various other tidbits I can’t recall. After she is satisfied that she has impressed upon us the importance of paying attention, she and her partner get up front to drive back to the station.
Jules and I look at each other in the darkness. We are silent for a minute or two, and then burst out laughing.
“That was awesome!” I say. “We’ve had the Medic One experience. We’ve been yelled at by the seniors!”
It is the first and only time I’ve ever been berated for saving someone’s life.
Evaluations
Five months or so into the program, the senior paramedics began to step back on calls, allowing the students to hone their newly acquired assessment and treatment skills in the field. We entered a phase known as “Third Man Evaluations,” in which we were evaluated in several critical areas on each call. This phase was in preparation for the often-dreaded “Paramedic Evaluations.”
In Paramedic evaluations, the rubber met the road. It was an opportunity to demonstrate what we had learned in an environment in which the senior medics stepped back completely and only intervened if it became apparent we were about to do something dangerous. Skills were evaluated in depth in a multi-page document that gave a single score, 1 for hopeless, 5 for rock star, for an entire shift’s work. Rarely would a senior paramedic award a score of 5. A 4 was high praise.
I got a few 2s on my evaluations, mostly 3s and 4s. There were days I felt I had absolutely no business in this field and let myself be intimidated by particularly gruff senior paramedics. “One wonders if Matt knows what to do” read one particularly blunt evaluation.
On some days, everything flowed perfectly and I was with medics who put me at ease. Paramedic training could take you from the highest high to the lowest low. I learned that to be completely comfortable with the job was not a good thing. Always at the back of the mind should be a sense of the awesome responsibility with which we are charged, counterbalanced by a confidence gained by experience and solid training.
Doctor evaluations comprised the final phase of training before the written and practical examinations that would certify us as nationally registered paramedics. These were pretty low-pressure affairs. The doctors were usually just excited to get to ride in the back of a medic unit with lights and sirens. They were impressed that we could get down on our hands and knees in a dark alley and intubate a vomiting overdose patient, so the scores the doctors gave us were pretty liberal, for the most part.
See Me
Paramedic students and senior medics alike were required to document their patient care on Seattle Fire Department’s aid forms, known as Forms 20-B. On them, we recorded the patients’ names, ages, presenting symptoms, the result of our examinations, and treatment rendered. Every morning, Dr. Copass arrived to pore over each one, critiquing our treatment modalities, often with indecipherable scrawls of red pen. At times, the reviews were merely informative, to apprise us as to conditions found upon the patients’ arrival at ER, admission, and hospital course; other times, “See Me!” was scribbled passionately across the narrative section of a report or on a separate review sheet. Medics and students dreaded “See Me’s.” Usually, it meant one had erred in the eyes of Dr. Copass and immediate action was required to set things right, a “Coming to Jesus” session, as one senior medic put it, in which one was expected to arrive at sunrise either at Dr. Copass’s car in the parking lot of Harborview, or in the glassed-in office at the center of the ER, where the good doctor would begin his morning reviews.
Sins were confessed and explanations proffered by errant students and medics. “Suggestions” were made by Dr. Copass, often loudly and with colorful language. But no excuses were to be made. Lives were at stake and Dr. Copass expected that every paramedic, medical student, or physician in his charge perform to the absolute best of his or her ability.
I had my fair share of “See Me’s.” On one call I had inserted a too-small IV catheter into the vein of a woman suffering from a gastro-intestinal bleed: “18 gauge? Fooey!” Dr. Copass had scrawled all across my narrative. I should have placed a 14G, or at least a 16G, to be prepared for fluid replacement if the woman’s vital signs began to slip. Another said “I’m disappointed. Deserves a more serious approach.” Notes from Dr. Copass were more or less equal opportunity. Nobody escaped his watchful eye and most were “in the doghouse” at one time or another.
Though Dr. Copass could be quite pointed, he was fair. He didn’t expect perfection, but he did expect excellence, humility, and compassion. “There’s no place for judgment in medicine,” he once said during a lecture. I have tried to adhere to this bit of advice with greater or lesser success over the years since training.
