Silent Siren, page 11
Dana withdraws from the ventilation kit the cloth roll that contains the implements required for the procedure: two scalpels, one to slice through the soft tissue of the neck, the other to open a tiny hole in the cartilage of the larynx; army/navy retractors, forks on one side and spades on the other, designed to isolate the tissues and create a visual field; and a hooked instrument to allow a tube to be placed through the tiny hole in the airway.
CPR continues as Dana makes a vertical slice through the skin and fat of the thick neck. Maroon blood gushes from the wound and disappears into the thick carpet. This is not good.
“Suction!” I yell, and the Yankauer suction catheter is stuck in the wound to evacuate the rapidly expanding pool of blood. Dana needs to see where to place the tube. There shouldn’t have been any major blood vessels in the area Dana cut. The man must have had a vein that traversed the midline—not so lucky for us, very unlucky for him.
I stuff 4x4 inch gauze into the wound in a further effort to staunch the bleeding. Our patient is now a much darker shade of purple and we are, as they say, way behind the eight-ball. The heat rises in my cheeks. I feel as if I’m on a terrifying amusement park ride and can’t bail out.
I retract the wound, giving Dana access to the trachea, and he is finally able to locate the thin ivory-colored membrane he seeks, puncturing it with the scalpel. His entrance into the trachea is heralded by the appearance of bloody bubbles arising from the hole—the residual volume of the last breath he ever took.
In the midst of this drama, my sense of the absurd kicks in and the Don Ho tune “Tiny Bubbles” begins humming through my head. I guess it is my way of coping with a call that has gone hopelessly awry—a mental diversion.
Can anything else go wrong? It does. Somewhere in the forest of dimly lit high-shag carpet, we have lost our all-important hooked instrument. Flashlights click on and we search frantically for the stupid thing.
It is all an academic exercise at this point anyway; the man has little chance at survival but we need to do everything that can be done for him. We need to complete the cricothyrotomy. I can’t remember exactly how we manage to do it, but ultimately Dana was able to slip the tube through the bloody neck and into the windpipe.
By this point, we have done about all we could. We have accomplished an airway, artificial breathing through the bag-valve mask, and some semblance of circulation through CPR. The ABCs are done. Three or four rounds of the heart-jolting drug epinephrine have been infused through the man’s veins to no avail. We now have a dead man with a hole in his neck. He had been a sick man without a hole in his neck when he arrived—not a very satisfying call on any level.
The adrenaline has worn off. Now I’m just sapped of energy, bloody, and a little numb, trying to remember the chronology of events. Just when did things begin to go all pear-shaped? What could I have done to change the outcome? The answers don’t come.
A sheet is pulled over the man’s head. The medical examiner will come to pick him up. The fire crews, Dana, and I gather our disheveled equipment and make our way back to our rigs, idling in the street outside.
“Your first kill,” Dana remarks as we drive back to the station.
Hot Dog
I am working on Bainbridge Island as a volunteer when the tones hit for a choking victim at Serenity House on the south end of the island. I hop into my maroon Chevy SUV, plug in the dual dash strobe light, and roar off, much faster than the speed limit allows.
As I pull up the winding driveway, I notice Medic 21 and Aid 22 idling at the top, their red lights revolving against the dilapidated old building, exhaust pipes issuing gray trails in the early morning cold. Two volunteers’ pickups are parked haphazardly, their hazard lights blinking.
The ancient building houses about twenty residents, most of whom are both elderly and mentally retarded. They have outlived their families and now have nobody to care for them. The staff does not speak English and the place is grossly under-funded. It’s never a pleasure to go on a call here.
We grab our aid kits and are led inside to the kitchen, past curious, wide-eyed residents, mumbling to themselves, perhaps wondering which one of their friends is in trouble. The smell of burnt toast and scrambled eggs wafts from the open-doored kitchen.
The patient sits at a table in the corner of the crowded dining hall, attended by a couple of worried aides. He’s still conscious, but clearly in distress. His color is a bit on the bluish side, and he is wheezing.
The lead paramedic listens to his lungs as the duty officer gets the story from staff. The man has evidently choked on a hot dog and it is still lodged in his throat. He has not a single tooth in his head and the staff has fed him an entire, un-sliced hot dog. Incredibly, this is not the first time he has choked on a hot dog.
Why would anyone feed a toothless mentally retarded man a whole hot dog? It made me question who was more disabled—the staff or the residents.
The man, now an unpleasant shade of purple, is placed on an oxygen mask. Though he is struggling to breathe around the obstruction, he seems more concerned with his hat, which keeps falling off his head. He keeps reaching down and placing the dilapidated, dirty baseball cap back on his head. I guess it’s his security blanket.
We make the decision to get him to the medic unit to work our magic. He’ll need his airway controlled with an endotracheal tube. The lead medic stays inside to apprise the emergency room doctor at Harborview of our situation, and leaves me in charge of the choking man.
An EMT who has an endorsement to start IVs slides an 18G steel needle into the crook of the man’s arm, leaving in place a plastic catheter. He attaches it to an intravenous infusion of the fluid-expanding solution Lactated Ringers, and opens the roller clamp. The man is now ready to receive the medications I will use to stop every voluntary muscle in his body from working and facilitate the passage of a tube past his vocal cords and into his trachea. I get the bag-valve mask ready to ventilate the man before I pass the tube.
