Silent Siren, page 20
As the Mount Vernon firefighters, Steve, and I heft Miss Waste of Oxygen onto the gurney, I break into a broad grin that lasts until the hospital. The circumstances couldn’t be much worse. I haven’t slept in twenty hours, our patient is fat and combative, and we have to drag her down a staircase on a tarp. Smiling and laughing about my circumstances beats throttling the patient or smothering her with a pillow (even though I want to).
We use restraints to secure both the woman’s arms and her legs to the stretcher and transport her to Skagit Valley Hospital.
Steve the Unintentional Punster delivers one last comedic interlude for the shift. By 0800 hours, we had still not been to bed. This has been the worst shift I have ever had on Med 2, with the calls totaling about seventeen. We get called to a local nursing home for a woman with an altered level of consciousness. She has kidney failure, atrial fibrillation, hypomagnesemia, hyperkalemia, and various other multisyllabic ailments. In EMS parlance, she is a “train wreck.”
Our hapless patient lies nearly comatose in her hospital bed at Life Care Center of Mount Vernon, gasping away at ten respirations a minute, assisted by an oxygen mask that, predictably, is set at 4 liters per minute, so low that she is rebreathing her own carbon dioxide. Her wishes are “no heroics.” This is stated as such on her Physician’s Orders for Life Sustaining Treatment, thrust in front of my nose by an edgy RN with a shrill voice and a bouffant hairdo that, for some reason, annoys me considerably.
“Her family wants her to be seen,” she says.
As we prepare to transport the old woman, I take a look at her eyes. Her pupils are extremely small, which could indicate the possibility of opiate overdose. Though the nurse assures me the patient has no narcotics on board, I’m not convinced. According to the nurse, the patient has a history of Digoxin toxicity as well as opiate toxicity.
Steve and I move the patient to the ambulance. We attach her to the heart monitor and check her blood sugar. Her arms are bloated and weeping with fluid, so IV access is next to impossible.
The blood sugar is low—59—but not so low as to explain the woman’s somnolence. Together, Steve and I make the decision to administer Narcan up the patient’s nose using the Mucosal Atomization Device.
I squeeze 2 milligrams of Narcan into the elderly woman’s nostrils, Steve gets up front and drives the mile to Skagit Valley Emergency Room. En route, the woman opens her eyes spontaneously, her pupils increase in size, and she begins to make unintelligible, though encouraging sounds like “ack” and “erf.”
Once in the emergency room, we square the gurney parallel to the hospital bed in preparation for moving our patient over. The emergency room nurse stands ready to take a report from me, her pen poised, her clipboard in hand.
We’ve piled several blankets on our patient—it’s a cold day, so we have to unwrap her some in order to release the seat belts that hold her to our gurney. It’s difficult to find all three straps and when we attempt to move the woman over, nothing happens. Undoubtedly, one of the straps is still secured around the patient, underneath the blankets.
Steve sifts through the blankets and attempts to troubleshoot. “I think I still have a strap on,” he says.
The nurse smiles slightly. “I don’t want to hear about your strap-on.”
I swear I’m twelve years old again.
Code Save
I’m working with Jeremy on Med 3. The day has been pleasant so far, though I am dreading Saturday night in a small town where there isn’t much to do but drink and get into pointless arguments. Med 3 acts as a backup to the much busier Med 2, and if they are busy, generally we are too.
The tones hit at a little after eight o’clock for chest pain at Beaver Marsh Road and McLean Road, precisely the intersection of our ambulance station. Somehow the closest calls are the most difficult to locate. The intersection is an approximation; it could be any direction and any distance from where they send us. I take off from the station without my red lights on until we have a better description.
Red and blue flashing lights flicker across the night sky from a police car located just south of the intersection. Jeremy gets on the radio to ask for a vehicle description, but I am already homing in on the traffic stop. A gray van sits on the shoulder just behind the Skagit County Sheriff’s patrol car. As we pass, I notice a man sitting on the ground, leaning against the van, his head flopped on his chest. Nobody seems too excited. An older woman and a deputy sheriff watch as we pull up.
