Two Saves In Two Days

A retread from the book, as a favor to Kim, who asked what was my most memorable save. I’ve attempted many resuscitations, but I have succeeded in reviving precious few, and only a tiny number (less than ten) have actually recovered to lead productive lives.

I have worked the vast majority of my career in rural EMS, where the typical response time is upwards of twenty minutes. Not often will you find a patient still workable in such an environment, but we tried, and thus every time we got a pulse back is memorable.

Here’s a story of one shift where I had the Golden Touch:

Green Acres Nursing Home isn’t too bad as nursing homes go. The prevailing stench there is of Clorox and baby powder, but without the faint essence of shit and stale urine common in so many other nursing homes.

The trend around here is to build large, sprawling “geriatric care centers” with pastoral sounding names like “Oak Lawn Manor,” or “Shady Lane Care Center,” but the only thing that really distinguishes them from the older nursing homes is that there are urine stains on carpet instead of linoleum. Other than that, it’s a wash.

I have a major problem with an industry that warehouses old people, and considers 50:1 an acceptable patient to nurse ratio. So families will know what they’re doing to their parents and grandparents, I think they ought to give them names that describe the actual living conditions, like maybe “Our Lady of the Clogged Feeding Tubes,” or “Aspiration Manor,” or my personal favorite, “Chateau of Methicillin-Resistant Staphylococcus Aureus.”

Some of these places are really grim. There is one near Lake Podunk where you see people shuffling around in a drug-induced fog, dried food on their faces, and feces and urine stains on their clothes – and that’s the nursing staff I’m describing. The patients are really bad.

There is a love-hate relationship between paramedics and nursing home nurses. We hate them because of the ignorance and apathy we see in them, yet we probably couldn’t get paid without the patients they ask us to transport. They hate us because we’re often arrogant and condescending, with no concept of how tough and emotionally draining their jobs are, yet love us because we’re trained to handle emergencies, which is not the forte of the average nursing home nurse.

I am reflecting on this relationship because Effeminate Partner and I have been called for a cardiac arrest at Green Acres. Our relief crew, Frick and Frack, have managed to alienate most of the staff at the local nursing homes, which reflects poorly on Podunk EMS in particular, and paramedics in general.

This has made my job tougher when I have to deal with these people. There is usually a distinct chill in the air when we pick up a patient from Green Acres, but not this time. This time, they’re going to be damned happy to see us arrive. This time, we’re the cavalry. The pros from Dover have arrived.

Effeminate Partner and I are directed to a room at the far end of one wing, where we find a tiny, frail little woman in full arrest. The staff is doing effective CPR, for a change. They have even removed the head of the bed and placed it under her shoulders as a CPR board. There is an equally frail little old man in the next bed, sobbing pitifully.

“Just let her go, you bastards! Why can’t you just leave her alone?” he pleads in a quavering voice. “Please just let her go!” Everyone seems to be ignoring him.

The nurse doing ventilations looks up at us as we enter the room. She’s been working hard; there is sweat dripping off her nose, and her hair is in disarray.

“How long has she been down?” I ask as I do a quick look with my defibrillator paddles. The rhythm looks like ventricular tachycardia.

“Maybe five minutes,” the nurse answers as I charge the paddles. “She collapsed while the aide was feeding her breakfast.”

“Everybody clear!” I sing out, and then light her up with 200 joules. The rhythm changes immediately to ventricular fibrillation, so I charge the paddles to 300 joules and pop her again. The rhythm changes to asystole. I pause to check a pulse, don’t find one, and put my paddles back in the defibrillator. I notice that EP is desperately scrabbling through the monitor case, opening every zippered compartment.

“No electrodes!” he says, anguished.

Well, that figures. Frick and Frack told us the truck was stocked up and ready to go when we relieved them this morning. I should have known better.

“Well, hustle out to the truck and get some!” I snap, and then turn back to the nurses. “Could you ladies resume CPR while I get her intubated?”

