DWPA (Died With Paramedic Assistance)

A timely excerpt, and not just because I’m feeling lazy today:

His name is Frankie Maryland, and he’s 25 years old. He comes around to visit me occasionally, usually when I’m feeling pretty cocky. He reminds me that I’m fallible, that I make mistakes.

I believe that every paramedic has his own personal cemetery, a dark little corner of his psyche where he stores the faces and memories of people he wished he had served better…things he wished he had done differently. The rest of the calls you run, good or bad outcomes, blur with the years until you’re lucky to even remember the vaguest of details. The faces and the names fade into half-remembered diagnoses – Diabetic Lady, Homeless Man, The Kid in The Rollover…

But occasionally, in the wee hours when you’re alone and nagged with self-doubt, some of the faces materialize with startling clarity, phantoms from the past come home to haunt you. You never really get rid of them, the ones you killed. All you can do is hope to make friends with their ghosts.

Frankie is black, well over six feet tall and 250 pounds, and a pretty good linebacker during his high school days. His friends will tell you he’s a funny guy, the kind who is quick to loan money to a friend, and then forget about the debt. His friends aren’t the most reputable people around, but Frankie is extremely protective of his younger brother and sister. He doesn’t bring his friends around the house, and he’s pretty strict about who his brother and sister run around with.

Frankie and his siblings live with their aunt, a single woman with no kids of her own. Carlotta has raised Frankie and his little brother and sister since Frankie was eight years old, when their mother abandoned them and ran off to Detroit with her dealer.

I first met Frankie on his 25th birthday. He wasn’t having much fun, the festivities interrupted by gunfire from persons unknown. Frankie took a round in the belly. I was called to Podunk General at 3:30 am to transfer him to Big City Regional Medical Center for exploratory surgery. I am tired, groggy, and in a foul mood. They’ve called me from Quaint Little Hamlet to make this transfer while the Podunk crew sleeps comfortably, less than a mile from the hospital. I’m only half listening as the nurse gives me report.

Blah, blah, blah…BP 100/52…blah, blah…two IVs, good for you…blah, blah, blah…oxygen at two liters, yeah you people think oxygen is a poisonous gas…blah, blah…combative, huh? Well, can’t blame him. I wouldn’t be happy about being in this fucking Band-Aid Station either…blah, blah, blah…restrained on a long board…blah, blah…yeah, you too. Thank you for calling the big white taxi.

Fifteen minutes into the trip, I’m taking vital signs and I can’t get a blood pressure.

No big deal. It’s hard to hear in the rig. I’ll just palpate one.

While I’m trying unsuccessfully to palpate a blood pressure, Frankie moans and says, “I’m gonna puke.”

“Just hold on,” I tell him, scrambling for an emesis basin. “Take deep breaths.”

He does just that, as I find an emesis basin and set it beside me on the seat.

We’re evaluating a new vital signs monitor, so I figure now is as good a time as any to try it out, and I wrap the cuff around his arm. As the cuff is inflating, Frankie moans again and vomits before I can get the emesis basin under his chin. It’s pure, bright red blood, and there’s a lot of it. Frankie heaves again, and more blood fountains out.

Holy shit! Where is all this blood coming from?

I scramble to loosen the straps and tilt him on his side with one hand, while reaching for the suction with the other. He’s too big to tilt with one hand, so I yank at the suction tubing to untangle it, then drop the suction tip on the seat. I grab him with both hands and roll him onto his side, and the blood drains out of his mouth and puddles on the floor. His eyes are rolled back, and he’s making horrible gurgling sounds.

God, he’s aspirating this stuff right here in front of me!

I jam the rigid suction tip into his mouth and flip the switch, but nothing happens. In my haste, I’ve pulled the tubing loose from the suction canister. I hurriedly reattach it as Frankie vomits again. I am having trouble tilting him and working the suction unit at the same time. I apply suction, and watch the blood creep up into the suction canister at an agonizingly slow rate. Frustrated, I yank the catheter tip off and stick the hose in his mouth and breathe a sigh of relief as the blood clears. He’s still got a nasty rattle when he breathes.

I look up at the vital signs monitor, and the blood pressure is only 72/40. The cardiac monitor shows a sinus tachycardia at 130. I pull my knee from under the board where I’ve been attempting to prop him on his side, and put a non-rebreather mask over his face. I open up both the IVs wide open, but they seem to be running awfully slow. I look carefully at the lines and at both sites. Both of them are 22-gauge catheters – in the antecubital veins, no less.

“Fuck me!” I blurt in frustration. “Goddamnit!”

Who is the idiot snurse who put 22-gauge catheters in a trauma patient?

“Everything all right back there?” asks my partner, Marlboro Man. Aunt Carlotta is riding in the front passenger seat, and she has turned around in her seat, watching through the small window between the box and the cab.

“No, everything is not all right!” I shout back at him in frustration. “Step it up! And call Big City and tell ’em he’s crashing!”

“That all you want me to say?” he asks as he hits the lights and siren.

“No, but I’m too busy to talk right now. Just drive!”

I manage to see a little stretch of vein above the IV site in his left arm. I delicately insert a 14-gauge and switch the IV line over, and it flows quickly with no swelling.

So far, so good.

I’m taping down my second line when Frankie vomits again. It’s more blood, and it keeps on coming.

Oh no, not that again! Please, please stop this. Where in the fuck is all this blood coming from?

