Silent Siren, page 16
Any number of scenarios could have transpired. With the woman’s weight, she could have suffered an arrhythmia or thrombosis to the heart. She could have also had a seizure and drowned in the bathtub. Either way, pulseless was pulseless—treated the same way.
Three minutes have elapsed and I again turn my attention to the monitor as the firefighter on compressions wipes sweat off his brow, rises and stands, stretching. The monitor shows faint blips where there had been none before and that then began to quicken. Better than we had before. “Check pulses,” I say, and we immediately begin rooting for the telltale signs of life in the arteries of her neck and groin.
“I’ve got a pulse,” Danny says. “I’ll get the backboard.”
A middle-aged woman has entered the fray and now sits in a chair a few feet away, tears streaming down her face. An older woman, maybe a neighbor, comforts her with a hand on the shoulder.
I introduce myself. “How are you related to the patient?” I ask.
“She’s my sister!” the woman cries.
“Your sister is very gravely ill,” I explain. “I don’t know how long she went without air. Her heart is beating but she is still unconscious and we are breathing for her. We will take her to Skagit Valley Hospital.”
The woman nods.
The backboard arrives and we roll our patient onto it, being careful not to dislodge the myriad of tubes, wires, and needles festooned in, on, and through our corpulent patient. We pull a sheet up to her chest and then grunt in unison as we heft her to the wheeled gurney for the trip to the ambulance.
Danny is grabbing gear, wishing he had more than two hands. He glances at the monitor: “V-tach. You want to shock it?” The monitor shows a rapid saw-tooth pattern obliterating any chance of a normal heartbeat.
“Yep,” I say. I hit the “charge” button on the monitor and the capacitors whine as they ramp up to 360 Joules of energy. “Clear!” I shout.
The woman at the table sobs. I hit the “shock” button.
Her body jerks upwards and her arms flail slightly. She is back in a perfusing rhythm with a pulse.
Danny injects 100 milligrams of Lidocaine into the IV medication port. Related to the Novacaine given in dental offices, it will calm an irritable heart and help prevent her from going back into a lethal heart rhythm. We load her into the idling ambulance.
The ride to Skagit Valley Hospital is brief and nauseating for its bumps and rapid turns. I call Dr. Lopez at Skagit:
“Med 2 en route with a seventy-six-year-old female patient found down in a bathtub, unconscious and unresponsive. Unknown down time. Pulseless on arrival. Initial rhythm asystole. We’ve given 2 mg epinephrine, 1 mg atropine, shocked her once. She’s back in a perfusing rhythm at 130. No pressure yet. Intubated with good breath signs bilaterally. ETA’s five minutes.”
The rhythm on the monitor becomes disorganized again— jagged chaotic peaks and valleys where there had been a steady rhythm. She’s back in ventricular fibrillation. I shock her again. This time she does not respond favorably. Her heart has once again stopped beating. We resume CPR.
Med 2 arrives at Skagit with ongoing CPR. We are met by Dr. Lopez who asks, “What happened between the time you called me and now?”
“Just arrested again,” I say, stating the obvious.
We turn over patient care to the code team and now comes the monumental task of printing out a code summary from the heart monitor—the entire resuscitation from start to finish, every time, every intervention we did and when. I will be bogged in paperwork for a while.
The woman stabilizes in the ER and is admitted to the ICU. We don’t have much time to wait and see what her outcome is because we are tapped out on another call.
Mushroom
I’m working with Jay, one of Central Valley Ambulance’s more senior medics and quite an entertaining fellow. Tall, with a white mustache that contrasts with his salt and pepper hair, Jay is known for singing to his patients and for helping himself to cookies he finds in patient’s kitchens. Thoroughly at home with his job, he is confident and philosophical in dire emergencies. His name tag reads “Jay Fallihee, RN, EMT-P.” He had qualified as an RN years ago but chose to work as a paramedic instead.
We are called to the tiny fire district of Hickson-Prairie for respiratory distress in a lung cancer patient. To this day, I am unable to hear them toned out without laughing. Some time ago, one of our paramedics was toned to respond to a call in Hickson-Prairie after a night of very little sleep on Med 1. He picked up the microphone and asked the dispatcher for the address in “Prickson-Hairy.”