“Aw Jesus,” says Jeremy, with obvious annoyance. “What the hell is going on here?”
I flip on my reds and Jeremy and I saunter over to the truck without our kits.
Jeremy stoops to examine the man and even in the limited light I can see that he isn’t moving. The deputy sheriff shines his light on the slumped man and I notice his face is purple. His eyes are wide open and he isn’t responding.
“Has he coded?” I ask.
Jeremy probes the thick neck for a carotid pulse. “Nothing,” he says. “Shit! Get…”
He doesn’t have time to finish the sentence and I am already running to the medic unit to grab our kits. I get on the radio as McLean Road’s rescue truck screeches to a halt. “Cascade from Med 3—full arrest. CPR in progress.” The dispatcher acknowledges and I run to the man’s side with the kits. Jeremy has started chest compressions.
“Every time I start CPR, he breathes!” says Jeremy.
I pull the bag-valve mask out of the kit. The man gasps between cycles of compressions, his chest heaving beneath his button-up plaid shirt, toothless mouth gaping.
I shake the man. “Sir! Sir!”
He stares blankly, unconsciously, uncomprehending.
“He’s in VF!” says Jeremy. He charges the defibrillator to 360 J. “Clear!”
The electricity hits; the unconscious man heaves with the shock and he emits a low groan as bubbles escape his mouth. The man’s wife crumples, sobbing. A bystander puts his arm around her.
McLean Road’s crew delivers our backboard and gurney and they load the man into Med 3, continuing to thump on his chest. As I gather my disheveled gear from the scene, I am compelled to give the man’s wife some information. “We’re taking him to Skagit. He’s got a good shot.” I say this more to convince myself than to convince her.
“He’s got a good shot,” the bystander repeats, his arm around the sobbing woman.
A female firefighter relieves me on BVM duty and I search for an IV site. I’m not having much luck. Sweat beads on my forehead and my heart beats in my throat as my attempts at entering a vein prove fruitless. I miss twice before sliding a small 20G IV into the crook of his left arm. Oxygen hisses. The medic unit smells of soot-covered firefighting gear mixed with antiseptic.
Like a fish rudely plucked from the water, the man gasps as the firefighter attempts to coordinate her resuscitation with his disorganized breathing. Frothy blood pours from his mouth. She drops the BVM and inserts a plastic suction catheter deep into the man’s throat. The on-board suction unit grumbles as bloody fluid fills the suction line and spills into a transparent canister.
The firefighter has switched out with another volunteer and is now on compression duty. I reach across her to grab an amp of epinephrine off the shelf, bumping her in the side as I go.
“Sorry about that,” I mutter.
“I don’t mind if you touch me,” she says absently.
I grin. “Well in that case…”
Laughter erupts from the gathering of rescuers, briefly breaking the tension—a much needed moment of levity in a crisis situation. I push 1 milligram of epinephrine into the IV line in an attempt to jolt the man’s heart back to life. A McLean Road firefighter slams the rig into gear and takes off for Skagit Valley Hospital, siren yelping.
Jeremy, laryngoscope clutched in his left hand, navigates his way through an airway full of blood.
“Suction,” he yells. He passes the clear plastic tube into the man’s airway as the rig careens through the streets.
A bunker-clad firefighter “stretcher-surfs” into the ER, performing one-handed CPR as we wheel through the glass double doors.
Our medical director, Don Slack, meets us at the sliding emergency room doors. After a minute or so more of CPR, Dr. Slack directs the ER team to check for a pulse.
The man’s heart is now beating and it is possible to feel a pulse in his neck, groin, and wrist. The monitor reads out a slightly elevated but fairly normal heart rhythm and a perfectly normal blood pressure. Success!
He is stable for now and we turn our attention to our trashed medic unit, bloody syringes and plastic packaging strewn across the floor, kits rifled through and thrown haphazardly on the benches. It will be a long clean-up.
We get the rest of the story from the deputy sheriff on scene. The man had been driving so badly the deputy had pulled him over, thinking he might be drunk. His wife stated that he hadn’t felt well all day long but had refused to go to the hospital. When he was pulled over, he told the officer he was attempting to make it home to La Conner. He had complained of chest pain, exited his van and fallen over dead. I knew if he hadn’t been pulled over and had made it home, he would have arrested and been dead for good.
