“Pete’s gonna get the tube,” John said as we entered.
The other crew stood aside. A man lay on the den floor, dried blood on his nose, his color purple from the shoulders up. Asystole—flat line—on the monitor. I knelt down, went in with the laryngoscope, spread the tongue to the left. I couldn’t see anything. I went in again, saw the vocal cords and passed the tube. “I’m in,” I said. Mike MaGoveny, an EMT, attached the ambu-bag to the end of the tube, and squeezed the bag, forcing air through the tube into the lungs. I checked breath sounds. Positive. I checked over the stomach for sounds in the belly. None. Bingo. Confirmation that the tube placement was good. Cardiopulmonary resuscitation continued. A round of drugs was given.
“Good job,” Mike whispered to me as I ventilated the patient.
The man, though, never really had a chance. He’d been found by a niece. He’d been down awhile and from his color probably had a pulmonary embolus. The ER worked him only about five minutes before they called it.
I was ecstatic about getting the tube. I had been worried that with all the talk about needing a tube, what if I got the chance and didn’t get it? But I had done it. I’d passed that sucker right through those cords.
After I’d helped clean the rig, I went back into the ER with a shit-eating grin on my face, so happy I was on the verge of doing a funky break dance. The family was there. Women were sobbing into handkerchiefs. Grown men wept in each other’s arms. Children had frightened expressions, clutching to the coats of their elders. I did a quick about-face and went back out into the parking lot and stood in the chill night.
Drug Box
We carry twenty-four different drugs: dextrose and glucagon for hypoglycemia, Narcan for heroin overdoses, epinephrine 1:1000 and Benadryl for allergic reactions, Ventolin for asthma, oxytocin for postpartum bleeding, nitroglycerin (called “nitro” for short) and baby aspirin for chest pain, Lasix for congestive heart failure, dopamine for cardiogenic shock, and adenosine for supraventricular tachydysrhythmias. Our chief drugs for cardiac arrests include atropine, epinephrine 1:10,000, and lidocaine. Our second line cardiac drugs are bretylium, procainamide, and sodium bicarbonate. We also carry Dramamine, magnesium, calcium, isoproterenol, and propanolol. In the lock box above the monitor shelf we keep our narcotics—morphine for chest pain and pulmonary edema and Valium for unceasing seizures. The drugs come in either pre-filled syringes or syringe inserts, small glass ampules or single and multisize vials, where the fluid is drawn out with a syringe. Some drugs such as Narcan can be given either through an IV line or intramuscularly (IM). Valium will cause tissue necrosis if given IM, but it can be given rectally if a line is unobtainable and the patient is in serious enough condition to merit going that route. Atropine and lidocaine can be given intravenously or down an endotracheal tube in the case of cardiac arrest. Other drugs such as dopamine are injected into a bag of D5 solution and given by slow IV infusion into the vein to ensure a steady level of the drug in the body.
We have a protocol book that tells us what drugs we can give on standing orders depending on the situation, and when we have to call on the radio for direct verbal orders to give the drugs. For chest pain, our routine care means the patient will get oxygen, cardiac monitoring, and an IV. We have standing orders to give up to three nitroglycerin tablets sublingual (under the tongue) at five-minute intervals provided the blood pressure stays above 100 systolic as well as two baby aspirin, but we must call to get permission to use morphine. For asthma we can give two Ventolin treatments (a mixture of the drug and saline water is put in a small humidifier through which oxygen is run, producing a vapor that is inhaled into the lungs) within twenty minutes, but must call for permission to give epinephrine.