I quickly open my airway kit, grab my laryngoscope and a 7.5 tube, and intubate her without much trouble. An aide hands me the BVM, and I pause, looking in vain for any nurse with a stethoscope hanging around her neck. Normally, EP checks breath sounds for me while I ventilate, but he’s fetching electrodes right now.

“Uh, anybody got a stethoscope?” I ask hopefully, to which everyone replies by shaking their head.

Well, shit! Okay then, we’ll improvise.

I place my hand on the woman’s stomach. “Bag,” I tell the aide. She complies, and the stomach doesn’t rise. “Again,” I tell her, placing my hands on the woman’s chest. Both sides of her chest rise equally.

That’s good enough for me.

I grab some tape from my thigh pocket and quickly tape the tube down, wrapping the tape all the way around her head several times for good measure. I hand off the BVM to the aide, and step back over to my monitor. I do another quick look, and the rhythm is still asystole. I drop the paddles next to the monitor, pull up two milligrams of epinephrine from a multi-dose vial, and jam the needle into the side of the ET tube, just above the lips. I inject the contents, and order the nurse doing chest compressions to stop for a moment. The aide doing the ventilating takes this to mean her as well, and stops bagging. I tap her on the arm.

“Not you,” I say. “Bag like hell for a few seconds.” EP reenters the room, carrying several packages of electrodes. He is red-faced and out
of breath.

You regret those cigarettes now, don’t you partner?

He quickly attaches the electrodes and switches the lead selector switch on the monitor to Lead II. The rhythm is still asystole, as flat as can be. The old man in the next bed is just crying and moaning pitifully to himself now.

“We need a line,” I tell EP, who digs through the jump kit for a bag of saline and an infusion set. He curses under his breath and straightens up.

Shit, don’t tell me. No saline either? Frick Medic, you will roast in Hell for this!

I meet EP’s gaze, and he looks as if he’s about to cry; whether in frustration or the prospect of sprinting to the rig again, I can’t tell. I say nothing, just point at the door, and he wheels and sprints out of the room. I dig through my drug box, and manage to find a 250 ml bag of 5% dextrose and a microdrip infusion set. I hand it to a nurse, grab a 14-gauge catheter and start looking for a good external jugular vein. She’s got a whopper, so I sink the catheter and attach the line the nurse hands to me.

I tape it off securely, open the clamp and watch the fluid flow. It’s patent, so I close the roller clamp, grab pre-filled one-milligram syringes of epinephrine and atropine, and administer them both, opening the clamp briefly to flush the meds in.

“You’re doing great, ladies,” I tell the nurses as I hand the bag off to one of them. “Just keep doing what you’re doing.” The pitter-patter of little feet in the hallway herald EP’s return, and he bursts into the room with a spiked bag of saline, trailing a trickle of fluid behind him. He hands me the bag without a word, and leans over with his hands on his knees, gasping for air.

“Switch this out for me, would you please?” I ask the IV nurse, handing her the bag of saline. As she does that, I notice a rhythm change on the monitor. It’s v-fib. Charging the paddles again, I holler, “Clear!” and hit her with 360 joules. The rhythm changes to sinus bradycardia, then rapidly speeds up to the prettiest sinus rhythm I’ve seen in a long time.

Sinus rhythm at seventy; I’ll take that any day. And from the combination of relief and amazement on the BVM aide’s face, there is good news on the airway front as well.

“She’s trying to breathe through the bag,” she says wonderingly.

I’ll be damned, she is! Gagging on the tube, no less!

“Great work, ladies. She’s got a pulse,” I grin at the nurses. We take a couple of minutes to get her on the stretcher, secure her arms, and bolus her with 75 milligrams of lidocaine. As we roll her toward the door, one of the nurses stops us as we pass the old man’s bed.

“Her husband,” she explains, a fact that I feel shamed for not picking up on. He is still crying, rolled partly over in the bed reaching feebly for the stretcher legs. EP and I lower the stretcher and maneuver it as close to his bed as we can. He gently kisses her cheek and strokes her hair, his hands palsied and trembling with the telltale signs of Parkinson’s disease. I wait quietly, allowing him as much time as I dare, then reach down and gently pull him away. Her cheek is wet with his tears.

