“Stop! Stop!” Janice and I yell. I picture his head dropping into my hands. Blood spurting from his severed neck.
They stop. There is a delay, while a new approach is decided upon.
“It’s okay, you’re going to be all right,” I say.
“Just get me out of here, please,” he says.
“You’ll be okay,” Janice says. “We’ll get you out.”
I hear more creaking and mechanical sounds. My hand is by his neck, ready to pull loose at the first leverage. I picture the glass coming up quickly, then suddenly falling down, taking my hand with it.
It seems like we’re there for an hour.
“Just get me out,” he says.
Suddenly there is a pop, and his head is loose.
“Grab his neck,” I shout to Janice as I ease him free.
She holds his neck. I call for the board and, under the glare of the TV cameras, we quickly extricate him. Remarkably he is all right. He just has an abrasion on his neck, though I worry that with the compression he suffered, he may have swelling. He’ll also need his spine X-rayed. I put in an IV en route just as a precaution. Janice rides along with me and patches to the hospital.
We describe the scene to the doctors and anyone who will listen. “Never seen anything like it,” Jeff says. “His head was wedged on the dashboard. This close, and he’s dead.
“The fire department saved your life,” Jeff tells him. “They screw up and your head is off. Plop! Just like that. Decapitated. Just your neck spurting blood. The end. Dead.”
The man is very contrite.
When I come back with my paperwork done, I wish him well, then ask, “So what are the lottery numbers for tomorrow?”
“I don’t know. Three-eight-two.”
“Three-eight-two. All right.”
I buy a ticket on the way home. The following morning I’m back on my regular shift with Arthur. “Hey, check the lottery numbers for me,” I say as he reads the paper. I tell him about the call and how I bought a ticket figuring to capitalize on the patient’s luck.
“Sorry,” Arthur says. “Four-zero-three. No luck left.”
Saving Lives
I think most of us became EMTs to save lives. To be heroes. Both Arthur and I have saved lives. People walk the earth because of our skills and actions: The woman in cardiac arrest shocked back to life. The pregnant girl in anaphalactic shock, her pressure dropping and airway closing, saved by a critical shot of epinephrine. The man in congestive heart failure, his lungs filled with fluid, his skin cold and clammy, his pressure and pulse through the roof, slammed with Lasix, nitro, and morphine and then intubated as his respirations dropped.
Getting a chance to truly save a life is rare in this job. Not an everyday occurrence. When we do get called for the big one—not breathing, can’t wake up, crashed into a wall at eighty miles an hour, shot in the head—the person is often already dead, and despite our very best efforts, they are not coming back. Only a few calls involve true life and death where our actions in a few critical minutes make the difference between a living, walking, talking, loving, laughing human being, and the morgue that very day.
Rick Ortyl gets sent to a choking. The woman is blue, not breathing. No pulse. Using his laryngoscope and Magill forceps, he scoops macaroni and cheese out of her throat, then intubates her, starts a line, runs epinephrine and atropine in, and brings the woman’s heart back. Before he leaves the hospital, she is awake and profusely thanking him. As he narrates, I wish I was called for that one, that I was the one there with the Magills in my hand, that I was the one saving the life, making the difference, winning the glory, justifying my own existence.
Ed Grant, Shirley Lessard, Tom Harper, Rick Scanlon, Shawn Kinkade, Joel Morris; they all have fresh stories of saves. I am jealous of their calls, their opportunity, their success.
It’s been a while since I’ve had a true save. Months. First you need the call, the moment. Then you need to deliver, to perform.
Bag and Drag
We’re called for a motor vehicle accident and find a large man who looks to be in his late forties or early fifties slumped across the seat of a car with light front-end damage. He is unresponsive. His pupils are pinpoint, and he has been incontinent. Beside him on the seat is an empty bottle of amitriptyline, a tricyclic antidepressant. He wears a bracelet that says he is a diabetic. Since there is no damage to the steering column, windshield, or invasion into the compartment, and the front-end damage is minor, we take him right out of the car without C-spining him. This, I am thinking, is a medical problem, not the result of an accident.
