“Yeah,” I said. “This is really going to hurt, but it won’t matter because you’re going to be dead in ten minutes.”
We laugh so hard we nearly roll down the stairs.
“Something is wrong with us,” he says.
I say, “It doesn’t bother me because I have a cold, cold heart.”
That night I keep seeing the man flinch as the electricity hits him. I see his face as he seizes and his complexion turns purple. I wake up gasping for breath.
The next morning Tom reads the obituary page. I have already read the man’s entry three times. He had a wife and four children and two grandchildren. He was born in Ohio. He’d worked at the same company for twenty-six years. The funeral was to be held in Columbus.
“I don’t like it when they die,” Tom says.
Waiting
I am worried about how I am coming along. While my IV skills are getting better, and Tom has few quarrels with my treatment plans, I feel slow and worry that I will not be able to handle the bad ones on my own. Daniel Tauber, the chief paramedic, asks me about the call where we shocked the guy. “Did you run the call?” he asks. “Tom ran most of it,” I say. “I made some of the decisions. He got the tube.” Daniel nods. He has been a paramedic for almost ten years, and I find him very intimidating. I want his respect, but know that I am far from it. Tom tells him that we did the call together, that I am coming along fine. I think that another less noble preceptor would tell him that he has doubts about my ability. I know I have doubts about my own. What I know is that I need more calls, more chances to learn, even if it is through mistakes. I’m on line twelve hours a day, waiting for them to call our number. I go to each call, wondering what lies ahead. Will this be the one to give me the boost I need? The chance to stand ten feet tall, to work with godlike speed—to save a life? Or will this one be my undoing? A disaster that will forever shame me?
I wait.
Can I Get a Heartbeat, Please?
Meg and I get a call for a woman with chest pain at the medical clinic of a retirement complex. The woman is lying on the examination table of the doctor’s office. She is having, in her words, heart palpitations. She is pale, diaphoretic, and nervous. Her skin is cool and clammy. She developed the pain last night, but didn’t want to bother anyone so she waited until this morning to come in. We put her on our cardiac monitor. Her heart rate is 177 with a narrow complex, meaning her atria, the upper chambers of her heart, are firing rapidly, conducting the impulses to the ventricles, the lower chambers, which are responding at the same pace. By firing so quickly, the heart does not have time to fill completely with blood. The volume pushed out with each beat is grossly inadequate. While some people can tolerate this rhythm for quite a length of time, if she’s been having the trouble since last night, she is not going to be able to take it much longer.
Fortunately, she has beautiful large veins. Meg spikes a bag of saline and inserts a sixteen gauge IV needle in her left antecubital (AC) vein, which is the big vein in the crook of her arm. I draw up six milligrams of adenosine in one syringe and ten cubic centimeters of saline in another syringe. Meg sticks the adenosine syringe in one port of the three-way stopcock on the IV line, and the saline in the other. She pushes the adenosine, then flips the stopcocks and pushes in the saline. “You’ll feel very strange in a moment, but it will pass,” she tells the woman. “Watch the monitor,” she says to me.
Adenosine shuts down the electrical conduction between the atria and the ventricles at a place called the atrioventricular (AV) node. It has a half-life of only twelve seconds. Unless it is given in the vein close to the circulation center and flushed rapidly, it will lose its effect before it gets to the heart.
Three seconds pass. Suddenly, instead of a mass of beats closely bunched together, the monitor goes flat line. We watch it. It is flat line. It is still flat line. All we see rolling past is a straight flat line. Flat line. Flat line. Flat line.
Meg and I look at each other, then back at the monitor. Our right feet are tapping the floor in nervous time. “Com’on, com’on,” she says. I am thinking about what I am going to have to do if the beat doesn’t come back. While this is the first time I have seen adenosine used, I have heard stories about it, so I am not in full panic. Still, I am thinking about grabbing the ambu-bag and assisting her ventilations, doing CPR, putting a tube down her throat, and pumping her body with epinephrine and atropine.
