The results from her blood gases come back. Even though I couldn’t intubate her, she was well ventilated. I didn’t mess around trying to get the tube this time. I couldn’t get it and moved on. I didn’t waste time on scene. I learned.
We call for the times. We were on scene within five minutes. She’d gotten CPR within one minute of keeling over. She got her shock within eight and drugs within twelve. She was in the hospital within twenty minutes. Great times.
Within an hour they transfer her to Saint Francis for emergency angioplasty to clear out the blockage in her coronary artery. When we hear they are getting ready to transfer her, we get in our ambulance and get as far away from the hospital as we can. We saved her and we don’t want to push our luck and have her code on us on the short trip to Saint Francis, and not be able to get her back.
Fifteen minutes later, our dispatcher assigns another crew to the stat transfer coming out of Sinai, postcardiae arrest, on monitor, oxygen, and med pumps.
“That’s our save,” Glenn says over the radio.
Later the other crew tells us the lady was talking to them on the trip.
In a couple of weeks, she will walk out of the hospital, doing fine, with no impairment.
A true save.
It is called the chain of survival. When you drop in cardiac arrest, you have four to six minutes to pray someone gets there and starts CPR or your brain will die. The odds are your heart is in ventricular fibrillation, a condition in which your heart quivers like a handful of shaking worms. Cardiopulmonary resuscitation will pump only a small amount of poorly oxygenated blood through your body, but it will give you a few extra minutes. Once you fall, you have eight minutes to get an electrical shock or defibrillation, where an electric current stops your heart cold; then your heart, with fortune, may restart itself with a life-providing rhythm. You have another four minutes to get cardiac drugs into your system to help your heart maintain that rhythm until you can get to the hospital and get more definitive treatment. In nearly every case, if you are not revived in the field, you won’t be revived in the hospital. The ability to meet the chain of survival—CPR within four minutes, defibrillation within eight, cardiac drugs within twelve—should be the standard in every city and small town in the country.
Too many people don’t know what they have in their cities and towns as far as EMS goes. Most think when they call 911 they get a dispatch center like the ones they show on “Rescue 911,” where a trained specialist talks them through the emergency, while paramedics speed to their rescue. Most people think every ambulance has paramedics. Do you know what you have? Do you know what the average response time is where you live?
Connecticut is proud of its tradition of home rule, which, while providing many benefits, has some significant drawbacks. Here when you call 911, the call is likely to go to your local police station, where a solitary dispatcher answers the phone. Your husband is having a heart attack. They say they’ll send an ambulance and hang up. The local volunteers are toned out on their pagers or portable radios. They awake from their sleep and dress quickly, then run out and get into their cars. With luck the first arrives at your door within four minutes and begins CPR. The second crew member drives to the ambulance barn and picks up the vehicle. With luck, your local service carries a semi-automatic defibrillator, and again with luck, they arrive within eight minutes and quickly deliver a shock. The hospital is twenty minutes away. It will take five to load your spouse on the stretcher and negotiate outside. Are paramedics on the way? How long will it take them to get there? Four minutes? Ten? Twenty? Are they coming at all? People need to know these answers. They need to find out what their town offer—is it just basic life support (BLS) where they just do CPR, or is it advanced life support with defibrillation, intubation, heart meds, and cardiac pacing? If it doesn’t meet the standard, they need to do something about it. There are many towns in this state that have excellent systems and excellent people in place. There are other towns that have excellent people but weak systems. There are places where, if you or a loved one has a cardiac arrest, you don’t have a fighting chance, only a prayer and not much else.
Back in 1989 when I was working for Eastern Ambulance I was on duty in East Longmeadow with a brand-new EMT as a partner. I was in the Minute Mart buying a Coke when I heard the air horn from the ambulance outside. I ran out and caught the tail end of the radio transmission. Person not breathing at an address only minutes away. I got behind the wheel and swung out so fast I knocked the Coke over, splattering it on my shoes and the floorboard.