“Sir,” I tell him softly, and a little huskily, “I promise we’ll take good care of her. We’ll be gentle.” He says nothing, just rolls on his side and closes his eyes. Unsure of what else to say, I nod to EP and we lift the stretcher and roll her out the door. There is no backslapping, no exchange of high fives in the hall. If this is a save, it doesn’t feel like one.

On the way to East Lake Podunk Hospital, I take the time to hang a lidocaine drip.

What the heck, I’ve already got the right bag spiked.

At the ER, Dr. Idris takes report. He listens, nodding occasionally as I talk, then looks up at me, horrified.

“You started an external jugular IV?” he asks incredulously. “Couldn’t you find a vein somewhere else?”

“Uh, well Doc,” I say hesitantly, not sure of what his problem is, “I never actually looked anywhere else. Is that a problem?” He shakes his head angrily.

“We cannot admit her like that!” he blurts, motioning to the nurse. “Nurse, find another vein and discontinue that IV!” Future Missus complies, winking at me surreptitiously as Dr. Idris turns his back.

Our patient, Mrs. Couvillion, is moving now. She gags on the tube and tosses her head, her eyes tracking Mary as she moves around the bed. I walk back into the corridor and find a middle-aged woman and her husband standing there at the desk. Dr. Idris is nowhere to be found.

“Can I help you folks?” I ask.

“Edna Couvillion?” the lady asks me uncertainly. “Is she here? I’m her daughter,” she explains. “The nursing home told us they sent her to the hospital.”

“Oh, okay!” I say, shaking their hands. “I’m the paramedic who brought her in. The nurse or doctor should be able to let you know how she’s doing in a minute.”

“What happened?” the son-in-law wants to know. “Well, apparently she went into cardiac arrest while they were feeding her breakfast,” I tell him, then hurry on as I see the shocked expressions on their faces. “It’s okay, though. We managed to revive her in time, and she’s awake right now. Her vital signs are good, and she’s aware of what is going on around her. Keep your fingers crossed, and the doctor will be able to tell you more, but right now it looks as if she’s going to be okay,” I smile reassuringly.

“But I don’t understand,” the woman says, confused. Her husband just looks pissed. “She didn’t want any heroic measures taken. Her and Dad didn’t want to be resuscitated. They signed a form and everything…”

“Oh,” I stammer. “I didn’t know that. Well, I mean I wasn’t told…the nurses were…uh, I don’t know what to say…well, the doctor will see you in a moment,” I finish lamely and beat a hasty retreat back into the ER.

“FM,” I hiss as I walk back inside, “this woman has a DNR! Her family is outside, and they want to know why we did anything!”

“Green Acres,” she groans, hanging her head, “codes everybody, no exceptions.” “Even the DNR patients?” I ask disbelievingly.

“Even the DNR patients,” she confirms. “Apparently, their lawyers found something wrong with the way their Do Not Resuscitate orders were w
ritten. They said none of them were valid, so Green Acres resuscitates everybody until they get it straightened out.”

Good Lord! Well, I suppose if she codes again, we can just let her go this time.

I say as much to Future Missus. “Relax,” she says, “you got a save. I’ll explain things to the family.”

“Well, it doesn’t feel like one right now. It actually feels kind of disappointing,” I confess. “You’re going to talk to the family, instead of Dr. Idris?”

“He’s probably already gone home,” she snorts, then grins wickedly. “And you’re not the only one who is in for disappointment today. Idris will not be happy when I send this lady to the floor.”

“Why should he be disappointed?”

“Because the only vein I could find was in her foot. I’ve got a 22-gauge in it, with your fluids hooked up,” she explains with a twinkle in her eye, “but I’ll be damned if I’m going to discontinue a 14-gauge IV for a 22-gauge in the foot. So I heparin-locked yours, and if Dr. Idris doesn’t like it, he can kiss my ass.”