“Com’on, com’on,” I see Meg’s lips motion.
She looks at me and we exchange nervous glances. Sweat is beading on our foreheads.
It is still flat. Still flat. Still flat.
Blip. There is a heartbeat, then more flat line, then, blip, another heartbeat.
The air escaping from our mouths says, “Whew!”
The rate is now 80. We smile at each other. Then in the next second the rate is back up to 178.
I am already drawing up the next dose. This time we will hit her with twelve milligrams.
“We have to try again,” Meg says to the woman, brushing the hair back from her forehead.
I push the drug, then switch the stopcock and slam in the saline, shooting the drug up the vein, hurtling it through the venal rapids, through the superior vena cava and swirling into the right atrium, where it again stops the heart dead.
Flat line.
Flat line.
Flat line.
Flat line.
Flat line.
Flat line.
Flat line.
“Com’on, com’on.”
Flat line. Flat line.
Flat line.
I look at the woman and she has one of the strangest expressions on her face I have ever seen. It is like she has left her body. I imagine her ghost standing next to us observing the scene.
Flat line.
“Com’on.”
Blip. A beat.
Blip. Another.
Then another. Blip. Blip.
Blip. Blip. Blip. Blip.
A beautiful normal sinus rhythm at 80.
“You okay?” Meg asks.
“Yeah,” I say.
“Yes,” the woman says, “I feel much better.”
“Me, too,” Meg says.
We transfer her to our stretcher and bundle her up against the cold.
Her rhythm is nice and steady all the way to the hospital.
I think, isn’t it great to be a paramedic? Politicians get plaques and awards and get to cut ribbons in front of buildings, but we get this lady’s smile. She was sick. We used our skills and our trusty drug box and it worked in front of our eyes. Magic. Paramedicine.
Later, we look at the rhythm strip. Her heart was stopped for six seconds the first time. For ten the next.
I stand there holding the strip. I don’t believe it. It was a minute at least. No, two, three, four minutes. Minimum.
Anaphylaxis
The call is for a woman having an asthma attack at the corner of Farmington and Laurel. As we approach we see a woman in a green jacket waving to us from the sidewalk on Farmington. I see two women trying to prop up a third woman who is stricken.
“Four-seven-two on scene,” Tom says on the radio.
We get out.
“What’s going on?” I ask.
An older woman, wearing an eye patch says, “She’s got asthma. She’s three months pregnant.”
“When did it start?”
“A few minutes ago. She can’t get her breath.”
The girl, who is seventeen, appears to be crying. She is pale, holding her stomach and breathing rapidly, struggling for a breath. Her skin is hot.
We sit her on the bench in the ambulance. I tell Tom to get a Ventolin treatment set up as I listen to her lungs. There is some wheezing in the upper fields. I look at her face. Her lower lip is swollen out an inch.
“Did you get bitten or eat something strange?”
“I ate a peanut,” she cries.
“Does she have hives?” Tom asks.
“I itch al
l over,” she says. “I’m hot. Get my sweater off.”
We pull her sweater off. She is wearing just a bra. I can see small raised welts on her stomach. I glance at her face. Hives appear in front of my eyes. She vomits on the floor. I grab an emesis basin and ask her to hold it, but she can’t. She is using both her arms to hold herself up. Her every effort is to breathe. She seems like she is about to pass out. Spit drools from her mouth. I throw a towel on her lap and take a quick blood pressure. It is low at 90. Her skin feels cooler. She says her throat itches. Tom hands her the Ventolin breathing treatment—and tells her to breathe in the humidified air, which will help expand her bronchioles, though it will take five minutes to achieve its full effects. We move her across to the stretcher. This is not asthma—it is a full anaphylaxis, a severe allergic reaction.
“What are you going to do?” Tom says.
“I’m thinking about epi and Benadryl.”
“Thinking about?”
“That’s what I’m going to give her.”
“I’ll get the IV,” Tom says.