When we got to the house we found the man lying on the kitchen floor with a cop giving him air through a demand value oxygen tank. He had a faint pulse, but he was completely unresponsive. We lifted him onto the stretcher, put on an oxygen mask and got him out to the ambulance. I tried to take a blood pressure but couldn’t get any. Since my partner was new, the company rules said I had to drive. I took off going about sixty miles an hour. We didn’t have paramedics then. My partner started shouting to me and I noticed the stretcher had broken loose from its lock stand in the back. I had to pull over and run around to the back and slam it back in. A couple of minutes later, I called back to my partner for an update on the patient’s condition. “Does he still have a carotid pulse?”
“No, I can’t feel one.”
“CPR!” I shouted. “Start CPR! Fifteen and two! Fifteen and two!” I said, referring to the sequence of compressions to respirations for one-person CPR. I got on the C-Med radio and called the hospital. “CPR in progress!” I told them.
I was driving about seventy on I-91 North, I was so hyped up. Only later did I learn I had forgotten to put the red lights on.
When we arrived at the hospital and pulled the patient out, his stomach was distended with air. His complexion was blue. They didn’t work him long. Going back out to the ambulance I encountered the man’s son, who shook my hand and thanked me. I looked down the hall and saw a priest coming our way. I told the son, sure, no problem, then quickly exited.
We didn’t kill him, but we sure didn’t help any. Like his neighbors in the exclusive town of Longmeadow, he didn’t have access to paramedics then. If he had gone for a walk and crossed the line into Springfield before keeling over, he would have gotten his heart shocked, been intubated, and gotten an IV followed by rapid doses of potent cardiac drugs. The life-and-death battle would have been fought on the spot he dropped rather than on a hospital gurney fifteen minutes away when he was already gone. He might be alive today. Then again, it might have taken twenty minutes for an ambulance to arrive because the Springfield system was probably overloaded with BS calls and there might have been no ambulances available.
At the health department Commissioner Susan S. Addiss and I and the staff at the OEMS worked to put together a strong statewide system. We formed an advisory board of thirty-seven committed individuals representing physicians, nurses, paramedics, commercial ambulances, volunteer ambulances, police and fire services, towns, and cities. It was chaired by Richard L. Judd, Ph.D., a nationally renowned EMS educator. And while good work came from, and continues to come from, the group, there remain too many competing interests. Everyone believes he or she is putting the patient first, but the disagreements are endless. Can volunteers, who unselfishly give long hours, continue to meet the constantly upgraded standard of care, or should we allow them to just continue the old level which once upon a time was enough? Are paramedics too expensive? Can commercial ambulances, which offer regional approaches and economy of service, be counted on to put the patients above profit? Who should dictate what paramedics can do? Individual doctors who will receive the patients, or a state board that can prescribe common guidelines to ensure the same standard of care across the state? In a time of tight budgets, how much medical care is too much? Who should decide who can provide ambulance coverage in any particular area? The state? The town? The ambulance services? Should EMTs be allowed to practice their skills in hospitals, better preparing them fo
r fieldwork, but possibly costing nurses their jobs?
I don’t know the answers to all of these questions, but if I could suggest a guideline it would be: What would you like if your wife, your parents, your child were hurt and needed help? What would you want then? That’s the only way I can answer it. Government should try to provide the best care possible and if it can’t, then it should not get in the way of others providing it. Consumers have to find out what kind of care they want and then demand it. Paramedics and health professionals have to do their best to provide it.
In the case of the woman who went down in Bloomfield, she got it. In the end, it wasn’t just me and Glenn and the first responders, and the other crew, and the ER staff at Mount Sinai, and the medical staff at Saint Francis, who saved this woman. It was the system.
The experience gave me respect for all those endless meetings people sat through to put the system together—meetings that paid off in a human life.
Veins
Having acknowledged the importance of system building, I have to reaffirm my preference for the street and the pure challenge of the trade.
