9
CALL
THE PAGER IS A PICKAX hurled through the window of dreams. The signature deedley-deedley-deedley-deedley tones are a sonic cleaver, splitting the night wide open, driving straight to the base of my brain. I lurch in the sheets, heart drumming. The dispatcher’s voice blasts from the dark three feet from my head and I jump to the light and grab my pants.
“New Auburn first responders needed at the northbound rest area on Highway 53 for a person having difficulty breathing.”
The northbound rest area is eight miles away. By the time the second page bounces off the repeater, I’m sprinting across my backyard.
This kick-start thing worries me a little. When you get paged out from a deep sleep, somnolescence disintegrates like a crystal vase dropped on a parking lot. One minute your heart is idling in a nocturnal lup-dup groove, the next second it’s bucking beneath your sternum like a startled carp. Adrenaline floods your system like white-hot light. Usually you wake on reflex, ready to roll. But if the page comes while you’re swimming a particularly murky section of the sleep cycle, you’ll be utterly fuddled. There are times I hear the tones and burrow deeper in the sheets, thinking it’s too bad for the poor slob who’s gotta answer that, then they hit the tones a second time and I jackknife out of bed, panicky, realizing that slob is me. There are times my head crackles and buzzes, as if my cerebrum is wreathed in static, waiting to discharge. I hear buzzing when my eyes move. I feel that if I roll them too quickly, I’ll have a seizure.
I should probably get that checked.
Folks who have tracked these things tell us that a firefighter’s heart rate increases by over sixty beats per minute in the first fifteen seconds after an alarm sounds. The blood pressure spike created by this instantaneous, thundering tachycardia is profound. Long-term, this isn’t good for you. Think of how you ease and creak around for those first few waking moments in the morning. Now imagine beginning the day at the arbitrary crack of a starting pistol, followed by a quick wrestle with your clothes, capped by a lung-busting 100-yard dash to the breakfast nook. Within five minutes of sweet dreamless slumber, I find myself hammering down the highway, lights flashing, siren whooping, and an update blaring out the radio:
“Further information, patient is a twenty-four-year-old male, bystanders are now performing CPR.”
Our guts tighten and sink a notch. Pam unzips the oxygen bag, checks for oral airways. “Might as well use the Ambu bag,” says Jack, referring to a simple device that we use to pump air and extra oxygen into the patient’s lungs. You squeeze it like a soft rubber ball. Beagle is in the passenger seat describing—as he always does—where he was when the pager went off, and I’m at the wheel, hammer down, head rapidly clearing. Some departments have taken to softening their pages, starting quietly and gaining volume gradually. Others have taken to using a soft female voice to announce calls. This will help, I suspect. But no matter how gently you are wakened, you still have to find a way to pass the news to your heart: Eight miles from here, someone has stopped breathing. They need you, now. Boom. Right back to startled-carp mode.
You can’t buffer yourself against the page. You never know when the call will come. Somewhere out of sight someone is blowing up a balloon, and you will be alerted only when it explodes. There are times late at night, when I’m one of two people on ambulance duty, that I am haunted by a vision of the thousands of hearts beating out there in our assigned patch of darkness. The county plat book hovers in my head, a tangled maze of dead-end roads and out-of-sequence fire numbers. I get spooked by the responsibility. The idea that if one of those hearts fails, someone will call for help—even this instant a finger might be punching out 9-1-1—and out of all those hearts, and all those twisted addresses, we will have to narrow it down, get there as fast as we can, and put our hands to the very chest that holds that heart.
They call at night, they call during the day. They call on sunny June Saturdays, holy holidays, run-of-the-mill Tuesdays. Usually they call on the phone. I have had people run up my sidewalk and pound on the door. I was jogging up Main Street one day when someone called out through a screen window, “In here! In here!” There is no way to know who will call, or why they will call, or when they will call. But they will call, and they will trump everything on your agenda, whether it is supper, the football game, a good novel, or your matrimonial duties. You’ll be in a rush, but you have to keep your head. Once, when a fire call came at three A.M., we all showed up red-eyed and rumpled, and charged off to do our thing, and it wasn’t until we were on scene that I realized my helmet was still hanging in the rack at the hall.