A poorly maintained dirt driveway leads to a double-wide mobile home. A car parked outside is emblazoned with “In Loving Memory of Brandy Jackson” or some such name on its back window. I try not to be prejudiced, but such a decal is a dead giveaway to one’s social class. It tends to go along with mullet haircuts, wife-beater T-shirts, and “Singing Bass” plaques.
The patient sits on an overstuffed couch, pale and thin, breathing compressed oxygen from the portable tank by his side. He is in his sixties but looks much older. A child who appears to be about twelve sits nearby, seemingly oblivious to the sudden influx of strangers entering his residence. An old woman sits in a far corner of the kitchen. She does not make eye contact.
I ask the usual questions: “How long have you had trouble breathing? Have you been coughing up any sputum? Do you have pain or discomfort?”
I try to get a more accurate feel for the patient’s prognosis: “What kind of cancer do you have?”
The man seems irritated, tired of my questions. “I don’t know. I’m like a mushroom. They keep me in the dark and feed me shit.”
This would be a good time, I think, to abort my line of questioning and instead prepare the man for transport to the hospital. As the volunteer firefighters and I load him onto the gurney, the old woman, her speech slurred, begins hollering from the kitchen. Her speech is unintelligible, but she is angry about something. Also, she seems to be drunk.
“Shut up, Grandma!” says a younger woman, who seems to be the family spokesman. “Grandpa’s sick and he needs to go to the hospital!”
While we’re en route the hospital, the man tells me he would have had his granddaughter take him in, rather than the ambulance, but that, “He just won’t put up with her drinkin’.” He seems calmer once separated from his dysfunctional family.
Jay and I transfer care at United General and place clean linen on our stretcher.
“I wanted to get the heck out of there,” I said. “As soon as he made that mushroom comment, I realized I’d asked enough questions.”
Jay smiles in a way that conveys both humor and superior experience. “I think you realized that a bit late.”
Darryl the Nearly Indestructible
It’s evening and I’m working Med I in Sedro-Woolley with Christina Heim. We’re having a good shift; it’s pretty slow and I enjoy chatting with Christina. She’s one of the younger medics, very pleasant and fun to work with.
We get called to Burton Care Center of Sedro-Woolley for respiratory distress, low oxygen saturation, labored breathing, poor color, the works. It seems like everybody that comes out of that place is in extremis by the time we get there.
The story is always the same when we get to nursing homes. The only differences are the various inflections and accents. We start our questions out open-ended: “What’s going on?”
“I don’t know. I’ll get the nurse.”
“How long has he been like this?”
“I don’t know. I just came on shift.”
“What can you tell me about his medical conditions?”
“I don’t know. He’s only been here twenty-four hours.”
Then they disappear, leaving us to baffle through the examination with a non-communicative or demented patient.
We pull up to the back of the building, where they like us to move our stretchers in and out. Nobody likes to see a dying patient parading through the dining room and out the front door. Very bad for business. Christina backs the rig a few feet away from the glass doors. In an adjacent smoking alcove, an old man sits in the dark, huddled in a wheelchair, attached to nasal oxygen, smoking a cigarette. He seems oblivious to our presence.
We grab the med box and Lifepak and place them on the stretcher. We wheel in our lifesaving equipment and ask the first nurse we see: “What room is he in?”
“He’s outside in the smoking shelter,” she says.
Christina and I are dumbfounded. “You’ve got to be kidding me,” I say. “Does he know you called us?”
“Oh yes,” she says.
We reverse the process and head back towards the rig, our gear in tow. The man in the smoking shelter glances at us but doesn’t acknowledge our presence otherwise.
Christina says, “Sir, you’re going to have to put that cigarette out before you get in the ambulance.”
He harrumphs in an annoyed way and stubs the cigarette in an ashtray. I open the side door of the ambulance and the light catches him. “You look familiar,” I say. “What is your name?”
“Darryl,” he replies, puffing as he struggles to rise from his wheelchair.
I know this guy, I realize. This is Darryl the Nearly Indestructible. The first time I saw him as a patient, he was at a bar in Burlington. He had passed out, fallen off a bar stool, and was complaining of chest pain. He looked like hell and his blood pressure was unobtainable. Burlington Fire Aid 619 had him on a non-rebreather oxygen mask. Sweat poured from his pallid forehead, creating a ring on his cowboy hat. I suspected it was a heart problem. As I put him on the heart monitor, he had ripped off the oxygen mask and attempted to light a cigarette.