In the case of cardiac arrests we have advanced cardiac life support (ACLS) algorithms that we follow. A person in ventricular fibrillation (v-fib) gets shocked rapidly at 200 J, 300 J, and 360 J provided the rhythm doesn’t break after any of the shocks. Then CPR is continued, the person is intubated, and an IV is established. One milligram of epinephrine is administered every three to five minutes through the IV, or down the tube if IV access can’t be obtained, followed by a shock at 360 J. After the first epinephrine (“epi” for short), the person gets lidocaine at one point five milligrams per kilogram, again followed by a shock. As long as they stay in v-fib, the algorithm runs through a variety of drugs including bretylium and procainamide. If a pulse returns or the patient converts to another rhythm, there are other algorithms that provide guidance for those situations. There is no need to contact medical control other than to alert them that you are en route to the hospital with a working code (cardiac arrest). All paramedics, as well as emergency doctors and critical care and emergency nurses, are required to pass a biannual two-day ACLS class that teaches the lastest standards for dealing with a variety of significant cardiac events from ventricular fibrillation to hypotension, shock, and acute pulmonary edema. (Some hospitals are offering experimental one-day recertification courses for those full-time paramedics who regularly work cardiac arrests.)
While we sit in the ambulance, I reread the manual.
“What’s the dose for Valium in status epilepticus?” Tom asks.
“Five to fifteen milligrams.”
“What’s the dose for bretylium?”
“In v-fib, it’s five milligrams per kilogram IV push, followed by ten milligrams per kilogram if the first dose doesn’t convert.”
“Wrong,” he says. “Think again.”
I stutter and fumble. “Damn. Wait, let me think.”
“Wrong,” he says again. “You were right the first time, but you’ve got to be more sure of yourself, you have to know it.”
He’s right. I know it on paper, but can I do it in the heat of the moment, when it’s all going down around me? Can I get the job done?
Deportee
I’m jumpy, expecting every call to be the big one. “Four-seven-two, man down corner of Park and Seymour. Respond on a one.”
“We’re all over it,” Tom says.
We race down Washington Street, full lights and sirens. This is going to be a cardiac arrest, I think, I can feel it. I go over in my head what I will do. Assess responsiveness. If he’s not breathing, do a quick look on the monitor and shock him if he’s in v-fib. Otherwise, go to the head, ventilate, get out the intubation gear, sweep the tongue to the left and up with the laryngoscope blade, visualize the cords, and bang the tube right between them.
“Eight-forty.”
“Go ahead, eight-forty.”
“Tell four-seven-two the man’s up.”
“You got that, four-seven-two?”
“Got it.”
We are at the corner now. “It’s Jose,” Tom says.
A man with a thin mustache and glazed eyes is leaning against a telephone pole, supporting himself with a cane.
We get out.
“You been drinking?” Tom asks.
Jose shakes his head. His face is covered with scabs in various stages of healing.
“I fell,” he says.
“Get in,” Tom says.
The man walks to the back of the ambulance with an unsteady gait, working hard to swing his left leg ahead and plant his cane.
I notice a fresh hospital bracelet on his wrist.
He tells me he is forty-seven. He has no address other than the mission. I ask him what happened and he says he fell. We are only three blocks from the hospital.
“They are not going to want to see him,” Tom says as he brings a wheelchair to the back of the ambulance after we have parked outside the ER.
As I wheel him in, a doctor says, “Isn’t that Jose?”
“Jose? We just released him,” a nurse says.
“Oh, no,” another nurse says. “Get out of here. We just released him. He didn’t have time to make it to the liquor store. Who called you?”
“Nine-one-one. He says he fell.” I add, “It’s cold out.”
Jose looks at the floor.
“Oh, brother,” she says, grabbing her chart.
She inputs his name in the computer and says to us, “Put him in the waiting room.”
“That man gets transported two, three times every day. He costs the state over eight hundred thousand dollars a year just in ambulance and hospital bills,” Tom tells me as we leave. “When he gets drunk, he’s mean. He whipped his dick out once when I was working with a woman and tried to pee on us. The scars on his face aren’t just from falling; they’re from other people beating the crap out of him. He’s got a foul mouth and an ugly temper. He’ll swing at you if you give him space. He is the scum of the earth.”
A week later, I am at the hospital when I hear a nurse tell a paramedic that Jose is being deported. They have him in a back room all doped up on Ativan, awaiting the Immigration and Naturalization Service (INS) agent, who will accompany him back to Nicaragua. He is leaving from Bradley Airport in the morning, though no one has told him yet. The hospital has been working with INS for over a month to get the deal done.