I remember thinking too young when the page came in tonight, and it turns out the man at the rest area has a history of heart trouble. We find him on the sidewalk, where his friends have pulled him from the car. He collapsed two exits ago. It is unclear why they continued driving. This does not bode well. The American Heart Association preaches a thing called the Chain of Survival. The Chain of Survival consists of four links: early access; early CPR; early defibrillation; and, early advanced care. You try to shrink the links, keep the chain as short as possible. In this case, access was delayed until someone at the rest area dialed 911. In the meantime, the car drove fifteen miles past the hospital back in Bloomer. It’s not clear when CPR began, but even if the man’s friends were doing their best, it’s likely that his position—sitting upright in the back of a crowded compact car—affected the efficiency of their efforts. Frankly, early defibrillation is unlikely in these parts, as “early” is defined as occurring within minutes—for every minute that goes by without defibrillation, the chances of survival decrease by 10 percent; after ten minutes, the chances of survival are practically nil. The last link—early advanced care—we address by driving as fast as conditions and prudence allow.
The ambulance arrives. It is the volunteer service from Chetek, nine miles to the north. I cover several shifts a month for the Chetek service, and so I am familiar with the EMTs and their rig. While the others continue CPR and prepare the cot, one of the Chetek EMTs is applying the defibrillator. I pull the airway kit from the side door of the ambulance and prepare to insert a Combitube.
In simple terms, the Combitube is a breathing tube. Actually, it is two tubes in one. If you have surgery in a hospital, you will be intubated with an endotracheal tube. That is, the anesthesiologist will place a tube down your throat and into your trachea, which leads to your lungs. If the tube goes down the wrong “pipe”—the esophagus, the tube that delivers food to your stomach—the patient will suffocate. As such, proper placement of the endotracheal tube is critical. Endotracheal tube placement is a delicate procedure under any circumstance; in the field, everything from vomitus to blood can make the procedure extremely difficult, and its use has generally been limited to paramedics. The Combitube is designed so that no matter which “pipe” you stick the tube down—the esophagus or the trachea—you can still get air into the patient’s lungs. It is essentially a tube within a tube. You grab the patient’s lower jaw, lift, and push the device down the throat. Once it has reached the proper depth (you try to position the patient’s teeth or gum line between two black lines inscribed on the tube), you inflate two balloons. The larger balloon fills and blocks off the nasopharynx—the space in the back of the throat. The second, smaller balloon, located at the tip of the tube, presses against the walls of the passage into which it is inserted, creating the seal necessary for effective air flow. Once the tube is inserted to the proper depth and the balloons inflated, you attach the Ambu bag to the blue-coded tube and try to push air in while listening under the arms and over the stomach with a stethoscope. If the chest rises and you can hear air going in the lungs beneath each arm, the tube is placed in the esophagus and you can continue to give the patient air through the blue tube. If there are no lung sounds, but you can hear a gurgling sound in the stomach, the device is placed in the trachea, and you have to switch to the white tube. Either way, you can get air into
the lungs.
Sometimes you can hear air going into one lung but not the other. In this case, you’ve pushed the tube in a little too far, past the spot where the trachea forks into bronchi—a place called the carina (long I). I have long felt some car maker should produce a mid-size four-door and dub it the Carina. If you push the tube past the carina, you need simply deflate the small balloon and retract the Combitube back past the carina so that air can pass down both bronchi and thus to both lungs. Basic plumbing. It is amazing sometimes, how a patient will pink up when you get the tube placed. Even patients who are PNB—pulseless nonbreathers—will take on a healthier hue.
That doesn’t mean they are fixed.