Two weeks later, the man walks out of the hospital to the normal routine of his life, a brand-new cardioverter-defibrillator bulging through the skin of his left chest.
Off Duty
Whether I’m on the clock or not, I’m always a paramedic, 24 hours a day, 7 days a week, 365 days a year. If a medical emergency transpires in front of me, I have, at the very least, a moral obligation to lend assistance until on-duty emergency responders arrive. I think of this every time I board an airplane. What if someone has a heart attack? I can’t imagine doing CPR at 30,000 feet in the cramped aisle of an airliner, then waiting until the pilot is able to make an emergency landing. As medical personnel, we are held to a standard unlike that of any other profession—the obligation to go to work even thousands of miles away from our offices.
I am with a group of friends at a resort in the San Juan Islands. Ostensibly, I am there to relax and get away from the stress of the job. Unfortunately, on one day that weekend, work comes to meet me.
The man is boisterous and loquacious, as he and his obese wife stride onto the hot tub deck overlooking the wind-swept beach. He wears a dilapidated broad-brimmed hat, which he continues to wear even in the hot tub, and he is undoubtedly quite drunk. Both his eyes and his skin are pink, suffused with blood from the venous dilation caused by alcohol. This should have been my first clue that trouble was to follow, but I am blissfully in my own world, soaking in one of three hot tubs, gazing at the cloudy San Juan sky.
The man and his giant wife plop themselves into the middle hot tub, causing the water to rise considerably. Speaking in a thick German accent, the man strikes up a slurred conversation with a couple of my friends, who seem a bit put off that he has interrupted their soak. The man’s plump wife is silent, simply a sidekick to his larger-than-life personality.
After a few minutes in the very hot tub, the man begins to lean more heavily on his wife. It seems at first he is simply engaging in a public display of affection, but in reality, he is having difficulty keeping himself above water. He’s still talking but mumbling now. His hat is getting wet.
Abruptly, the man’s wife exits the tub and makes her way to the cold tub farthest from me. I can’t fathom why she did it, other than the fact that her fat was keeping her too warm and she needed to cool off. By her exit, the woman has deprived her husband of his flotation device, and he is left spinning helplessly in the current produced by the spa’s jets. His breath makes bubbles in the water as he attempts to suck air from the surface. Time for action and well past it.
I leap out of my hot tub and recruit a friend of mine to assist me in pulling the now-unconscious man out of the tub and onto the deck. He is deeply red in the face and snores for a minute or two as his body cools. The alcohol in his system combined with the heat from the spa caused his blood vessels to dilate, in turn causing his blood pressure to plummet, causing him to lose consciousness from lack of blood flow to his brain.
As the man slowly regains consciousness, his wife continues to display a stupendous indifference to his plight. She has exited the tub but has done very little else. Management comes by to document the incident, and finds that the man and his wife are not documented guests, and therefore, not covered by the insurance policy. They don’t seem pleased. A woman from the office asks if I would like 911 called, but now the man is up and walking, his hat firmly and wetly atop his straggly locks. I decide it would take too long for a rescue unit to arrive at the resort, and the man seems ready to leave anyway.
The man is banned from the resort for his violation of policy, but at least he left with his life. Had he and his wife been in the hot tub alone, he would have been dead, as I’m fairly certain his wife would have required a command from God Himself to lift a finger to help him.
For my troubles, I got a T-shirt that read “Orcas Island.” When I wear it, I will always remember the man whose life I saved when I was supposed to be on vacation.
The End of the Road
I learned long ago that when a patient tells you he’s going to die, he’s usually right. When I was very new to Bainbridge Island Fire Department, I remember being involved in a transport of an elderly woman who had had chest pain that had resolved before we arrived on scene. The lead paramedic at the time seems to have a sixth sense, and encouraged the woman to go to the hospital anyway. We loaded her into the medic unit and headed for the ferry boat to transport her to Virginia Mason Hospital in Seattle. As we entered the staging area of the ferry dock, the woman remarked, “I’m scared.”