Man, I like this girl!

It’s the second day of our 72-hour weekend shift in East Lake Podunk. Yesterday morning, we resuscitated a DNR patient from Green Acres Nursing Home, and then transferred her to Big City Memorial a couple of hours later. After a fitful sleep on the first night of my 72-hour shift, I get a call from the ED. The word is that our patient will not only live, but will be back in the nursing home within a couple of days, none the worse for wear. It’s some consolation at least, knowing that even though she had a DNR, she will be going back to her husband.

Future Missus has invited us to East Lake Podunk Community Hospital’s annual crawfish boil to commemorate National Nurse Week. The three of us are sitting on a blanket on the hospital’s south lawn, devouring a huge mound of crawfish piled between us, taking painstaking care to keep from staining our uniform shirts.

Dr. Idris wandered by a few minutes ago, looking very relaxed. He sat his drink down next to mine, and I mistakenly picked it up and drank from it. Whatever it was, it burned like fire all the way down. It was definitely not tea, and I strongly suspect it was something that a nice Muslim fellow like Mohammed Idris should not be drinking.

Nevertheless, he seemed to be enjoying himself, and his wife could have driven him home if need be. He even sampled quite a few of the crawfish with us infidels, and then wandered off mumbling something about the men’s room.

“We should have warned him to wash his hands,” EP muses.

“Oh, I’m sure Dr. Idris knows to wash his hands after using the bathroom,” Future Missus admonishes.

“It’s not after he takes a piss that he needs to worry about,” EP explains tolerantly. “These crawfish are spicy, and he’s got cayenne all over his hands.” FM and I chuckle at the mental image.

She is leafing through a copy of Brides magazine, looking at wedding dresses. Since we’ve become engaged, EP has been dropping serious hints about being our wedding planner. Problem is, he has expensive tastes while I have an EMT pocketbook. He and FM are constantly whispering conspiratorially over flower arrangements, photographers, bridesmaid dresses and the like. I’ve washed my hands of it, requesting only that my groomsmen and I wear black tuxedos. I hate white tuxes.

“Medic 306, Dispatch. 1158 Highway 27 North, on a cardiac arrest,” the radio rudely interrupts EP extolling the virtues of a particular wedding dress. We both groan and reach for our shirts.

“We’re en-route,” I respond as FM sighs. I give her a quick peck on the cheek and sprint for the truck. Just north of the East Lake Podunk city limits, an old man flags us down. We back into his driveway as he impatiently shouts, “Hurry up!”

As soon as I get out of the rig, he confronts me angrily. “What take you so damned long?” he demands in a thick Cajun accent. “I call fifteen minute ago!”

“Calm down sir,” I reply, trying to placate him. “We just got the call no more than two minutes ago.” I step around him and help EP unload our gear. Inside the house we find two identical burly young men wearing identical overalls and white tee shirts, kneeling beside a frail body on the floor. They have the large, calloused hands of pulpwood haulers, and are delicately yet efficiently doing picture-perfect CPR on an elderly woman. The one doing compressions looks up as we enter the room.

“My grande mama,” he tells us breathlessly in an accent every bit as thick as his father’s. “She fall out mebbe two, t’ree minutes gone.”

“Mais non, she got a bad heart,” the man’s brother confirms.

“Okay gentlemen, step back please,” I order as I check for breathing and a pulse. There is neither, and I gesture for them to resume CPR. The cardiac monitor shows coarse ventricular fibrillation, so I charge the paddles and shock her. Her back arches violently, drawing a muttered oath from the twins. The monitor rhythm changes to sinus bradycardia and I feel for a carotid pulse, slowly breaking into a grin as I feel a strong, steady beat. She is still not breathing, however.

“Is she back?” EP asks hopefully.

“I think so,” I nod, to the relieved sighs of everyone present. “Get some vital signs, okay?” I ask EP as I begin to prepare my intubation equipment. I ask one of the twins, “Keep breathing for her for a minute, would you?”