I love doing IVs. The best veins are in the bend of the elbow—the antecubital (AC) veins. There is also another great vein that runs along the thumb side of the wrist. It can sometimes take a needle as big as a sixteen, and is easy to tape down and doesn’t ihibit the patient’s movement like the AC can. The hand has the most visible veins but can rarely take more than an eighteen.
If you can’t see a vein, then you have to feel for one. Veins are soft and spongy. Finding a vein by feel is like being a prospector stumbling onto a lode.
Depending on the vein size and whether you want to administer medications or replace fluids, you choose your catheter size. The lower the number the bigger the catheter. Twenties and eighteens are for administering medication. Sixteens and fourteens are for fluid replacement, although sometimes I have used eighteens and even twenties to replace fluids if I cannot find a vein big enough to take a sixteen.
I like doing IVs because it is a skill that you either have or don’t have. It gives you a sense of accomplishment, a moment that tells you are doing your job well. It is very much like sinking a basket. It doesn’t mean you win the game, but for that one moment, you are getting the job done.
Putting in IVs takes practice, as you need to learn to develop your technique. I was terrible at first. I’d often go right through the vein, or I’d get a little flashback and then advance when only the point of the needle was in, so the catheter would shred the vein. Small hematomas would rise up under the skin. They would sometimes grow to the size of golf balls, and I’d have to hold pressure on them to keep them down. Other times I’d be under the vein or to the side, and the vein would move or roll when nudged. When I took the paramedic class I did as many IV rotations as I could, knowing that if you can’t get a line, you can’t do your job. I didn’t want to have to worry about it.
Some people have great veins, particularly athletes; other people don’t, particularly fat people. Some older people have frail veins that puncture easily; even the catheter can rip the vein if not inserted very, very gently. When I started doing IVs I’d first look at the person’s arms, and either say no problem I can get this guy or oh, no, this is going to be a hard one.
I missed my first eight IVs as a paramedic. That was two tries each on four people who had nothing for veins. I was greatly bummed, then I got an old man with huge great veins, but my confidence was so low, I almost missed on him.
In playing basketball—and in doing an IV—confidence is just as important as technique. You get in a groove and you’re in the zone. You know you’re not going to miss. I follow the same ritual every time. I apply the tourniquet, select my catheter, swab the site, then take the vacutainer adaptor and pull off the protective covering with my teeth. All the while keeping the plastic cap of the vacutainer in my mouth, I take out the catheter, stick the IV, remove the needle, clamp off the vein, attach the vacutainer, draw blood, release the tourniquet, clamp off the vein, secure the saline lock, and tape the IV down.
I have gone months without missing. I want to be the best at it. Some paramedics put in IVs only if they are going to give medications or fluid. I stick everyone who I know will get an IV in the ER, even if I am not planning on giving any meds. I have the protocol to do it, and the ER nurses in the busy hospitals like it. If the patient suddenly crashes, I have instant access. It also makes me better. The more I do, the better I become. I want to be so good that someday I will be able to put a catheter into a stone.
Depending on the call, I either do the IV in the back of the ambulance before we take off to the hospital, or if the patient is acutely ill or a trauma victim, I stick him while the ambulance is moving. Doing an IV in a moving ambulance is sometimes like shooting a basket with a defender in your face. The ambulance hits a bump, and you and the defender go up together. There is a tiny second when you are airborne that you get your opening, and bam, you fire it before you land with a jar. I don’t always get it, but once you get under the skin, it is sometimes easier to get the IV then when you are waiting like Queequeg with the harpoon in your hand, hoping that the ambulance won’t jar you when you go to stick the great blue vein. Under the skin, you fish gently for the vein in a straight motion, hoping to hit it from the side.
Getting an IV on a critical patient is like sinking a basket in the final seconds of the game. A person in v-tach, a person in anaphylactic shock, a person with a pulsing triple A(aortic abdominal aneurysm), a person having a massive myocardial infarction (MI)—they need the line immediately.