I have a dream that night of a small plane landing on an airfield in Nicaragua and a body being thrown out. Jose struggles to get up and balance himself with his cane. He looks around. It is warm; the road is made of hardened mud. To the left is lush jungle; to the right, urban slums where the homeless pick through garbage cans and men yell at each other in the street. Suddenly a dog leaps at Jose, catching him in the jugular vein. Another dog rips into his right arm. A third dog knocks him to the ground and tears at his groin. There is ferocious barking. All you can see are dogs—twenty, thirty of them fighting over the body. When the dust clears, all that is left is a carcass—an empty chest cavity with the backbone showing through like the remains of a postfeast Thanksgiving turkey. There are a few stringy pieces of meat left and lots of dog hair. Jose’s cane lies beside the body.
Oh, Mama, I’m glad I’m not a mean, drunk Nicaraguan.
Life and Death
It is three in the afternoon. We get called for a seizure at a factory. A basic unit is closer so they are reassigned the call. We slide over in that direction anyway in case they need us. The traffic is heavy, so Tom says screw it and puts on his lights and sirens. As we arrive, we hear the basic unit call for us.
“Did you hear that, four-seven-two?” the dispatcher says.
“We’re out,” Tom says.
A woman meets us by a side door and leads us up three flights of long broad stairs. We come out into a large open room. The other crew is by a corner desk. A man is sitting in a chair. He is pale, ashen, diaphoretic, and anxious. He looks like a ghoul—like death is whirling around inside of him. Even to speak seems a great effort for the man, who is fifty-four years old.
“I can’t get a pressure,” one of the EMTs says.
“Lay him down on the stretcher,” Tom says.
He already has an oxygen mask over his face turned up full. He has a weak pulse in his neck. None in his wrist. He has been having pain since nine that morning, which disappeared, then came back at one-thirty. He thought it would pass, but it has gotten worse.
We put him on the monitor. He has a slow rhythm with couplets of ventricular tachycardia (v-tach). I pause. It is a rhythm I studied in class. It is there on the monitor. In real time in real life. Sweat pours from my forehead. We carry him down the stairs on the stretcher. I am at the bottom, and as the EMT pushes the stretcher forward, I trip momentarily and feel myself falling backward. I grab the railing with my left arm and catch myself, relieved not to have me and the stretcher and the patient tumbling down the stairs in speeding somersaults.
We get him in the back of the ambulance. On the monitor he is in full ventricular tachycardia—a lethal rhythm. I go for an IV line in his arm. We need to get medication and fluid into him right away. I find a vein in the crook of his elbow. It’s not a big one, but I ought to be able to get it. I go in with an eighteen. I get the flashback in the chamber, but to my horror, I see a hematoma growing around the site. I swear. I’m through the vein. Tom is spiking a one thousand milliliter bag of saline. Rene Barsalou, one of the EMTs and an old partner of Tom’s, gets out the airway kit, while the other EMT is preparing to assist the man’s ventilations. I spot a thin vein in his hand. I go in with a twenty, a size smaller. I get no flashback, but I feel I am in. Rene looks at it. She has been an IV technician for years and her skills are exceptional. “You’re in,” she says, “he’s just clamping down.” We hook up the IV line, run the fluid into the vein. It goes in steadily.
Tom already has the defibrillation pads, one to the right of the sternum, the other lower on the left side. The pads are connected to the monitor by two wires.
I hit the synchronized cardiovert button. “A hundred?” I say to Tom.
He winces. It is the right amount for the protocol, but the man is still responsive, and there is no time to call for orders for Valium to premedicate him. “Fifty,” he says, “and tell him it’s going to hurt.”
I lean over the man. “Sir, you need to keep your hands by your sides and don’t grab anything. We’re going to apply some electricity to your heart to correct your rhythm. This is really going to hurt.”
I set the joules to fifty, hit the charge button, then look to see if everyone is clear. I press the buttons simultaneously. A few seconds later, the charge hits him. His body convulses. His teeth and arms clench. His whole body comes up off the stretcher, then settles back down.