I’ve just inserted the tube and inflated the cuff when a commotion at the door attracts my attention. Dr. Idris is standing there brushing off the mud he got on his pants from falling on the porch steps. His wife is standing just behind him, looking concerned.

“I saw the ambulance outside,” he explains. “What happened to Mrs. Pitre?”

“Ah, the doctor, he done come!” the old man exults, throwing his hands into the air. “Everyt’ing be all right now, you watch and see,” he assures his grandsons.

I am still trying to frame my reply to Dr. Idris when Mrs. Pitre arc
hes her back again, gags and pulls out the endotracheal tube before I can stop her.

Ouch! That’s not going to help her singing voice.

“Cardiac arrest, as best we can tell,” I tell him. “We shocked her once and converted her, and as you can see, she just extubated herself.”

Please don’t come any closer, Dr. Idris. They’ll be able to smell the liquor on your breath.

“Okay, then give her 100 milligrams of lidocaine and set up a drip at…” he trails off, noting my amused expression. “Well, you know what to do,” he finishes. “I’ll meet you at the hospital.” I say nothing as he steps into the room and helps us package and load Mrs. Pitre on the stretcher. Thankfully, her family stays several steps away, out of sniffing distance.

“Look, we’ve got this under control,” I lean close and say softly to him, putting one hand on his shoulder. “Why don’t you let your wife drive you home, and then call Dr. Saleh with any orders you have?” I suggest gently. He meets my eyes for a long minute, then nods and backs out the door. The Pitre family waves at him gratefully as his wife drives him away.

“Merci beaucoup, Doc!” they bellow as his taillights fade into the night. “T’ank you so much!”

Hey folks, what about our thanks? What are we, chopped liver?

In the truck, Mrs. Pitre is quickly regaining consciousness. She has no memory of what happened. “I felt kind of swimmy-headed, that’s all,” she says hoarsely. “That’s all I remember.”

“Well, your grandsons were doing CPR on you when we got there,” I tell her as I gently slip a twenty-gauge catheter into the back of her left hand. She flinches slightly, then smiles at me as I mutter “Sorry,” apologetically. I bolus her with lidocaine as soon as I have the IV secured.

I have just enough time to set up the lidocaine infusion before we pull up to the hospital. I toss the spiked bag on her lap as we roll her inside. Melba Guidry and Sadie Dawson meet us in the ER.

“Dr. Idris already called,” Melba tells us. “Take her to Room one-sixteen.” “

Here,” I reply, handing her the lidocaine bag, “I mixed this, but didn’t have the time to hook it up. Dr. Idris gave me verbal orders for-“

“He called in all the orders,” Melba interrupts me as we walk down the hall, “but Dr. Saleh is coming in to evaluate her. What’s up with that?” she wants to know.

“Did you see him at the crawfish boil?” I ask her pointedly. Her eyes narrow slightly, and she nods in understanding. She enters the room ahead of us, then shoos us away as soon as we transfer Mrs. Pitre over to the hospital bed.

“Get out of here, you two,” she tells us mock-sternly. “I’ve got to get this lady undressed and get a gown on her.” We don’t argue as Melba ushers us firmly from the room.

I’ve already seen her tits, Melba. I’m the one that defibrillated her.

EP ducks into the men’s room down the hall to relieve his bladder. I’m sitting at the nurse’s desk completing my report as Melba emerges from the room.

“Did they know?” she asks me quietly, meaning the Pitres.

“No, they never got close enough to smell his breath,” I shake my head.

“Lucky for him,” she sniffs.

“He wasn’t on duty, Melba. He was just at a party. He saw an ambulance at a patient’s house on the way home, and he stopped to help. He had enough sense to stay out of the way, and he had enough sense to let Dr. Saleh handle things up here,” I remind her.

“I guess so,” she admits grudgingly, and then turns her head at the sound of a painful yelp coming from the men’s room. EP emerges a minute later, wincing a bit and grinning ruefully.

“Damned crawfish,” he explains sheepishly. “I forgot to wash my hands first.”