Silent Siren, page 15
The final stage before a formal job offer was an interview with Bill Holstein, Operations Manager for Central Skagit Medic One. I was completely honest in explaining my troubles with Shoreline Fire Department. Bill, I felt, understood, and could see a great paramedic beneath a bad resume. So thanks, Bill, for taking a chance on a guy with a less-than-stellar history.
I was hired January 1, 2007. I was a paramedic again.
A public agency administered by a board of commissioners, Central Skagit Medic One served a largely rural area and many small, mostly volunteer, departments. Although our response times could be very short within the city limits of two or three of the communities we served, we at times were called upon to respond to rural and wilderness emergencies forty-five minutes away with lights and sirens. If the patients were acutely ill, it could take all of our armamentaria of skills, medications, and devices, to keep that person alive for nearly an hour transport to a hospital.
A Substantial Woman
The tones chirp “right out of the chute,” first thing in the morning, for a sixty-year-old female patient in respiratory distress. Brad guns Sedro-Woolley’s Med 1 through the mostly deserted suburban streets while attempting to slurp freshly brewed coffee from the mug he balances precariously against the steering wheel. This proves to be a challenge as he maneuvers the rig around multiple ninety-degree corners to the modest, tree-lined house where our patient resides.
As we walk into the single-family residence and into a cluttered kitchen, I know immediately we have a big problem. Seated in a straight-back chair and leaning forward to breathe is one of the most enormous human beings I have ever seen. She is clearly a card-carrying member of the Clean Your Plate Club. Her ragged T-shirt is tight and conforms to every fat roll, so much so that she appears not so much to be dressed, but rather upholstered.
Her ponderous belly covers both thighs making it impossible for her to move her legs together. Instead, she adopts a froglike squatting posture. It is obvious from the color of her skin— mottled, beginning to turn purple—that she is getting very little oxygen. Having seen so many obese people in my career, I’ve become quite good at estimating weight, and I figure this woman tips the scale at around five hundred and fifty.
An older Hispanic woman, quite obese herself, stands and watches us work with fear in her eyes. She is unable to answer our questions and neither is the patient, whose breath comes in short gasps.
“Don’t let me die!” she heaves, sucking mightily on the nonrebreather mask the fire department has placed on her.
I put my stethoscope in my ears and listen to her lungs as she struggles. Fine crackling sounds known as rales are present in both lungs and in all fields. This indicates the presence of thin fluid backing up from a struggling heart into her lungs—flash pulmonary edema, as it is known, and she is full of it.
A firefighter wraps a blood pressure cuff around her forearm. Her upper arm is way too large to accommodate even our largest blood pressure cuff. “It’s going all the way up to three hundred,” he says. Her blood pressure is literally off the chart. Her laboring heart is faltering with a pressure it can’t pump against.
I am faced with a conundrum—treat in place or try, somehow, to get her to our gurney and out the door. If I try to treat her in place, I risk my treatment not working and her going into respiratory arrest in her chair. She would be physically impossible to lift. If I choose the “load and go” approach, even the slightest movement could overwhelm her weakened heart and tip her over the edge. She is already in extremis. Some have compared moving a bad CHF’er to shaking a snow globe. The fragile homeostasis she barely maintains would be upset and she would die.
I look at Brad and think out loud, “She needs a tube!” Easier said than done. What she needs and what is physically possible are two very different things in this case. In order to intubate her, I would need to paralyze her, taking away her respiratory drive, causing her to slump over in her straight-backed chair. How could I position her to pass the tube? Could I lean her back or not? Which way would she fall? We choose to stem the tide of fulminant pulmonary edema with the mainstays of CHF treatment—Lasix and nitroglycerine.
By some miracle, Brad is able to locate a vein in the meaty forearm and slide in the tiniest catheter. We have venous access, through which we could administer the diuretic Lasix. Within twenty minutes, her kidneys would excrete through urine some of the excessive fluid choking her heart and lungs. I give her 80 milligrams—just to start. I spray the venous dilator nitroglycerine under the woman’s tongue. It will allow for more blood to flow to her oxygen-starved heart as well as lower her astronomically high blood pressure.
