Silent Siren, page 7
Even as a full-time employee at American Medical Response, I lived and worked at the Bainbridge Island Fire Department. I was a resident firefighter and “pulled shift” every third night. It was typical for me to be up on responses at Bainbridge fire two or three times a night and then go to work at AMR in Seattle, pulling a twelve-hour shift.
I look at pictures of myself from back then, and I looked positively awful. One hundred and thirty pounds, pale, and with dark circles under my eyes; I was overdoing it and needed a change of scene. On occasion I would wake up to the tones at the fire station and confuse them with my alarm clock. I would put on my AMR uniform and stand, bewildered, in the middle of my room as the aid vehicles left without me.
I’m Worried
For several months at AMR, my permanent partner was Mike Bailey. He and I had graduated high school together and had served together as Bainbridge Fire Explorers. His ambition, like the ambitions of so many others at Shepard, was to be a full-time firefighter. We worked well together; I did most of the patient care and he did most of the driving. I always considered him to have a better sense of direction than me and I had a stronger stomach, so the arrangement worked out well. Mike couldn’t stand vomit, or, for that matter, any bodily secretions we so often encounter in EMS. Twice in the months I worked with him, a patient vomited, triggering him to vomit as well, once in an emergency room (while a patient in another room laughed at him), and once on a newly shampooed rug. We worked nights together for a time, though Mike had to transfer off the shift because he kept falling asleep at green lights. Night shift isn’t for everyone.
Mike and I get the call to respond to the north end of Seattle for a person unconscious at a nursing home. Mike hits the lights and sirens and we scream off on Interstate 5. A further radio report states it’s a ninety-nine-year-old woman with a possible head injury. Another AMR unit had just dropped her off from the hospital and now, for some reason, the doctor wants her to go back.
Ah, nursing homes. What a pleasant ambience of overheated feces and urine!
Helen lies sheet-white and motionless in a hospital bed, the pillow beneath her head maroon with blood. A heavyset black nurse and a tiny Asian nursing assistant stand by her side. She had fallen some time the previous night, we were informed, was transported to the hospital for sutures, and had just been dropped back off by an ambulance crew who had remarked rather casually that they couldn’t measure the patient’s blood pressure or pulse.
Never mind those pesky details. She had Do Not Resuscitate paperwork and had requested that if her heart were to stop, she would be allowed to go peacefully, without heroics.
I place two fingers on her neck and feel for a carotid pulse. It’s present, but slow, about 40 beats a minute. She gasps an agonal breath about six times a minute. Her pupils are fixed and dilated. She has no obtainable blood pressure.
“I don’t think I can do anything for her,” I say to the nurse. “She will probably die as soon as I move her to my stretcher.”
“I know,” replies the nurse. “The doctor wants her transported.” She shrugs as if to say, “It’s out of my hands.”
I place a non-rebreather oxygen mask on the woman’s face. It’s more of gesture than a therapy in this case, but at least I can say I’ve done something. Mike and I and the nursing team use a sheet to transfer the woman to our stretcher. As we lay her down, I realize she’s stopped breathing.
“Is she breathing?” asks the timid nursing assistant.
I wait for what seems like an eternity and the woman resumes her gasping respiratory pattern. “Well…yes. If you can call it that,” I reply.
The nursing assistant begins to cry. Maybe my comment was a little insensitive.
Mike and I wheel our nearly-dead patient out to the ambulance. It is an exercise in futility and I have to wonder if the nursing home is simply trying to improve their statistics by whisking away those who are about to die, so they don’t have to do the documentation.
We load her into our rig and I make one last check before Mike drives us to the hospital on our pointless mission. Helen has once again stopped breathing. I check a pulse and then place my stethoscope on her chest. Nothing. Her half-open eyes stare through the ceiling of the ambulance and past the clouds above, into the multiverse, a focal distance of infinity.
Mike gapes at me from the back of the ambulance. “Don’t tell me…” he says.
“Yep. She’s dead.” I turn off the oxygen and remove the mask from her face.
“What do we do?”
“I don’t know.”
“Do you want to just drive her to the hospital?”
“No,” I say. “They won’t accept her there.”
If we drive her to the funeral home, they’ll want to get the medical examiner involved. Either way, we’re stuck with a dead body in our rig for who knows how long.
“Let’s call dispatch,” Mike says.
I phone dispatch. They are incredulous. “She DIED?!” I am put on hold as the dispatcher contacts a supervisor.
The dispatcher comes back on the line. “Can you just put her back in bed?”
This seems as good a plan as any. However, there is no way to get her to her room without passing other residents. Naturally, it would be disconcerting for them to see their housemate, covered in a sheet, wheeled back to her room, so Mike and I decide to leave her face exposed and the oxygen mask on her face, providing the illusion that Helen is still alive.
Two old women, their hair Q-tip white, sit in hallway chairs and follow our sad parade with their eyes. I overhear one saying to the other, “I’m worried about her.”
II. Paramedic
“Air goes in and out, blood goes round and round, any deviation from this is a bad thing.”