I stick the suction tubing back into his mouth and reach with one hand for the airway kit. I grab a tube and stylet and assemble my laryngoscope, and without warning the suction unit stops working. It’s still making noise, but it’s not clearing his airway anymore. I look disbelievingly at the full canister.

Goddamnit!” I shout. “Don’t do this to me!”

Jesus Christ, that’s what, more than a liter of blood in just a couple of minutes? And his heart
rate is only – Oh God – forty-four beats a minute! What do I do now?

I’m not sure if I’m screaming at Frankie or fate, but I keep shouting as I hurriedly try to intubate. “Frankie! Frankie! Can you hear me? Stay with me, man. Hang in there!”

I can’t see the airway through all the blood. I try to scoop out as much as I can with my fingers, but it only wells back up as soon as I scoop it out. I try to empty the suction unit, and dump the entire canister into the biohazard bag, but when I reassemble the unit, it doesn’t work. Apparently I’ve put it back together incorrectly in my haste, and I snarl, “Fuck me!” as I give up on using the suction unit. Frankie still has a pulse, but it’s a faint one. He’s not breathing any longer.

“Frankie, stay with me!” I shout at him, my voice rising. Even I can hear the fear and desperation in my voice. Aunt Carlotta is sitting in the front seat, watching, but I can’t seem to shut up. “Goddamnit, don’t you give up! Hang on! Damn you, you sonofabitch, you will not die on me!”

I try again to intubate, and still can see nothing.

Fuck it! I’ll blindly insert the tube. If it goes into his trachea, I’ve got an airway. If it goes into his esophagus, at least the blood goes out the tube and onto the floor.

Sure enough, the tube winds up in his esophagus. The blood isn’t coming as quickly as it was before, just slowly oozing up out of the tube, but then I don’t imagine there is too much blood left.

I feel for a pulse as I reach for another tube. He’s got one, I think. The cardiac monitor shows a rate of 36 in an ugly idioventricular rhythm, Death writ large on the monitor screen in a lazy scrawl. I’m just getting ready to try another intubation attempt when the back doors fly open. We’ve already backed into the ambulance bay, and I haven’t even noticed. Marlboro Man looks scared. I can’t even imagine what I look like right now. Carlotta is standing off to one side, sobbing uncontrollably. I toss the tube, BVM and laryngoscope onto Frankie’s chest, as MM gets the IV bags. They’re both nearly empty.

The doctor meets us right inside the door. I don’t recognize him, but he doesn’t look pleased with me. Right now, I could care less. The doctor looks at me, at Frankie and at the tube and starts yelling. “What the hell is going on here? What happened?” He hooks up the BVM and squeezes it once, auscultating Frankie’s stomach as he does. “This tube is in the stomach!” he says angrily.

“Wait, don’t pull the-” I start to say as he snatches the tube out, but I am too late. “Well, that’s just fucking great! Now try to get an airway! Fucking idiot!” I scream at him, spittle flying as MM wrestles me away.

The doctor and several nurses wheel Frankie hurriedly into a room. I calm down enough to see that everyone has stopped what they were doing, staring at me uneasily. I look down at myself to see that I’ve got great smears of blood all over my uniform shirt and pants. There is blood all over my forearms. Aunt Carlotta acts like she hasn’t heard a thing, standing behind us sobbing quietly.

“Come on, AD. I’ll buy you a Coke,” MM says quietly as he steers me into the nurse’s lounge. He says nothing to me as I clean up at the bathroom sink. A nurse walks in a bit later. She hands me a scrub top.

“Here. It’s about the only thing we have in your size.” I nod gratefully and duck into the bathroom to change. My eyes are red, as if I’ve been crying. I can’t remember. When I come back out, the nurse is still there. “You okay?” she asks me, concerned.

“Yeah, I guess so,” I sigh shakily. “Is he gonna file a complaint?”

“Nah, I doubt it. He’s not really a bad guy. You just took him by surprise. I think he thought you were gonna flip out and whip his ass. We all tried to convince him you weren’t really unstable.” She grins at me and winks. It works – I feel a little better.

“Thanks. How’s my patient?” I ask her, dreading the answer.

“We called it about five minutes ago,” she says softly. “Never did get an airway,” she adds, as if this will make me feel better.

“Yeah, I figured that. Well, thanks for the scrubs. I appreciate it,” I tell her as I turn to leave.

She shrugs as if to say, “don’t mention it.”

Outside, Carlotta is leaning against the wall, smoking. She has stopped crying, but I can’t face the look I’ll see in her eyes. I try to slip by her as if I haven’t seen her, but I feel her hand on my arm as I walk past, and she gently turns me to face her. I just stand there, afraid to say anything.

She reaches up and pulls my head down to her shoulder, and puts her hand on the back of my head. “It’s okay,” she whispers in my ear. “You did all you could. I know you did your best.” She holds me there for a few seconds longer and then grasps both of my arms, forcing me to meet her gaze. “Really,” she says seriously. “Thank you.” I nod dumbly and walk away.

Marlboro Man and I don’t talk on the ride back to Quaint Little Hamlet. The sun is coming up as we pull into the station. I walk alone into my bathroom, turn on the shower and sit down under the spray, arms wrapped around my knees, rocking and crying uncontrollably. I rock and shake and weep for I don’t know how long, then quietly dry off and climb into bed.

Frankie Maryland died on his 25th birthday, thirteen years ago this week. It was my fourth call as a paramedic.