“Why are you scared?” I asked.
“I don’t think I’m coming back home again.”
Nothing from the woman’s symptoms or vital signs suggested anything other than a brief episode of angina. There was no reason to believe that she had anything other than an aging heart, possibly in need of a stress test or some new medication.
“You’ll be fine,” I said. I have since learned not to placate my patients with false reassurance.
The woman was silent and the ride continued without incident.
An hour after we dropped her off at the hospital, the emergency room called back to say the woman had suddenly died. She’d never even made it up to the medical floor.
Somehow she just knew.
***
The woman is ninety years old and her daughter calls because she’s having difficulty breathing. My partner, Carl, is in charge of this call, and examines the patient, who, despite her obvious difficulty breathing, seems to have an unearthly serenity about her.
As Carl attaches the thin, aged woman to the heart monitor, I check her lungs. Fine crackles are present in the bases of her lungs, indicating thin fluid backing up from her heart. Overall, though, her lungs don’t sound bad. On the other hand, the heart monitor shows an abnormally fast and irregular heartbeat—atrial fibrillation. This may or may not explain her shortness of breath.
We load her into Med 1 with the assistance of Sedro-Woolley Fire Department. Carl explains that he is going to put more patches on her chest to take a closer look at her heart—a 12-lead EKG.
“To see if I’m going to have a heart attack?” she asks.
“Yes,” Carl replies.
“Maybe that would be best,” the woman says, without a trace of anxiety.
“Why do you say that?”
“I’ve been around a long time.” The woman pauses for a minute and looks wistful. “It’s my time.”
At thirty-five years old, I have so many plans, so many things left unfinished. At this point in my journey, death would seem a rude interruption of my mission, even frightening. I find that as people age, they become more reflective about their lives and more comfortable with the inevitable end that we will all face.
V. The Business
“We’re all just penciled in.”
- Mark Sias
Death
“You can be a king or a street sweeper, but everybody dances with the grim reaper.”—Robert Alton Harris, convicted killer, just prior to being executed.
He’s passed on, she’s gone, he’s expired—like a carton of old milk. Our society uses euphemisms to avoid using the word that nearly everybody fears, the fate that awaits us all—death. As a new EMT and thereafter, I was taught to use the word “death” and “dead” when I had occasion to break the news to a family. To use euphemisms such as “passed away” would leave some doubt in the loved ones’ minds, I was told, as to whether or not the person really had died. Directness was best. I was taught the extreme opposite when I became involved in the funeral business, maybe because the mortuary industry is much more customer service oriented, and maybe because it was so completely obvious that because we, as funeral directors were involved, someone was dead.
I learned this distinction between the languages of my two professions the hard way. When working at the mortuary removal service, I completed a residential call, representing Bonney-Watson funeral home. We were removing the body of an elderly man who had died peacefully in bed in the back hallway of his house.
Before we had moved him to our stretcher, I needed some information for the form I was to bring back to Bonney-Watson. I asked the new widow, “What time did he die today?” It seemed an innocuous question, and a necessary one.
The next day, I was informed by a supervisor that both the family and Bonney-Watson funeral home had complained that I had used the word “die.”
Likewise, on our emergency radios in the ambulance, the subject of death is cleverly disguised, some might say avoided. In Tacoma, where I worked at Rural-Metro, calls to confirm death were dispatched as “signals,” i.e. signal 2 or signal 3. At Skagit County Medic One, we are dispatched to a “possible unattended,” whether someone had witnessed the death occurring or not. Kitsap County Cen-Com for many years used the term “full arrest” to denote not only someone who had suddenly collapsed, breathless, and pulseless, but also someone who had been found cold and stiff after hours to days of lifelessness. A Skagit County paramedic I work with informs me that dispatch in New Hampshire, where she used to work, used the term “possible untimely” to dispatch a death call. Ironically, most of these deaths were indeed timely—the ninety-five-year-old woman who doesn’t wake up one morning, the eighty-two-year-old man who slumps dead over his morning coffee.