I go into the house to find an elderly woman, pale, diaphoretic, short of breath with sharp chest pain. I can’t get a blood pressure. I put her on the monitor. Her heart is beating at 180. I’m shaking on account of having had too much to drink this weekend and not having had a chance to eat breakfast yet. All I have in my stomach is two Cokes, which make me shake even more. I put the tourniquet around her arm. I can’t see any veins. To give adenosine—the drug she needs to stop and reset her heart—I need to get a vein as close to the heart as possible. I feel in her AC. My fingers palpate. I feel something soft and springy. I swab, grab an eighteen, pull off the vacutainer adapter in my mouth, and stick her. The flashback chamber fills. “I’m in,” I say. I draw bloods, pop in the saline lock, then slam in six of adenosine, followed by a rapid saline flush. I watch the monitor. The line goes flat, and a few moments later, beats start, then the rate sets itself at 80, regular, beautiful, pain free. We drive to the hospital without lights or sirens. The woman thanks me. The triage nurse smiles and says you did your job for the day.
Later Glenn tells me I was shaking so much he thought I was going to have a seizure.
“At least I got the line,” I say.
I give up drinking Coke on the job, promise to cut down on my weekend drinking and to eat solid breakfasts.
Glenn and I have a paramedic student with us, which means I let the student have the first IV attempt on each call. I am a little upset that I have a rider today because yesterday I missed my first IV in almost six weeks. It was on a seizure patient who had no veins, and whom I really didn’t even need to stick because we were just a couple of blocks away from the hospital, but I went for it and missed. Then I had an elderly woman on Coumadin, a blood thinner, who was having a mild episode of shortness of breath. She had a palpable AC. I went for it and went right through it. I was so pissed off at missing it that I went for the left AC and went right through it again. When I wheeled her into the hospital they saw me and said you have bloods for us of course, which I always do, but I had to say, with the sadness of Casey at bat after his big whiff in Mudville, “I don’t even have a line.”
Although I got a line later in the day, I still needed to build back my confidence. I was worried I was going to start throwing up air balls and clanking them off the rim. Doubt was creeping into me. I feared a slump—a run of bad luck.
We are sent to a lar
ge insurance company for a diabetic. They lead us into the building and through a cavernous open atrium. At each turn a guard in a sport coat and tie, holding a walkie-talkie, points where to go. They take us up in the freight elevator. We are led into a room where we find two more security guards and three nurses and a clerk who is sitting in a chair.
“He is a diabetic,” the nurse tells me. “We did a finger stick that came out at ten, and we gave him some glucose, but he’s still a little combative. You’re familiar with glucose?”
“Yes,” I say.
I size up the situation. The paramedic student is evaluating the clerk, who at first seems calm but then starts talking irrationally and won’t let the student take his blood pressure.
“We have glucagon,” the nurse says, referring to a drug that can be given intramuscularly.
“I want a line,” I say, “He needs some dextrose. That ought to bring him around.”
The student goes aggressively for the line. He missed an AC earlier in the day, but instead of shying away from another attempt, he goes right for it. Earlier he had missed a fair-sized AC on the left arm. I’d then put on a tourniquet and a great AC had popped up on the right, which I drilled but felt no great satisfaction because it was so big.
Glenn helps him find a vein, and while Glenn and the guards hold the man, the student goes after it with an eighteen. He gets the flashback, but it does not advance well. When he goes to draw bloods, it blows.
The man is flailing his arms about and swearing up a storm, so I say, “All right, we’ll give him some glucagon.”
I draw that up and stick it in his shoulder.
I have never given it before and am expecting an instant reaction, but the change is barely perceptible. I will read later that it can take up to twenty minutes to work.
“Let’s go for a line again,” I say.
While Glenn and the student look in the left arm, I put a tourniquet on the right. A beautiful AC pops up.
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