Smock Burning
Paramedic school wound to a close in June of 2003. We started with twenty-five students; twenty-three graduated. One student decided after the first block of classes to return to his position as a fire officer for financial reasons. Another student nearly made it all the way through training and flunked out in Doctor Evaluations when his own fire department medical director rode with him and deemed him unfit for a life of street medicine. He simply couldn’t apply his vast medical knowledge to his patients in the field. Still, though, our pass rate was excellent, and everybody was excited to try out their skills as newly minted paramedics.
Our end-of-school celebration was held on Alki Beach in West Seattle. As was tradition, we brought with us the short white smocks we had worn during hundreds of hours as paramedic students, now discolored with faded bloodstains and Betadine, to a pile where they would be ceremoniously set ablaze as the sun went down, signifying our transition from students to practitioners.
Alcohol flowed freely, stories were swapped, and two lovely pairs of breasts belonging to two lovely female paramedic students were flashed in the glow of the blazing smocks, much to the delight of the overwhelming male majority. We bathed in the glory of an enormous accomplishment. Whether we were the smartest in the class or simply the kindest, we all had the title “paramedic” to tack on to the end of our names. It was the end of a long and arduous journey, but in some ways, it had just begun. As new paramedics, we would have only ourselves to look to when, as one senior put it, we were “up to our asses in alligators.” As patients sat pinned in twisted wreckage, struggled to breathe, infarcted their hearts, and delivered the next generation, we would often look behind us for advice, assistance, even a gruff word of admonition from a senior paramedic…and none would be there.
My fellow paramedic students and I graduated in July, with the obligatory exit interview with Dr. Copass. Though it was considered a formality, he fired obscure medical questions at us, such as “Define cannon a-waves?” None of us had ever heard of this phenomenon but it didn’t really matter. He drove home the point that none of us, despite the in-depth education we had received, should ever stop learning. We were to be humble as ordinary people doing extraordinary work.
I walked out the door to my exit interview and felt the warm sunshine hit my face. Suddenly, I had no idea what to do with myself. No more classes, no more riding along on Medic One and Medic Ten. The senior paramedics did 180s in their attitude towards us. We had made it. We were colleagues. A senior paramedic who had terrorized me as a student shook my hand and growled his congratulations. I had a couple of weeks of vacation before I was to start work at Evergreen Medic One in Kirkland.
An Impossible Airway
Very early in my career as a paramedic at Evergreen Medic One in Kirkland, I had been sitting in the Bothell Fire Station quarters where our unit was housed as I listened to the basic life support unit responding to a call for seizure activity at an address several blocks away. Several minutes passed and then I heard the urgent call on the radio: “Aid 42 to Dispatch. Tone the next available medic unit.”
Paramedic Dana Yost and I head off to Aid 42’s location. We arrive at a single-wide mobile home and enter with all our kits. The musty odor of shut-ins hits our nostrils as I attempt to squeeze myself, a defibrillator, and a twenty-pound bag of airway supplies through the flimsy metal screen door that opens onto a dated, dark, and cave-like kitchen. An elderly woman, tethered to a portable oxygen tank, sits at a cluttered table in a threadbare bathrobe. Her thin arms, like two pieces of driftwood, clutch a stained coffee mug. A firefighter leads us into the living room, where an elderly man lies, unconscious on the thick rust-colored shag carpet.
His muscles writhe rhythmically as his brain repeatedly misfires with the uncontrolled electrical activity of a seizure. His face is beet-red, his eyes tightly closed. He breathes noisily. When he exhales, air hisses out the side of a jowly cheek and a faint groan escapes his throat. A large urine stain has formed on the front of his white boxer shorts.
“Have you gotten vitals on him yet?” I ask one of the firefighters.
“210/110,” he says. “Rate is 60.”
The man has no history of seizure disorder and his blood pressure is very high. I surmise he might be having a brain bleed. Likely an expanding clot of blood has pressed on vital neurons, causing them to malfunction and spread a wave of disorganization throughout the man’s ailing brain.
His pupils are widely dilated and do not react to light. Another bad sign. I begin to formulate a plan. I have to stop the disorganized firing of his brain cells and guarantee the patency of his airway.
“Let’s start a line on him, give him Valium to stop the seizure, then paralyze and intubate him.”