She is sweating profusely. Her skin is clammy and cool now. She is crashing in front of us. Her body’s reaction to the peanut is releasing histamine, dilating her veins, dropping her pressure, and filling her tissues with fluid. Not forty seconds have elapsed since she stepped into the ambulance. If we don’t act right away, she will die. Tom spikes a bag of saline and puts a tourniquet on her arm. I open the med box, take out a one cubic centimeter syringe and break the top of an ampule of epinephrine 1:1000. I draw up .3 milligrams. I swab her right biceps with an alcohol wipe and stick the needle in at an angle and inject the epinephrine. She pukes again. The epi blasts her heart rate up to 140 on the heart monitor. Tom has an IV established in her left arm, and opens up the roller clamp on the bag of saline that allows us to regulate the flow of fluid so it runs wide open, pouring fluid into her veins to try to restore her depleting volume. Her eyes are swollen shut. I draw up 50 milligrams of Benadryl and push it through the IV line, where it will directly enter her veins. The Benadryl will block the release of the body’s histamine. The epinephrine will dilate the bronchioles, enabling her to breathe and constrict her veins, increasing her pressure. Without these two drugs, her swelling throat will seal itself shut.
We go lights and sirens. Tom tries to call C-Med for a patch to the hospital, but they don’t answer.
In the two minutes it takes to get to the hospital her heart rate comes back down to a hundred on the monitor. Her lungs sound better. Her eyes are still shut, but her breathing is improving. She lies on the stretcher, exhausted.
The C-Med radio operator finally connects us to the hospital as we park in front of the hospital door.
“Seventeen-year-old in anaphylaxis,” Tom says. “We’re at your door.”
“How soon?”
“Look out the window,” he says.
When we wheel the girl in, her eyes are open. Though she says her throat still itches, her breathing is unlabored.
The triage nurse looks at us like she doesn’t understand what the big deal is. This certainly doesn’t look like anaphylaxis. The girl’s lip swelling is barely noticeable now. We are just a pair of sparky EMTs all excited over nothing.
Tom explains that we have already given epi and Benadryl. She looks at us like sure you did. And I’m supposed to believe this girl was at death’s door. Right. Sparkies. “Room twelve,” she says.
We take the girl down the hall and transfer her to a hospital bed.
“Good luck with your baby,” Tom says.
“Thank you,” she says.
I feel both great and oddly, uncoordinated, like I did something good in spite of myself, like luck and good fortune were on my side.
When we walk back down the hall to our ambulance, Tom says to me, “That was a good job. You saved her life.”
“Yeah, I guess, but I was a little slow.”
“That’s all right. You were right on it.”
“I guess. But you were right on it, too.”
“You’re right, and two seconds earlier than you were.” He flashes me a big Wyatt Earp smile as he slaps me on the back. “Pete, you’ve got to be cocky if you want to be a paramedic.”
Kids
We’re a few blocks from Hartford Hospital after dropping off another cold and flu—a mother who met us at the curb with her four-year-old who had a runny nose and a stomachache. Ahead of us I can see the health department where I once had a top-floor office. I think if I were there now I might be at the window looking out on the feast of the snow-covered city, and gazing down longingly at the ambulance approaching, wondering about what great calls and adventures I was missing.
Something thwacks against the side of the ambulance.
“What was that?” Tom says.
I look in the side mirror.
“Are they throwing snowballs at us?” he says, braking suddenly in the middle of the street.
“It’s just some kids,” I say.
He puts the rig into reverse.
The kids scatter as he stops the ambulance. Three of them pass us, careful not to meet our eyes.
“Roll down the window,” Tom orders.
“Hey!” he calls to a fat kid, maybe twelve years old, wearing a New York Giants snow hat.
The kid stops. “I didn’t do nothing,” he says.
In the mirror I see four other kids have stopped at a safe distance to watch.
“Tell him to wait there, I want to talk to him.”
“Tom,” I say, but he is already out of the car.
I look at the kid. “He wants to talk to you,” I say.
“It wasn’t me,” the kid says in a high quivering voice. He points down the street. “It was him.”