I draw up 5 mg of Valium and 100 mg of succinylcholine in preparation for paralysis and intubation. Intubation is a frightening experience, and I don’t want the man to remember it. The Valium produces a retrograde amnesia, erasing or at least dulling the memory of being helpless and having a metal scope inserted between your teeth.
I get ready my laryngoscope and tube, inserting a stylet inside to give the tube stiffness, and a syringe to inflate a bulb that will keep the tube in place in the man’s throat. I also pull out a long, curved pair of tongs known as Magill forceps. After the IV is in place, I push the Valium and succinylcholine. The man’s hat-replacing activity ceases instantly. He twitches slightly and stops breathing.
Visualizing anatomical landmarks is much easier in someone who doesn’t have teeth, I have found. There is much more room in which to work, and no danger of chipping teeth with a blade. I shine my lighted laryngoscope down the reddened throat, sweep away the man’s flaccid tongue, and am immediately met with a sizable chunk of hot dog that completely obscures his throat. I maneuver my Magills into place, grasp the offending chunk of hot dog, and pull it free, revealing the gleaming white vocal cords and epiglottis. I pass the tube between the vocal cords, inflate the balloon, and attach the BVM.
Disaster averted. As the medic unit makes its bumpy way down the gravel driveway, I look down at my patient with his closed eyes and dirty baseball cap atop a balding pate. I squeeze the bag.
“Not his lucky day,” I muse.
The lead medic injects an additional 5 mg of Valium into the IV line. “Depends on how you look at it,” he says.
The Split
I worked for Evergreen Medic One for six months before Evergreen Hospital in Kirkland, Washington made the decision to get out of the ambulance business. This was disappointing to me since I had come to regard Evergreen as the acme of my career and a perfect niche. Relationships with ER physicians were collegial, decision making was liberal, oversight was minimal, and the compensation was excellent.
Since all Medic One agencies in King County are supported by tax levies, the county executive made the decision to split the money allocated to Evergreen between two other EMS agencies, Shoreline Fire Department and Redmond Fire Department. The agreement was that Shoreline Fire, who had a pre-existing paramedic program with two medic units, would take over our Medic 47 in Bothell, while Redmond Fire Department, which up until then had no paramedics, would administer Evergreen’s former Medic 35 in Woodinville, Medic 23 in Kirkland, and Medic 19 in Redmond.
This change was sudden, though not completely unexpected. I had heard rumors while I was in paramedic school that a fire agency would eventually absorb our service. However, I had more pressing things to concentrate on at the time, like passing paramedic training. In theory, we were given the choice as to which agency to join, although Redmond would take the majority—about twenty-five paramedics. The remainder, eight, would be employed by Shoreline Fire Department.
For reasons primarily pertaining to the shift schedule— Shoreline’s 1 on, 5 off schedule worked better for somebody commuting from Bainbridge Island, I chose to join Shoreline Fire Department. It would prove to be an auspicious choice, one that would change my entire career path.
Shoreline Fire
I started my employment with Shoreline Fire Department on January 1, 2003 and became almost immediately aware of the difference in mentality between Evergreen Medic One and Shoreline Fire Department. To be sure, the differences between the two agencies represented the differences between a hospital-based and a fire-service based EMS system in general. For example, a paramilitary hierarchy exists in the fire service. Shifts are divided into platoons—A, B, and C, each headed up by captains and lieutenants heading up each engine company, ladder company, and shift of paramedics. On the next administrative tier up, a battalion chief is in charge of all fire suppression personnel on a platoon; an EMS battalion chief headed up all paramedics in all platoons. This was in contrast to the more civilian role of the Medical Services Officer and Medical Services Administrator that supervised each shift and division respectively in civilian EMS.
Each shift at Shoreline Fire Department started with the off-going crew arising at 0700 hours, an hour prior to termination of shift, to wash all vehicles in the station, dirty or not. The oncoming crew would, out of courtesy, arrive half an hour before shift commencement, and be ready to respond if there was an early/late call.
Station duties were assigned to each member of shift, including washing windows, taking out the garbage, vacuuming, and Kitchen Police. Whereas these duties were informal but expected at Evergreen, at Shoreline they were written in stone. During the day, if we weren’t on calls, we were expected to be busy, either studying Standard Operating Procedures, participating in fire training, or working on documenting our calls.
Though all of us had passed a King County probationary employee period at Evergreen Medic One, we were put back on probation at Shoreline for an additional year. In addition, we were expected to complete and be checked off on a book full of firefighting operations, including ladder placement, rescue procedures, hydrant operations, interior firefighting attack, and salvage and overhaul. I thought it would have made more sense for us all to complete a three-month fire academy in North Bend, Washington, but the powers that be considered the on-shift program to be a concession.