In the ambulance, I take his blood pressure—it is 200/120. His pulse is 84. He is in a sinus rhythm on the monitor. I put him on a nonrebreather at full power and get an IV in his arm. I am thinking heroin overdose. I give him 1.2 milligrams of Narcan, then an additional .8 milligrams. No change. His blood sugar is around 80, so I try an amp of D50. Still nothing. I recheck his pupils and notice they have dilated somewhat, so maybe there was some opiate in there, maybe mixed with the tricyclics. I listen to his lungs again, which were clear, and now I hear rales, the wet bubbly sound of fluid flooding into the lungs. I look at the monitor, and see he is having ST elevations—a sign of ongoing injury to the heart. I tell Arthur to drive like hell to the hospital and reach for my med box to draw up some Lasix. This man’s case is beyond my ability to solve. I glance back at his pupils. One has gone back to being constricted, while the other stays dilated. I think he has a bleed in his brain. He starts seizing. By now we are at the hospital. In the cardiac room he gets intubated, and the doctor gives him Valium, more Lasix. The twelve-lead ECG shows a possible heart attack. He is sent up for a CAT scan, which shows a massive bleed. Everything is going wrong. Later the doctor says he thinks it all started with the bleed, caused by the man’s hypertension, while the trauma to the system caused him to go into pulmonary edema, and the strain caused the heart to infarct. The car accident and the tricyclics were red herrings.
The man lives, but is permanently incapacitated.
Not all calls can be figured out. The key for us is to follow a logical train of thought, develop a style, a routine so we don’t forget anything in the midst of the chaos of the call.
We try to know when we can fix the problem there or when we have to bolt and run. “Stay and play” versus “Bag and drag.”
A fifty-year-old man collapses of a heart attack four blocks from the hospital and goes into cardiac arrest. I will work that man where he fell because I have the equipment and tools to bring him back, and if he is going to be brought back, it is going to be here. He cannot afford the time it will take to get him in the back of the ambulance, drive four blocks, unload him, and wheel him down the hall to the cardiac room. He needs immediate defibrillation, intubation, an IV with medications. Once I have him stabilized—either back alive, tubed with a round of drugs in the line, or shocked into a flatline—then I can move him to the hospital. But if that same man were shot in the chest, I would put him on a backboard and fly (doing IVs and intubation en route) to the hospital trauma room, where they would rush to get him upstairs to a surgeon or operate on him right there, cracking his chest, trying to sew the hole in his heart.
There is a concept called “the golden hour of trauma” and a concept called “the golden ten minutes.” The idea is a trauma victim has an hour to get definitive treatment at the hospital, and you never want to spend more than ten minutes on scene. Spend more than ten, and there is hell to pay. But they are both just concepts. Some patients have two hours, or two days, or the rest of their lives. Some don’t have an hour. Some don’t have twenty minutes, some don’t have ten, some don’t have sixty seconds. Spending ten minutes on scene for a guy who doesn’t have it to spend is wrong.
Much of the controversy about the death of Princess Diana centered on the French EMS system, which took over an hour to get her to the hospital. In France, they work on the trauma patients on scene and in the stopped ambulance, rath
er than trying to race them to a trauma center, getting done what they can on the fly. Many U.S. experts thought Diana would have lived had she been rushed to the hospital and gotten definitive care in an operating room.
When you come into the trauma room, you want to have your patient intubated, two large bore IV lines running, neatly C-spined, clothes all cut off and exposed, every bullet hole bandaged. Unfortunately, there often isn’t time for that, particularly when you are dealing with people shot within blocks of the hospital.
We’re called for a shooting, possibly two victims. We arrive to find only one victim—a nineteen-year-old male shot twice in the torso. We learn later the guy who shot him, whom he shot in return, was taken to the hospital by private car. Our patient is badly hurt. He is perspiring, pale, short of breath. He looks blankly at me and says nothing. Death reaching in. We load him quickly onto a board and get him in the back of the ambulance. He needs a surgeon.
“Drive!” I shout to Arthur. “Drive.”
And he does. Like the wind.