I grab the portable phone and contact the emergency room physician at United General Hospital to apprise him of our patient. Brad continues to administer nitroglycerine while the firefighters, who have now called for additional man-power prepare the much-too-small gurney. If we can just get her loaded on the gurney before she arrests.
A battalion chief and volunteer firefighter struggle to assist the dying woman to our gurney. It is not going well. As lack of oxygen dims her consciousness, she begins slowly to slump forward onto the table in front of her and lose muscular control. We are losing the battle but now have no choice but to get her loaded onto our gurney. No amount of oxygen, nitroglycerine, or Lasix will do her any good.
The battalion chief brings in a large tarp with multiple handles. “We’re going to need to use this,” he says. “We can’t fit the gurney in here.”
“She’ll die if we lay her down. She needs to be bolt upright,” I say, sweat beginning to form on my brow, even though it is early fall.
I realize within seconds the battalion chief is right. There truly is no way.
In a few inelegant moves, several firefighters and I flop five hundred and fifty pounds of humanity onto the tarp and drag her as fast as we can to the living room and the waiting gurney. I scrabble for our monitor, med box, and vent kit and run after them.
Brad yells from a few feet away, “She’s not breathing!” and a few seconds later, “She’s coded!”
The elderly Hispanic woman, who I have now decided is the patient’s sister, wails as we begin CPR, injecting adrenaline, sodium bicarbonate, and atropine into our one IV line. She sinks into a chair, her face in her hands. I thank God we at least established a medication route before her heart had stopped beating. A smaller man, weighing in at only about two hundred and fifty pounds, rushes through the door and puts his arm around the elderly woman as she sobs.
The resuscitation continues as, with great difficulty and with much help, we transport our patient to United General Hospital. A volunteer firefighter, clad in firefighting pants and suspenders, sweat dripping from his forehead, performs chest compressions, each one generating a rippling wave through the woman’s massive abdomen. Brad and I continue to defibrillate and administer medications as a firefighter drives, twiddling the siren between wail and yelp as we careen through downtown Sedro-Woolley, the powerful air horn blasting traffic out of our way at intersections.
The ER staff awaits us expectantly as the exhausted volunteer performs “stretcher-surfing”—CPR while riding the side rail of the gurney. We choose to keep her on our gurney for the duration of the resuscitation; it would have been too difficult to move her over.
An emergency room technician finds a stool to give him the proper height and takes over aggressive chest compressions. The doctor stands in the corner of the room, a conductor with his symphony, directing drugs to be administered and pulses to be checked.
I take a turn on compressions and then step back, exhausted. I happen to look down at my blue uniform pants, which have some unidentifiable white powder all over the front of them. Looking around at some of the other crew, I notice a similar pattern on their pants. Then I notice that every time the tech compresses the woman’s chest, her abdominal fat jiggles, releasing tiny puffs of powder from between the fat folds. The woman has applied baby powder to her fat folds to prevent chafing and it is creating a slight haze in the resuscitation room, getting all over the code team.
As the tech thumps his hands rhythmically between the woman’s watermelon-size breasts, he is moving her slowly in the direction opposite him. Her ponderous belly begins to shift with each compression, listing to port. She is about to tip the whole gurney over with the weight of her belly. At the last possible minute before the stretcher upends itself with five hundred and fifty pounds of obese flesh, two red-faced nurses and I rush to push her belly back to starboard and prevent injury to everyone involved.
After some defibrillation, the doctor looks disinterested, leaving the room a couple of times. He wanders back in briefly, calls out orders for the wrong drugs, then wanders out again. In short order, the resuscitation is over. The woman is dead.
I leave the room as the curtain is pulled around the stretcher. As I begin to write my report I can hear the sound of crying from inside the room. The man and the elderly woman are now in there with the body, saying goodbye.