- Unknown
Paramedic Training
I started paramedic school in 1999 in Vancouver, Washington. The College of Emergency Services Washington’s program was fourteen months long, not counting the internship. Lecturers taught us the fundamentals of cardiac physiology, interpreting EKGs, acid/base balance, advanced cardiac life support, and a myriad of other topics.
Paramedics differ from EMTs in scope of practice. While an EMT is trained in patient assessment, wound care, oxygen administration, and splinting, a paramedic’s role includes more invasive treatment and requires a deeper understanding of disease process. Paramedics learn to interpret EKGs, place breathing tubes in tracheas, start both central and peripheral IVs and administer about thirty different medications to victims of cardiac, respiratory, and traumatic emergencies.
A paramedic on the street is analogous to a physician in the emergency room—he is in charge of an entire lifesaving team consisting of EMTs, firefighters, fellow paramedics, and sometimes bystanders and police officers. It can seem like conducting a symphony. Every participant has a role to play and must come in at the right time. Paramedics need not only to be able to say, “This patient is having trouble breathing,” but must also seek to know the physiology behind each presentation and use the proper treatment modalities to alleviate suffering and hold back the tide of impending death. A patient with pneumonia is treated much differently than a patient with cardiogenic pulmonary edema. Give intravenous fluid to a dehydrated, feverish pneumonia patient and you will probably improve his situation. Do the same to one in pulmonary edema and you will kill him.
To be a good paramedic requires amalgamating an astounding amount of information from all senses in an incredibly short period of time, and arriving at a reasonable treatment.
Of course, it is not always possible, even for the brightest, most experienced medic out there, to always arrive at the right treatment. We are ordinary human beings doing extraordinary work. We do our best and are prepared to justify our decisions to those that hold authority—supervisors and the doctor who trusts us with his medical license.
The paramedic and EMT textbooks do a pretty decent job of elucidating the basics of managing an airway, starting intravenous lines, and administering drugs. The various required and optional courses in advanced cardiac life support, pediatric life support, and pre-hospital life support are illustrated in protocols and flow sheets.
It is impossible, though, to predict the multitude of different ways a patient’s symptoms will present. A myocardial infarction, usually heralded by the stereotypical crushing mid-sternal chest pain, may instead present as unusual fatigue, possibly mild shortness of breath, especially in women or diabetics. As the saying goes, “patients don’t read the book.”
What may seem like a routine call can turn into a disaster in seconds flat. A patient who seems normal anatomically at first sight may look very different when one is gazing down the end of a lighted laryngoscope into the unidentifiable soft tissue of the upper airway, maneuvering and repositioning in an effort to visualize the cartilage of the epiglottis.
We spent weekends rotating through the various departments of area hospitals, observing the burn ward at Emmanuel Hospital in Portland, learning pediatric emergency care at Doernbecher’s Children’s Hospital, and honing our nascent IV skills in area emergency rooms, often to the chagrin of patients used as practice subjects. It was all a dress rehearsal of sorts however, until we entered our internships at paramedic services across the nation, and proved our ability to do the job when the pressure was on.
Cough CPR
It’s my first paramedic student rotation through Legacy Good Samaritan Hospital in Portland and I am ambling around hopefully in the ER, searching in vain for the opportunity to inflict some sort of procedure on an unsuspecting patient, when an AMR medic unit rushes a patient to the major medical room.
The man is young and appeared healthy, fully conscious and alert upon arrival at the ER. However, his wife had called 911 after she had found him collapsed in the bathroom. She had said he was not breathing and had no pulse and that she had briefly performed CPR. Paramedics had arrived to find the man conscious. Though they had thought the report of his having lost pulses was dubious, they chalked his condition up to a fainting spell of unknown cause and transported him to the hospital as a precaution.
The man converses pleasantly with the nurses and technicians as they change over the ambulance monitoring equipment to theirs. He shows no signs of the reported cardiac arrest he had suffered earlier at home. His rhythm on the overhead heart monitor reveals a perfect sinus rhythm, normal in every way. His skin color is adequate. His oxygen saturation is perfect.
Suddenly, the man looks concerned. His eyes roll back and his head turns sharply to the left. His color deepens to purple and he produces a groaning, spasmodic sound as all his muscles stiffen at once. The instantly recognizable facial expression is sometimes called the “VF face”—so named by the appearance of a patient who has had a witnessed conversion to the lethal rhythm ventricular fibrillation, an ineffective heart quivering often the first rhythm seen in the setting of cardiac arrest. The ventricular fibrillation brings on an anoxic seizure, in which consciousness fades but the brain still has enough blood circulation to generate gasping breaths and seizure activity, even though the heart has stopped.
The monitor shows a flatline. The man’s heart has no electrical electivity whatsoever. Then small bumps begin to appear at regular intervals in the rhythm tracing—atrial beats unanswered by ventricular beats, the sign of complete heart block. No impulses generated by the primary pacemaker in the upper right part of the heart are able to make it to the thick-walled ventricles that squeeze blood to the body. The man’s blood flow has stopped flowing and he is losing consciousness by the second.
An ER technician rushes to the man’s side as apnea alarms begin to sound. “Cough! Cough!” he shouts.