“You can’t smoke. There’s oxygen here and you could blow yourself up,” I had said.
Darryl had been recalcitrant and attempted to leave. He began to peel the EKG patches of his chest.
“Your blood pressure is too low. We need to take you to the hospital.”
Finally, reluctantly, he had acceded. His cardiac tracing was awful, full of premature ventricular contractions. He told me his medical history—depression, five heart attacks, multiple cardiac stents, high blood pressure, lung cancer with one lung removed. I wondered if he would make it through this episode. I had started a large bore IV on him and squeezed a liter of fluid into him by the time we arrived at Skagit. I was unable to treat his chest pain because his blood pressure was too low.
Months later, I had seen him at his apartment in Mount Vernon. He had called the crisis line and said he had taken some pills during an episode of deep depression. We had followed the oxygen tubing to wear Darryl sat, surrounded by his own toxic atmosphere of cigarette smoke, on his couch.
So here he is again. The lung cancer is back and he’s lost twenty pounds since I’ve last seen him. He climbs into the back of the ambulance and the exertion of walking just a few steps thoroughly exhausts him. Sweat beads up on his pasty face. He begins to wheeze audibly.
I prepare a nebulizer for Darryl and slip the steaming mask over his face. A double dose of Albuterol should help widen his airways and make it easier for him to breathe.
I call United General and tell him who we are bringing. Over the phone the nurse sighs and says, “Yeah. We know him.” By the time we hit the ER doors, Darryl is breathing better. Some of his color is coming back. He’s not out of the woods yet but he is responding to treatment.
“You’re a tough son-of-a-gun,” I say as we wheel him in.
He grins slightly. Darryl the Nearly Indestructible lives to fight another day.
The next morning, I leave work and drive the two hours back to my home on Bainbridge Island. I don’t mind the commute; it is only two days a week. I change out of my uniform, stained and itchy from the previous shift, and into a T-shirt and sweatpants. And then I run. I run not only for health but because I can and so many of the patients I see cannot. Whether by bad luck, sedentary lifestyle, or accident, so many of the patients I see at work can’t cross a room without becoming short of breath. I feel blessed to be able to breathe without difficulty or pain, to be able to appreciate the natural beauty around me. The job teaches you to appreciate what you have and to live in the moment. In life, there are no guarantees.
One Confirmed
It’s a beautiful late summer day, and Clara and Leonard Fullerton are out for a drive. They had taken the grandkids out to a park and had just dropped them back off with their parents. In their ancient boat of a car, they had been on their way to the pharmacy to refill Clara’s heart medication. Neither is in excellent health, but, even at eighty, Leonard still insists on driving, though his reflexes and eyesight aren’t what they used to be.
At a four-way intersection off Highway 20 in Sedro-Woolley, Leonard pulls out in front of a mini-van driving at fifty miles per hour. The last thing he sees is a panicked look on the face of a young mother as she attempts to overcome inertia and bring her van to a halt. Metal curls and glass shatters.
David Lacy and I are on Med 4 that day in Burlington. The tones hit first at Med 1. Dispatch advises Med 1 of the possibility of multiple victims, so Med 1’s paramedic, Danny Weibling, requests our presence at the scene as well.
As David and I make our turn from Spruce Street onto Highway 20, siren blaring, air horn blasting, dispatch updates us: “Two patients unconscious, possibly one confirmed.”
One confirmed. Death is the last taboo, still referred to by euphemisms and half-truths such as “confirmed.” Confirmed what? I want to say. Confirmed dead is what the dispatcher means. This makes even less sense because nobody is on scene to confirm it, no police officers, no volunteer firefighters, nobody in an official capacity. Somebody on a cell phone has peered into the vehicle and said, “I think this guy is dead.” I’m reminded of how years ago, human reproduction was referred to euphemistically: “in a family way” or “expecting.”
We pull up to the intersection to find an old sedan on its top in the northwest corner of the intersection. Glass is blown out in all directions and it crunches under our boots as we approach. The vehicle has rolled over at least once, because centrifugal force has thrown its many unsecured contents twenty yards to the east and west through destroyed windows. Orange pill bottles litter the pavement. Crushed CDs lie scattered in the gravel. A walker lies twisted in the ditch. I detect the vaguely sweet odor of antifreeze.