They emerge a few minutes later. Red-eyed and looking exhausted, the old woman hugs me. “You did everything you could,” she says, speaking in a thick accent. “I know. I watched you work.”
“I’m sorry for your loss,” I say, an automatic response but genuine at the same time.
“She should have gone to the doctor a week ago when she had trouble breathing,” she says. The man stands nearby, his arms folding, trying to be strong.
They walk off, holding each other.
Fly Paper
My partner, Art, and I are called to a residence in Sedro-Woolley in the early hours of the morning for respiratory distress in an elderly male. The address is familiar—a patient with a history of congestive heart failure lives there.
The trailer is dimly lit and extremely disheveled. An oxygen tank hums to itself in the corner of the front room, clear plastic tubing extending out from it down a darkened hallway. Using my brilliant deductive skills, I surmise that the other end must be connected to our patient. I trace the tubing down the hallway and encounter a man who sits in the semi-darkness in a wheelchair, struggling to breathe, a nasal cannula, yellowing with age, hissing oxygen into his nose. The man leans forward to breathe, a sign of air hunger. Fly paper with a few winged victims dangles precariously above the man’s head. I am careful to avoid this obstacle as I check the man’s lung sounds.
His lungs exhibit the fine crackling sounds known as rales, indicating fluid infiltrating the lungs from a failing heart. He wheezes as he exhales. Art assembles a nebulizer to deliver the atomized medication Albuterol deeply into his lungs.
The man inhales deeply on the “peace pipe” and fine mist infiltrates his air passages, opening the small bronchi and easing his distress. I notice that his eyes are level with Art’s crotch. The man manages a wheezing laugh. In his hurry to get dressed and out the door, Art has forgotten to fasten his zipper.
I consider laughter to be a good sign, almost like an extra vital sign—Airway, Breathing, Circulation, Mental status, Humor. If all these are intact, your patient stands a good chance of making it through his ordeal.
Embarrassed, Art zips up and then exits to bring in the stretcher. We will continue our treatment in the ambulance.
Once in the medic unit, Art slips a 20G IV catheter into the crook of the man’s right arm, attaches the administration set, and then pushes 80 milligrams of the diuretic Lasix. I squirt nitroglycerine under the man’s tongue, and within a couple of minutes, his breathing eases. We drive five minutes down the road to United General Hospital and turn over patient care to the ER nurse.
The man’s wife arrives. Upon seeing her, our patient’s eyes well up with tears. He reaches out to her and they embrace.
“I thought this was the end,” he sobs. They hold one another and cry together, grateful to be given more time.
Cardiac Arrest
Rain pounds the windshield of Med 2 as it hurtles towards its destination. Blinking strobes reflect off the foul weather, creating a kaleidoscopic vision of urgency in red and white flashes. We have no idea what we will find when we arrive, only that it is an ALS response, meaning that dispatch has determined that the highest level of medical care is needed on scene. It is the seventh call in eight hours, and all I can think about is how late we are for dinner.
The residence is small, much like the others on the block, with an uninspiring front lawn, and a screen door ajar. I think of how often we arrive to find the front door wide open, even in the middle of winter—usually a sign of something terribly wrong.
A short, squat man stands on the sidewalk, terror in his eyes, pointing towards the residence. When I ask him what’s wrong, he gives me a blank look. He mutters something in Spanish. I look at my partner, Danny, and say, “Bring the airway bag. I don’t know what we have.”
Grabbing the heavy medication box and heart monitor/defibrillator, I jog towards the open door, Danny close behind. I hear the yelping siren of the fire engine approaching and the distinctive sound of Jake brakes as it slows to a stop on the curb.
Inside, I am met by another man, old, thin, and fragile-appearing. He appears lost. Dementia? He gestures to the bathroom where the problem becomes immediately obvious.
Lying facedown in a tub full of water is the naked and inert body of a very large woman. Approaching the tub and noting the characteristic purple tinge of cyanosis to the woman’s face, I turn to Danny, closely followed by the engine crew and yell, “This is a code! Call for manpower.”