He’s still in v-tach.
“We have to do it again. Don’t grab out.”
I set it for a hundred.
He screams as the electricity hits him.
Still in v-tach.
I set it for two hundred. “Hang in there,” I say.
He says through clenched teeth, “You guys are killing me.”
We hit him again at two hundred.
The electricity shoots through his writhing soul. We wince.
He is unresponsive. He’s in an idioventricular rhythm on the monitor, a flat line with only an occasional beat at a rate of about twenty a minute. He has no pulse.
I screw a one milligram dose of epinephrine into a bristo-jet syringe and plug it into the three-way medication port on the IV line. I push it in quickly.
He goes back into v-tach.
I give him ninety milligrams of lidocaine and defibrillate him at 200 joules.
His whole body seizes. He clenches his teeth. His face swells and turns purple before our eyes. He stops breathing.
“You killed him,” Tom says.
I move to the head of the stretcher as Rene hands me the intubation gear.
Laryngoscope in hand, I try to pry his mouth open. His jaw is absolutely locked. I can’t tube him. He’s clenched.
“Wait a second,” Tom says confidently. “He’ll loosen up.”
His muscles go limp. I put the blade in and sweep the tongue to the side, but I cannot see the vocal cords. I pull out and reventilate with the ambu-bag. I go in again, but still can’t see them. Please drop, please drop down into my sight, cords. Let me get the tube. Let me get the job done.
I can’t.
Tom and I switch places. I push atropine and epinephrine through the IV line. The EMT is doing CPR. Tom goes in for the tube but can’t get it. He switches blades, then passes the tube.
“It’s in,” he says.
He checks lung sounds to confirm placement, then connects the ambu-bag, and begins ventilating. The man’s color improves.
His rhythm is still idioventricular. “Com’on, com’on back,” he says, but it’s not doing the job for the man. Rene is driving now. I’m doing CPR, and the other EMT is following in the other ambulance. I stop CPR briefly to give another epi and another atropine.
“I want to save this guy,” Tom says.
At the hospital, we wheel him straight to the cardiac room, where a team of doctors, nurses, respiratory therapists, and assistants are gathered to take over. We lift him from our stretcher to the bed by pulling him on the sheet. Tom glances at me, then
goes ahead and gives the report to the team.
They continue the code, giving him more epinephrine, but they can’t bring him back either. He is dead.
We clean the ambulance and write the report. While I am excited by the adrenaline rush of the call and having finally gotten to defibrillate someone (something I never want to do again on a conscious person without sedating them), inside I fight the feeling that I failed badly. I couldn’t get the tube, and only got the line on my second try and only got a small hand vein. I don’t think I could have handled it on my own without Tom there. Maybe if it had just been him, he might have saved the guy. The death is an anvil in my soul. I step heavily, dragging it behind. Maybe I should have stayed back at my desk, out of harm’s way, and my harm out of others’ way. I wonder if this playing paramedic hasn’t just been a big game to me. Like a soldier going off to war seeking easy glory, only to flinch on encountering real combat. I keep my mouth shut. My mind races.
“Would you do anything different?” Tom asks.
“I don’t know, would you?”
“Our treatment was right,” he said. “He just didn’t make it—he should have, but he didn’t. His heart muscle was probably shot. He was having the bad one all day and wouldn’t admit it.”
He adds, “Did it bother you when I said you killed him?”
“No.”
“It seemed to go right past you. I say that sometimes just to see what kind of reaction I can get.”
“Sure.”
Another crew stops by our open back doors. “Hey, I heard you had a KBP call,” one of them says.
“KBP?” I say.
“Killed by paramedic,” Tom says. “Alive when you got there, dead when you left him.”
“Right,” I say.
Later we are back at the office, sitting halfway up a set of stairs, where we can get some privacy as we do our day’s evaluation form. There is an entry: “Properly explains procedures to patients.” “You did a good job on that,” Tom says. “I like the way you told him, ‘This is really going to hurt.’ ”
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