Med 1 idles parallel to the wrecked car. Danny is on his hands and knees, peering into the inverted remains of the patient compartment. Sedro-Woolley Aid 5519 is parked several feet past the wreck. Firefighters busy themselves grabbing head rolls, c-collars, and a backboard.
As I approach, I hear Danny speaking to somebody inside the vehicle. She is responding, but her husband is not. From my vantage point, I can see a man whose upper body lies on the car’s ceiling and whose lower body is tangled between the dash and front seat. His skull looks like a watermelon smashed with a mallet by the prop comic Gallagher. Part of the left side of his head is missing, as is some of his brain.
“Watch your step,” says Danny. A pink chunk of brain tissue lies in the gravel in front of my boots. Danny scoops it up with a piece of plastic as though it were a dog turd and moves it out of the way.
“I need somebody to get in the car to help me move this lady out,” Danny says.
Since I seem to be the only paramedic wearing bunker gear as well as the smallest, I volunteer to weasel my way into the wreckage.
The elderly woman lies prone in the car, moaning, her dead husband resting partially on top of her. Judging simply by mechanism of injury and the woman’s advanced age, death of occupant of the same vehicle, high energy transfer, and assumed poor health of the patient, she undoubtedly had some serious injuries. I slip a c-collar awkwardly around her neck, move her husband’s inert corpse to the side, and gently slide her out of the vehicle with Danny on the outside, holding the backboard.
David Zoeller and Danny load her into the back of the rig, starting large bore IVs and attaching the heart monitor. Though they are as yet unable to find any life-threatening injuries with her, she will be a full trauma alert at Skagit Valley Hospital due to mechanism of injury. They tear off in a cloud of dust, siren wailing.
A Skagit County Sheriff’s deputy arrives on scene. Noting the inert man still unattended in the vehicle and the pink chunk of brain tissue now covered with dirt, he keys his shoulder microphone: “One confirmed on scene.” Ah, there’s that word again. That tidy euphemism.
David and I make our way back to our rig and we can see that a half-block away, the BLS crew is attending to the other people involved in the collision—the van driver and her small children. Nobody seems very hurt, though, and our medical director, Dr. Don Slack, is filling out non-transport paperwork.
There is a commotion from just past the intersection. Two stocky, brown-skinned men sprint towards the wrecked vehicle. Like the two accident victims, they are Native American and I can tell from the distress on their faces that they are family members who have just come across the wreckage.
The deputy sheriff and I step out in front of the men, forming a human barricade. We don’t want them to view their relative in his current condition.
“That’s my father, man!” shouts one of the men. The deputy gently restrains him.
“Your father has passed away,” says the deputy.
The man balls his hands into fists and then relaxes, his eyes rimmed with tears. He sinks to the ground like a deflated balloon, kneeling in the dirt, his forearms covering his face. There’s nothing I can say, nothing the deputy can say, that will even come close to assuaging his pain.
The living patient whisked away to the hospital, the dead one awaiting the coroner, one still remains, and there is nothing we can do for him but to say, “I’m so sorry,” and stand silently, bearing witness, and being present.
Two Humans
I’d like to think I have matured as a medic, not only in my mastery of clinical skills, but also in my approach to sick people at the most vulnerable times in their lives. Our approach to patients is carefully thought out, from our uniforms to our professional demeanor. I wear a short-sleeved white uniform shirt with a Skagit County Medic One patch on one shoulder and a Washington State EMT-Paramedic patch on the other. The color white subtly conveys cleanliness. It is the color of medicine and of healing. I wear my name patch on my left chest. It is in military fashion, with the emphasis on the last name—M. Sias, paramedic. My uniform pants are navy blue, with cargo pockets on both thighs for scissors, pens, penlights, gloves, flip charts for medications, and sundry other tools of the trade. Blue looks professional without being intimidating and hides the inevitable dirt and blood stains accumulated throughout a twenty-four-hour tour of duty. My boots are black, with steel toes and shanks. Dropping equipment or stretcher wheels on an unprotected foot can be quite painful. Dusty and chewed up at the toes, they should be polished more.