Dana nods in agreement. The seizure activity, not ceasing on its own, would need to be quelled with the benzodiazepine sedative Valium. Because I suspect a stroke, I worry about the man’s ability to maintain his airway. Therefore, I would need to paralyze all his voluntary muscles using a medication called succinylcholine in order to facilitate passage of an endotracheal tube into his airway. If I were to simply paralyze him without benefit of Valium, his brain could still be seizing, but I would be unable to see any manifestation in his body.
A firefighter affixes four electrodes to the man’s heaving chest and flips on the EKG monitor. Dana plunges a green 18-gauge IV catheter into one of the man’s tremulous pale arms and begins to infuse the fluid Lactated Ringers. Reaching into the pocket where we kept our narcotics, I draw up 5 mg of Valium into a syringe.
Shortly after I have confidently injected the last milligram of medication into the intravenous line flowing freely into our patient, the seizure activity ebbs as expected. The wrinkles in his face smooth and he stops breathing. I draw up the succinylcholine in a separate syringe as Dana clicks together the components of his laryngoscope, readying syringe, end-tidal CO2 detector and the other essentials of intubation.
I push the muscle-paralyzing succinylcholine into a medication port on the IV line and Dana hunkers down on his elbows to visualize the airway. A firefighter kneels by with the bellows-style bag-valve apparatus, the mask detached, ready to attach to the end of the endotracheal tube.
Dana clicks the curved Macintosh #4 blade onto the handle and snakes it into the depths of the man’s open mouth. He is not meeting with success.
“Cric pressure, please,” he says. Dana is not able to locate the landmarks necessary to place the breathing tube and needs help positioning the anatomy.
I force two fingers down onto the patient’s larynx, hoping that Dana would be able to thereby locate the gleaming vocal cords, or at least the tip of the epiglottis.
Still no success.
“I’m out,” says Dana, and I move into his position to take his place.
Grabbing a straight-bladed Miller #4, I attempt to visualize the airway myself. I can see nothing but vaguely inflamed soft tissue. No gleaming white cords. In fact, no landmarks appear at all. With no option but to pull out and re-attempt to ventilate using the seal of the mask, I arise from my position on the floor. The firefighter claps on the mask and attempts to squeeze life back into the silent lungs. Inexplicably, the man’s ruddy neck begins to swell.
“I can’t ventilate him,” says the firefighter, looking up concernedly. Our patient’s skin has taken on an increasingly dusky tone, fewer and fewer of his red blood cells saturated with oxygen. An oral airway—a small plastic device intended to isolate the tongue is quickly placed, though it does little good. My grand patient care plan telescopes into single-mindedness, a focus on the difficult airway to the exclusion of any other thought.
Has he gone into some strange anaphylactic reaction? Has his larynx gone into spasm? I begin to sweat.
With all our attention focused on the dying man’s airway, we have focused away from the heart monitor. Dana is the first to glance at it and notice the glowing straight line on the oscilloscope. “Asystole,” he says. The man’s heart has stopped. Mine begins to beat faster.
The only good thing about a very sick patient going into cardiac arrest on you is that you now are able to follow an algorithm predetermined by the American Heart Association. Ironically, things become more simple.
With a spare hand, one of the firefighters keys the mike to call for manpower. “Tone Engine 42. CPR in progress.” With the other hand, he thumps on the frail chest as Dana and I figure out what to do next.
If we couldn’t visualize his airway using the laryngoscope, maybe we could access it backwards, through his neck. Out comes the retrograde intubation kit, a cumbersome device that, after that day, I will never use again as long as I live.
Dana inserts a steel needle through the man’s puffy neck, just above where a surgeon might perform a tracheotomy. He then inserts a thin flexible wire through the center of the needle and seconds later, it’s visible at the corner of the patient’s mouth. Dana passes an endotracheal tube over the wire and into the patient’s throat. In theory, this made it impossible for the tube not to go into the trachea. In practice, it doesn’t work well at all. It takes dexterity and patience that we are both short of. We abandon that idea, re-attempt to ventilate, and go to the next logical step.
“We’re going to need to cric him,” Dana says. A surgical cricothyrotomy, a close cousin to the tracheotomy, is the last-ditch, back-against-the-wall, attempt to restore oxygen to a dying heart and brain.
By now an additional engine company has shown up for manpower and a battalion chief is attending to the man’s oxygen-tethered wife, who is now experiencing more than a little respiratory distress.