I get the Combitube in without much difficulty. The readout on the defibrillator screen indicates that we don’t have a shockable rhythm. In other words, shocking the patient will help nothing. And so we are on our way. Out the easy downsloping curve of the rest area exit and into a merge with the four-lane, our little cube of light flying through the darkness. From the scene to the hospital, there is a lot of time to focus. We check and recheck to be sure we have our equipment in optimum position. We recheck lung sounds, recheck the position of the Combitube. We cycle through our defibrillation protocols, hoping for a shockable rhythm. We continue with chest compressions, switching off if we get winded. But at some point, all the drama simply settles into a groove, and can become downright conversational. Utterly calm. We know the odds are stacked against us, or rather more specifically, against our patient. He has been PNB for too long. He has a history of heart disease and cardiac surgery. Our resources are limited. The hospital is fifteen minutes away. But we will give him what we can…we will deliver oxygen to his bloodstream, and do our best to keep that blood circulating with our chest compressions. It’s a primitive process, and dubiously effective. In fact, some studies have suggested a need to reexamine the efficacy of CPR. But there is always an outside chance, and that is what we are working for. The patient is absent, acquiescent, pliant, letting us do what we will do. You are pushing on a body. Out in the darkness, the night is flipping past, one delineator at a time. Mostly people are sleeping. I think of a man who used to pick up girls in local bars by telling them he was the guy in charge of polishing all the delineators.
Rick is driving, and he runs as fast as safety will allow. At the hospital, the sick bay lights are bright, and the patient’s skin appears pale purple. The doctor makes the call quickly: “Stop CPR.” Vicki pulls her hands from the man’s chest. A nurse writes the time on a chart. The Ambu bag is detached from the Combitube. We put clean linen on the cot, and retrace the route home. Out on the highway, we pass through strands of fog. This night is no spookier than any other, but the three of us ride quietly. You have this sense, after calls like this, that something is amiss. As if the earth, lighter by one life, is spinning just a fraction faster. On any other night, fog is fog—tonight, it suggests there are souls about, newly wandering. These feelings fade, but for a while you carry a sensation in your gut like a wheel in the air, slowly spinning down.
We nearly made the millennium without 911. Until 1999, whether for a grass fire or a heart attack, you dialed a seven-digit number that rang in the homes of everyone on the department. A “phone bar,” it was called. Now we’re summoned by pager, but some tradition survives: The old-timers still call the old number, and the first person to the fire hall still triggers the water-tower siren. We all come running. Someone is calling for help. It’s that simple, really, and that profound.
On a frozen December night, the pager goes off when I am on the edge of my bed, having just killed the light. A woman stopped to visit her grandfather and found him flat on the bedroom floor. In the parlance of the dispatcher, he is unresponsive. In the parlance of mechanics, his heart has stalled. Mine, on the other hand, is now pumping blood enough for two men. Light switch, pants, shirt, boots, I’m on my way. Grab a jacket on the porch, and thump down the backyard footpath.
On a dead run, it takes me roughly thirty seconds to get from my house to the fire hall. A little longer, if I have to punch through frozen crust and hurdle the snow bank at the Legion Hall. Once, on a warm summer night, I cut across the neighboring lot on the dead run at two A.M., tripped, and was airborne before I remembered the concrete foundation of the abandoned filling station. I experienced one of those extruded moments produced when startle precedes impact—when your car is skidding toward another car, for instance, or when a flowerpot is headed for the tiles—and time hypertrophies. Nanoseconds become roomy and habitable. The forces of physics continue apace, but our synapses fire with such stroboscopic precision that afterward we can’t believe we thought all we thought. I recall gliding in the pitch-dark night, recognizing what had just happened, considering the history of the long-gone building, the smell of the grass, the pleasant feeling of suspension and motion, the push of the air on my face, the arc of descent, the palpable bulk of the giant sugar maple I knew stood to my left. I visualized my hand, cocked at the wrist, reaching out for the ground. I entertained a series of omniscient stop-motion views revealing the orientation of my body in space. In free-fall, I calculated the likely angle of impact and prepared to roll with it. I thought of my father, telling me that a bullet shot from a perfectly level gun would hit the ground at the same time as a bullet simply dropped from the same height as the barrel. It’s a mind-twister, accepting that horizontal motion doesn’t extend hang time. And then I hit, tucked, rolled, and was just as quickly on my feet, running again, remembering to duck the neighbor’s clothesline.