Just then a snowball grazes the kid’s shoulder. In the mirror I see the others quickly scoop in the snow to arm themselves. Tom is firing snowballs.
I jump out. I make a snowball as one grazes off my leg. I take a blow to the chest as I fire wildly at the charging tribe.
“Come and get it,” Tom shouts, laughing like a wild man.
We are in a pitched battle.
Kids appear out of doorways, from alleys, and around corners. We are overwhelmed. We retreat to the ambulance. Snow thwacks against our side and windshield as we pull away.
“That was fun,” I say.
“Ah, winter,” Tom says.
I look back up at my old office. The window is empty.
On My Own
“I think you’re ready,” Tom says. “What do you think?”
“I think so, but I wouldn’t mind doing a few more bad calls.”
“I think you’re ready. You must be sick of me by now.”
“Well, I sort of am.”
“Get out of here, you are.”
On Thursday, Debbie Haliscak, the Saint Francis Hospital prehospital coordinator, rides with us. I know Debbie well from when she was the ALS coordinator for the state office, a part-time job in which she helped ambulance services, mainly volunteer, upgrade from the basic level of service to the intermediate or defibrillation levels. She also helped set me up as a volunteer medic in Bloomfield while I was still at the health department. This short, energetic mother of a two-year-old is always at her computer in her office, working on policy statements or updating protocols when paramedics stop in to chat. Her undeserved reputation for being more of a paper-pusher coordinator than a street-skilled coordinator will be forever put to rest a few months from now when she and Daniel Tauber will go to a cardiac arrest in West Hartford where a precepting medic will be attempting an endotracheal tube. The precepting medic will fail on two attempts, the medic will fail on two attempts, Daniel will fail on two attempts, then Debbie will step up, and using the laryngoscope blade like an ice pick, will stand over the patient, lift up on the jaw, and looking into the mouth upside down, pass the tube successfully. Daniel, in a rare admission, will tell people that even he learned something new. Debbie will become a legend.
T
oday is my day to prove myself. The dispatchers are on alert to give us the best calls that come in.
We are sent for a man with chest pain. The fire department is on the scene. We enter the building to find a man in his late fifties with a heart history lying on the floor clutching his chest, diaphoretic, looking like he is wrestling with an invisible superhuman opponent who has him pinned to the carpet, despite his efforts to get up. “Let’s put some oxygen on him,” I say. “Nonrebreather.” Debbie gets it out of the blue bag while I feel for the man’s pulse and ask him how he is doing. His pulse is very rapid. The man looks at me through clenched teeth like I am an idiot. I’m fucking dying here, you asshole! he seems to be saying. While Debbie puts the mask on, I take a blood pressure. It is 130/80, but again I am made aware of how fast his pulse is beating. “Let’s get him on the monitor,” I say. Debbie is right there into it with me, while Tom gets the stretcher. The man is going at 170 on the monitor. “SVT,” I say. It’s supraventricular tachycardia. “We’ll try some adenosine. Let’s get a line.”
Now comes the hard part. I put on a tourniquet and search for a vein, but see and feel nothing, all the while the guy is looking at me like he wants to beat the crap out of me and will as soon as his mysterious tormentor releases him from his viselike grip. I feel like everyone in the room is watching me, which they are. Debbie helps me look, but we are having no luck. I am cussing under my breath to my guardian paramedic gods. Please, just give me a line on this one. Don’t make it so hard, I whine. The longer I look the more I become aware that I am screwing up. My mind starts racing, what do I do, what do I do. I glance at the monitor. Heart rate down to 144. “It’s looking more like a sinus tach now,” I say. “I probably won’t do the adenosine. I’m going to give him a nitro as soon as I get a line.”
Debbie nods, and I can see on one hand she is approving how my mind is operating, but on the other I feel like I’m in a game show where everybody else knows the answer and they want me to get it, but I just can’t seem to guess it.
Finally, Tom says, “Why don’t we get him on the stretcher and get him rolling. We can do what we have to in the ambulance.”
Paramedic Page 6