I try to get a quick blood pressure but can’t. His pulse is fast, weak, and thready. I have time only to rip the young man’s shirt open and listen to his lungs to see if he has a tension pneumothorax—a collapsed lung caused by a rapid buildup of air in the chest, pressing against a lung, collapsing it—which could kill him before we can get him to the operating room. I can drive a large needle into the chest to release the air, but I don’t hear a tension. His lung sounds are equal on both sides, though very shallow. I get out the ambu-bag and start assisting his respirations. There is no time to intubate as we already are pulling into the hospital emergency entrance.
I come in with nothing, no tube, no line, no monitor, the guy on a backboard, no C-collar, only his chest exposed, bagging him with the ambu-bag, and mumble, “The guy’s shot at least twice in the side—there—I couldn’t get a pressure, pulse is weak and thready, I’d guess around a hundred and twenty.” His breathing is shallow, labored. They look at me like I am incompetent. They don’t see the clock on the wall of my imagination, the track and field million-dollar scoreboard that shows me breaking the tape to the trauma room door at 3:59 from arrival on scene. I go down the hallway, stripping my soaked gloves off my hands, my whole body drenched in sweat. I sit down and start my run form. Seven minutes later I look up and imagine my ambulance pulling in. I get out of the back with the same patient, backboarded, intubated, two large bore lines running, monitor attached, and oh yeah, CPR in progress. Good job, they tell me in the trauma room, you gave it your best. They look at their clock. Call the time. Patient pronounced.
Meanwhile upstairs in surgery, the surgeons have a live body to save. Our patient will live to walk out of the hospital, live to shoot, and likely, to be shot again another day. Saving lives can be complicated. You just have to try to do your job the best you can.
Baby Code
My portable radio crackles, “Stonington … Baby not breathing.”
I’m outside the Hartford Hospital Emergency Department. Arthur is in the back EMT room writing up the run form from our last call—a minor rush-hour motor vehicle accident up on I-91 near the Jennings Road exit. I’ve just finished restocking the ambulance, putting a long board back in under the bench, finding some straps, making head rolls.
Stonington is just a couple minutes from the hospital.
“Did they send a basic to that call?” I ask Melody Voyer and Jerry Sneed, the crew of 461, who are bringing their stretcher in to pick up a transfer out. A basic is a car without a paramedic, just two basic-level EMTs, who don’t carry heart monitors, breathing tubes, emergency medicines, IVs, and other advanced life-saving equipment.
“Yeah. Eight-five-six,” Melody says.
Jerry says, “That’s Pam Piseeka. She already did one pedi code this week.”
There must not be any paramedic units available nearby. “Do me a favor. Art’s in the back room. Go tell him we might be getting a call.”
I open up the passenger door of my ambulance, 471, and pick up the mike to the company radio. “Four-seven-one, do you want us to take that Stonington call? We can clear.”
“Yeah, four-seven-one, go. Eight-five-six, advise when you get there. I’m sending four-seven-one from Hartford.”
“Four-seven-one responding.”
I turn to go into the ER to get Arthur. A young paramedic student who has been waiting for 482 to come pick him up for the day, asks, “Do you mind if I come with you?”
“Hop right in back,” I say.
Arthur comes out the automatic doors.
“Baby not breathing,” I say.
“Where?”
“Stonington.”
We head out, lights and sirens on.
As we pull out onto Retreat Avenue, I turn and say to the rider in back, “There’s an orange box on the shelf under the monitor. That’s the pedi box. Open it and take out the pedi ambu-bag, and get it set up.”
“Four-seven-one,” our dispatcher says, “It’s confirmed, cardiac arrest.”
“Copy. Tell them we’re coming.”
As we try to cross Maple Avenue, a man driving a blue Lincoln, talking on a cellular phone, blows right in front of us.
Arthur curses and pushes the air horn.
We’re at a dead stop.
Cars ignore us. A Bronco whizzes by, oblivious to our whirling lights. A Taurus races past. Then a pickup.
Arthur guns the engine. We’re across.
I wonder what lies ahead. Will the kid be inside or out? Will I find only the mother or a crowd of hundreds? Is the kid going to be freshly down or long dead? Either way, we’ll go to the Connecticut Children’s Medical Center (CCMC) next to Hartford Hospital. We haven’t heard 856 put out yet. They must be coming from farther away.