The man, barely conscious, is somehow able to register the command given by the tech, a former paramedic. He coughs a couple of times and within seconds the reassuring spikes of a beating heart begin to appear on the monitor screen. The man immediately regains consciousness, his color returns to normal, and he is able to speak.
A tall, gray-haired man with glasses perched precariously on the end of his nose, the ER attending physician makes his way through a slalom course of X-rays machines, portable heart monitors, and a crash cart, to the patient’s bedside. He squints at the EKG tracing, mutters something inaudible to a squatty woman in scrubs, grabs the phone handset from the wall, and delivers clipped, precise commands to the cardiology department.
“Cough CPR” is based on the assumption that coughing temporarily increases pressure in the chest, generating forward blood flow and maintaining consciousness. Though the technique does not always work, it is based on the same principle as CPR, whose rhythmic compressions generate blood flow that forces residual blood out to the other vital organs, such as the kidney, brain, and liver. Its effectiveness is limited, but helpful in some circumstances.
Though the man’s heartbeat is restored temporarily, it doesn’t stay that way. Within minutes, he clutches his wife’s hand and says, “I’m going out! I’m going out!” It’s all he can say before he turns colors and stiffens again, his breath coming in gasping bursts.
“Cough! Cough!” shouts the ER tech once more. Once again, the man is converted to a normal sinus rhythm. The ER physician once again negotiates his way into the room, his pace now visibly quickened.
The man’s heart stalls several more times after external defibrillator/pacemaker patches are slapped onto his chest. A cardiologist arrives and places a trans-venous pacemaker by inserting a catheter into his right internal jugular vein in preparation for his transfer to the intensive care unit.
His cardiac conduction system damaged from an unknown cause, the man will leave the hospital with some extra hardware, an implanted cardioverter/defibrillator that will shock his heart back to a normal rhythm should it fail again.
Queens
At the conclusion of paramedic school, each of us was assigned an internship site. There we would apply what we had learned in the classroom to the field. It was to be make or break time. Some students went to Denver, Colorado for their baptism by fire in the highly regarded Denver EMS system. Others went slightly south to Metro West Ambulance in the Tualatin Valley area of Northwest Oregon.
Six of us, rural, naïve, and inexperienced, crossed the country from Washington State to New York in September of 2000 to begin our internships. I was assigned to Jamaica Ambulance Service in the heart of Queens. I had never been to New York City before and it seemed to me a foreign country when I arrived. The humid air, to which I was not accustomed, greeted me as soon as I got off the plane at JFK. My previously whitewashed world was transformed into an enclave of multiple different cultures and ethnicities. Orthodox Jews, with their forelocks and broadbrimmed hats, queued up at ticket counters. Indian families in saris and turbans waited at departure gates for outbound flights. Not a single Native American, I thought.
The quarters for the two advanced life support ambulances, or “buses” as they were known in New York, were in a graffiti-covered brick building just a few blocks off the subway line. The garage was humid and dark, almost medieval compared to the bright, airy apparatus bays I had been used to on the west coast. In the day room was a couch of questionable hygiene, its fabric manifesting a sheen of body oils and dust. I was hesitant to sit on it and had heard a crew had obtained it from a strip bar somewhere in town. A scantily clad blonde smiled lasciviously at me from a wrinkled centerfold on the supervisor’s door.
The crews of the two buses, 51-Victor and 51-William, worked two sixteen-hour shifts and one eight-hour shift as their weekly schedule. Rarely in quarters, each was assigned to a street corner, engine idling, to wait for emergency responses.
My preceptor, a self-described “surfer dude” named Ken had been a life-long New Yorker with a Southern California attitude. He had two rules: “Don’t lose our bathroom privileges at the convenience stores, and don’t use anything out of the kit.” Most of the street medicine was done en route to the hospital in New York, and our lifesaving supplies were usually obtained off the shelves on either side of the stretcher. The kit contained supplies, such as resuscitation masks, trauma bandages, IV gear—things we needed immediately, when we arrived at the patient’s side. Ken disliked restocking the kit but wanted it ready for the next call. I stood by those two rules and did well. I developed a reputation for using multi-syllabic words in my written and verbal reports, and I earned the nickname “Webster,” as in “This is our paramedic student, Webster. He knows every word in the English language.”
The advanced life-support units responded mostly to medical emergencies, while the BLS units, of which there were five, responded to traumas, i.e. motor vehicle accidents. It was common for a crew of two EMTs to arrive at the scene of a badly injured person in a motor vehicle collision, and “load and go” with no therapy initiated other than spinal immobilization, wound care, and high-flow oxygen. Victims of trauma needed a surgeon within the “golden hour” or the first sixty minutes after a collision to have a shot at survival.
As a result of this division of labor, I found myself responding primarily to a great deal of respiratory complaints. Asthma seemed epidemic in New York, and we got good at treating it. Every asthmatic in distress got an oxygen-driven nebulizer, a device that atomizes respiratory medications to deliver them effectively to the smaller branches of the airway. If the patients were sick enough, they would get a subcutaneous shot of epinephrine, or adrenaline, to widen their respiratory passages.