My days were transformed from relative peace and quiet in the absence of calls to the constant presence of supervisors making sure I was busy completing some task, however redundant. I felt like a janitor who was also paid to be a paramedic when the tones went off. There were a lot of what I considered to be “make-work” tasks, such as washing windows that were already spotless, and vacuuming minute specks of dirt out of already-shiny and clean medic units.
Sick Kid
I’m working Medic 65 in Shoreline and it’s the first hour of the shift. Medic 65 is staffed entirely with overtime; it’s quiet, and it’s an easy way to get twelve extra hours on my paycheck every two weeks—most of the time.
We are toned to a residence only a couple of blocks away from the station for a child in respiratory distress. The basic life support unit, Aid 65, has called for our assistance. The patient they have been dispatched to has proved too serious for them to manage on their own.
My partner, Brian, is in charge of the call and I pull up to the curb of a modest, one-story house in a residential neighborhood. Brian and I grab the kits and head in. As we approach the door, I notice a woman calmly watching us approach through the front window.
A small child of seven lies limply on the couch, his face pale, eyes closed. The aid car crew reports that his respirations are very shallow and his pulse is low.
We try to obtain more information about the events preceding the 911 call. The mother, who looks surprisingly unconcerned, states she thinks the child had a seizure, however his only history is of autism.
“I found him in the living room with a piece of cigarette in his mouth,” she says.
We open the slack jaw and look in the child’s mouth. We find no trace of a foreign object. Meanwhile, the patient’s mother decides that now would be a good time to do a load of laundry. She wanders out of the room.
Brian is, justifiably, quite worried about the child’s mental status and shallow respirations. He scoops him up in his arms and runs to the rig, the Aid 65 crew following.
As I gather up our kits to take them back to the medic unit, I attempt to confirm the mother’s story.
“He was in the bedroom. I found pills all over the floor around him.”
Quickly, I check the adjacent bedroom and, indeed, I do find pills scattered all over the carpet. I take the bottle with me and head to the medic unit.
Brian has placed the child on a non-rebreather mask and the heart monitor. He still shows no signs of consciousness and we haven’t a clue what has happened to him. The mother’s story has already changed in the very short period we were in the residence.
Suddenly, the child falls completely silent. His chest fails to rise and his oxygen saturation falls.
“He’s stopped breathing!” I say as I grab the resuscitation mask.
Because of children’s anatomy, they must be positioned differently from adults to keep their airways open. A child’s head is large, especially the back, and, if placed in a completely flat position, the head will flex forward and choke off their air supply. I place a thick towel under the limp child’s torso to compensate for his comparatively large head size.
I retrieve a device from our pediatric kit called a Broselow Tape. By placing the laminated paper chart alongside the child, I obtain a measurement that corresponds to the patient’s approximate weight and, accordingly, all the drug doses and endotracheal tube sizes I will need. It is immensely handy.
Without difficulty, I slip the endotracheal tube into the patient’s tiny airway and attach the bag-valve mask device. I check his lungs and they are clear. His oxygen saturation and his color return to normal. A crew member from Aid 65 gets up front and drives Brian, me, and the tiny patient to Children’s Hospital in Seattle, siren wailing.
We turn over patient care to the ER team and get our rig back into service for the next call.
Time to Retool
I was employed with Shoreline Fire Department eleven days short of one year, and I had come to regard my job as less of a passion and more of a necessary evil. Though I liked many, if not most, of my co-workers, I was unhappy with the uncompromising, rigid atmosphere of Shoreline Fire Department and I was pretty sure the feeling was mutual. I was of a different breed, a non-conformist refugee from the collegial world of hospital-based EMS. During that year, I had entertained notions of exploring an entirely different career altogether. I thought of continuing my education in medicine. I also considered a career in forensic investigation. All I knew was that I needed a break. The break came sooner than I had expected.
I didn’t have an especially warm relationship with my Supervising Captain, and I felt that we were two very different people who failed to understand each other. He was an excellent firefighter, a competent paramedic, and also an aggressive individual whose background completely failed to match up with mine. I, on the other hand, was a college-educated, intellectual paramedic whose emphasis was clearly on the medical side of the fire service. I clearly admitted my shortcomings when it came to mechanical ability. I never professed to be a logistical genius. I also found it frustrating to have to squeeze the time in to do firefighting exercises around an already busy day of responding to calls and performing station duties. On December 20, 2003 my career with Shoreline Fire Department ended. The day after I worked a shift, my captain asked me to come to headquarters station to review the results of my quarterly evaluation. From the moment I entered the upstairs conference room, I knew something very serious was about to occur. Seated at the oval table were the captain, the EMS battalion chief, and, in civilian attire, the chief of the department.
I was informed that I had, “failed to meet probationary requirements.” In the fire service, there need be no reason to fire an employee during a probationary period. The rules of progressive discipline do not apply. If you are deemed unsuitable by at least one influential person, your career with that department is over.
The EMS chief said, “You’re a good paramedic. You’ll be a great paramedic someday. But you don’t fit in here.”
I sat, stunned at the news, unable for a minute to reply. Finally, I said, “What recourse do I have?”
“There isn’t any recourse,” said the captain.
“Is that all you have to wear home?” the EMS chief asked, indicating my white uniform shirt and blue pants.
“Yes.”