We’re on Stonington now. Ahead on the right in the parking lot is a fire engine and a group of people gathered around a police car. They are waving at us, shouting. Two men are doing CPR on the baby.
I call back to the rider, “Get the half board out, lay it on the stretcher.” The half board is a short wooden board that we will lay the baby on; it will provide support for CPR compressions. I say to Arthur, “I’m going to grab the baby and we’re going to bolt.”
“Four-seven-one, eight-fifty-six, how you doing?” the dispatcher asks.
“Put us out in ten seconds,” I say. As Arthur pulls to a halt, I jump out and run over to the car, my eyes locked on the baby.
“Where the fuck have you been!” a firefighter shouts at me.
“Jesus fucking Christ!” another one shouts. “We’ve been here for five minutes. Where have you guys been?”
“Tell me what happened,” I say.
“His mother woke up and found him not breathing,” the cop says.
“Don’t fuck around. He’s not breathing. Don’t fuck around,” the other firefighter shouts.
I pick the baby up and cradle it across my right arm, its head in my hand. I start toward the car. It has a wide, round head, no neck. It is a white-blue color and stiff. It feels just like a CPR infant mannequin. I walk fast. Everyone is yelling and screaming, crying. I do CPR with my fingers. I raise the baby’s head up to my face and press my lips to its cold mouth and breathe in. You are not supposed to do mouth-to-mouth. There is danger of disease. You use the ambu-bag, but I don’t have it—it’s in the ambulance, and I couldn’t give it air while walking this fast anyway, and everyone is yelling. I blow tiny breaths. The chest rises slightly. They are the coldest lips I have ever kissed.
I get in back, lay the baby on the board. A firefighter jumps in. I shout to Arthur to drive. Pam Piseeka arrives in the other car; she gets in and says she’ll do compressions. She lies over the baby and works her fingers on its chest, a large woman over the little doll of the cold blue baby, beating her fingers, trying to change this world. The student has the ambu-bag. “Ventilate,” I say. He doesn’t have the mask attached. I root through the box for it but can’t find it.
“It’s on the f
loor,” Pam says. I spot it by my large black boot, grab it, tear off the plastic, and attach it to the ambu-bag. I hand it back to the student and he starts ventilating. I attach the oxygen tubing on the ambu-bag to the oxygen spigot on the wall and turn it up to fifteen liters per minute.
I hear our dispatcher on the radio. “I’ll notify CCMC for you.”
We’re off on a priority one, full lights and sirens.
I attach the heart monitor to the baby’s chest, three tiny star-shaped electrodes, one over the right upper side, one the left upper, the last on the left lower.
I look at the monitor screen. Flatline.
I open the airway kit and grab a small plastic tube and a steel blade, which I attach to the laryngoscope. “Out of the way,” I say.
“He’s going to intubate,” Pam says.
I ease the teeth apart, then stick the blade in the mouth, lifting up the tongue, and sweeping it aside. The bulb at the end of the blade illuminates the throat. I look for the tiny white vocal cords that should be hanging from the top of my view. I don’t see them. I pull out. “Ventilate.”
I wait thirty seconds and go in again. I look. Nothing. “Screw it. Ventilate.”
Pam pounds away with her fingers, tiny compressions a half inch deep. The student ventilates steadily.
We’re out at CCMC. The back door opens and Mike Lambert, a paramedic from another car, is there. I pass him a portable O2 bottle, which he sets at the foot of the stretcher. I unhook the in-house oxygen and pass him the tubing, which he hooks up to the portable. Arthur pulls the stretcher out. We wheel it in. There is a large crowd of doctors, nurses, and staff waiting for us. We go straight into room one. “We don’t know when the baby went out,” I say. “The mother woke up and found it not breathing. Asystole in all three leads. Couldn’t get a tube. It’s pretty cold and stiff.”
Doctors examine the baby. It’s got lividity and rigor, meaning the muscles have stiffened and blood has pooled in the lower parts of the body after circulation ceased. They put it on their monitor. Flatline. They keep doing CPR while they decide what to do. The baby’s dead. Long dead. We all know that. There is no point in doing anything, but they can’t quite stop.
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