As Danny calls for reinforcements, a firefighter and I grunt and grasp as we attempt to free three hundred and fifty pounds of slippery humanity from her soggy porcelain enclosure. The Mount Vernon Engine Captain, glasses askew and face red, joins in this fray, which would have been comical had a life not been at stake. Each of us grabs a limb and, by some miracle, we are able to extricate the woman and slide her along the cheap bathroom tiling to the hallway and then into the living room, where we begin resuscitation.
As is invariably the case, the first thirty seconds or so of the resuscitation are pure chaos, filled with staccato orders, the hissing of leaking oxygen, the clanging of an oxygen key against a tank, and the beeping of the defibrillator being readied for action. I unzip the airway bag and reach for the bundle that contains our laryngoscope.
The woman’s upper chest and face are deeply purple and her eyes, half-open, gaze at nothing. Her neck is short—almost non-existent, and I do not relish the task of passing a tube into her trachea, which I know will be difficult. Danny prepares a site on her arm for an IV and the firefighters begin CPR. Defibrillator patches and electrodes are slapped to the woman’s massive chest as it is simultaneously compressed by two hundred pounds of adrenaline-laden firefighter. The cardiac monitor shows only the rhythmic electrical depolarization created by external compressions. During a pause in CPR, there is nothing—a straight line.
Snapping the lighted blade on the laryngoscope handle, I pray for success, hunker down, and open the slack jaw. “Suction!” I say as I guide the long spade-like blade past the woman’s teeth and into a morass of tongue, vomit, and unidentifiable soft tissue. A fire medic pushes the button on the portable electric suction unit and it groans to life, sounding not unlike a diesel pickup at idle.
With my visual field somewhat cleared, I can just make out the tip of the woman’s epiglottis, the valve that covers her windpipe. It is not enough to be able to pass the tube, however, and I request assistance from one of the firefighters.
“Cricoid pressure please,” I say, and Danny obligingly puts two fingers on the woman’s larynx and pushes firmly downwards. I am surprised he can find it. The fleshy epiglottis moves slightly anterior and I can just barely see the opening for which I am aiming. Scope in one hand and tube in the other, I pass the plastic tube past her teeth and into her throat. At the last second, the end of the tube obscures my vision and I have to hope it went in the right place.
On cue, the firefighter to my right snaps the mask off the bag-valve mask apparatus and secures it to the end of the tube.
“Bag,” I repeat several times as I pass my stethoscope over the patient’s corpulent belly and chest. Clear on the right, diminished on the left, no epigastric sounds. I pull the tube back slightly and re-assess. I’m in. It’s a good tube. I attach the in-line CO2 monitor between the tube and bag-valve mask and attach the other end to the heart monitor. Her CO2 reading is 60. It should be around 35. The firefighter squeezes the bag harder.
Danny slams 1 milligram of epinephrine and 1 milligram of atropine into the IV line. It’s the shotgun approach to cardiac arrest. Epinephrine causes the peripheral blood vessels to constrict, shunting blood to vital organs and hopefully creating a spontaneous heartbeat. Atropine “takes the brakes off” the system; its effects negate nerve impulses that can slow the heart down. Two minutes pass.
“Stop CPR,” I order.
The firefighter, face red and sweat dripping down the end of his nose, leans back, relieved to have a rest. The monitor shows a perfectly straight line—no heart activity.
“Asystole,” I say. “Resume CPR.” Another milligram of epinephrine is pushed through the IV port.
Police have now arrived. One officer ushers the family into an adjacent room to question them on the circumstances of the woman’s collapse. Another shines his flashlight onto the dimly lit scene.
The other officer emerges from the kitchen where she had been conferring with the family. She is short but somehow intimidating, her hand seemingly permanently affixed to the holster clasp of the service weapon on her right hip. “Family says she’s an epileptic and she’s got high blood pressure. Said she went into the bathroom ten minutes before the call, they heard a gurgling sound, and found her like this,” she says, indicating the inert body on the damp living room floor.