That old foundation is gone now, replaced by a yellow prefab, and so tonight I run straight out my backyard, through eight inches of snow. The temperature stands at dead zero. I feel as if I’m pushing my face through rubbing alcohol. My cheeks stiffen, have the feel of butter hardening. With every inhalation, the hair in my nostrils freezes. The village is still, the stillness intensified by the cold. Christmas is a few weeks away. Here and there the neighborhood glows with illuminated plastic snowmen, electrified garlands, and strings of icicle lights. At the house across the street, a four-foot glowing Santa slumps against the door in a nimbus of red. From here he looks drunk.
I clear the snowbank at a good clip, cross Elm Street, and punch the combination into the fire door. In the summer, it’s click, click, click, and you’re in. Tonight the works are seized with cold. It feels as if I am pushing the buttons through taffy. I expect to see Pam or Jack or the Beagle, but no one is around. I’m pretty sure the address is just west of town, but the rule is, you don’t go anywhere before you find it on the map, so I run to the meeting room and check the wall to be sure. Yep. There it is. I spin on my heel, flick the garage door opener, start the van, and, hoping someone else is going to show up, let it idle while I pull on a pair of rubber gloves. Nobody shows. I’m going solo. I hit the lights and hit the road.
The calls blindside you, always. You will prepare and prepare, and you will never be prepared. We are never ready, and our patients are never ready. Over the years, I have developed a visceral reaction to families and victims expressing surprise at tragedy. Why are we surprised? Why do we forget we are mortal? Bad, bad things happen everywhere, every day. Humans, for better or worse, harbor this feeling that we—individually—are special. A patch of ice or a pea-sized blood clot makes a mockery of that illusion in a heartbeat. We are not special at all. I hear people on scene saying, “Why? Why?” and the answer is, there is no why. Ambulance work will exacerbate your inner existentialist.
My brother John made a call, he came busting in the kitchen, and the first thing that hit him was a palpable wave of cigarette smoke and bacon grease. A man was spilled backward on the floor, his chair upended. His plate was mounded with half-finished eggs and sausage links. His cigarettes had slipped from his shirt pocket. His white belly protruded like risen dough. And his wife looked at my brother, and she said, “I don’t understand…he’s never been sick a day in his life.”
And John says he
remembers his first thought was, Well, he’s sick now.
Alone in the van, I have a ball in my gut. I can already feel the eyes that will turn to me as I step through the door. The eyes will be stricken and hopeful, and I will throw myself into doing what I’ve been trained to do, not so much out of hope as a means of avoiding those eyes, because I know the man who lives here, and I know his health is poor, and I have a terribly accurate idea of the likelihood of my doing him any good. I step through the patio doors and one woman is tearful in the kitchen, pointing down to the end of the trailer, and in the bedroom, the man is flat on the floor and another woman is doing CPR, and as soon as I enter the bedroom she stands, backs away from the man, and bursts into tears. The bed has been pushed aside. A half-eaten muffin rests on the windowsill.
I strip my stethoscope out of the pack now and listen for a heartbeat. In the midst of the mess and panic, you plug the earpieces in, press the bell against the still chest, and listen. You are hoping to hear audible hydraulics from a fist’s worth of muscle. You are scanning for life’s backbeat. The lup-dup groove. A little heavier on the dup. That most ineffable iamb.
Nothing. I place an oral airway. It is a simple plastic device that keeps the tongue from the back of the throat, allows air to pass through the mouth. I resume CPR. Headlights sweep the window, and shortly my mother is kneeling beside me. She has a defibrillator and a Combitube. We attach the defib pads and fire up the machine. The line that should be bouncing across the screen is flat, flat, flat. Doing chest compressions with one hand, I grab my radio from the floor and call Chetek 245, to give them an update. When they answer, I can hear their siren in the background.
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