[Triage Note: 55 year old woman. Found unconscious by boyfriend at 17:30. Labored breaths. Paramedics performing CPR en route. Pulses present. No spontaneous resps. No previous medical history.]
It’s 6pm on a Tuesday. I’m supposed to work until eight, but I can leave early because the next doctor is ‘G’. The nickname isn’t original; it’s the first letter of a name that no one can say properly. He’s young, smart, and works so hard he doesn’t have time to buy food or furniture. As usual, he’s arrived with a team of interns, and he’ll have the entire waiting room seen within an hour.
G is holding my last patient’s elbow while I pull on her displaced wrist when a nurse pops in, and tells us a critical patient is two minutes away. G looks at me: “Mind staying?” He doesn’t need me, but it could be anything – a car accident, a choking patient, an unconscious child – who knows.
Paramedics are hunched over the patient as she is wheeled quickly into the resuscitation bay. At the top of the bed, a mask is secured over her mouth and oxygen is pumped with loosely gloved hands. It isn’t helping – her skin is grey – like the clay you hit when you’ve dug too far in your backyard. Fingers are at her neck, confirming that a pulse is present.
The story comes quickly: The patient’s boyfriend, a line-worker, last saw Lillian* at breakfast. Everything was fine – she was off, and had planned to have lunch with a friend. When he arrived home, he’d found her snoring and unresponsive in bed. Paramedics have placed an oral airway – a small plastic tube – between her clenched teeth so that the air can flow into her lungs. “Is she breathing at all on her own?” I ask.
“Gasps,” a paramedic says.
“Good now, but she went pulseless en route.”
“Maybe a minute,” he says, breathless. “Not sure.”
“You give drugs?”
“Couldn’t get an I.V,” he says. “Came back with CPR.”
The patient is on a scoop – a stretcher that separates into two halves – left and a right -and then connects at the top and bottom. Other than the metal rod at her feet, the scoop is obscured; Lillian is not small. She spills over the sides, and it takes four people to heave her to the hospital bed, where the scoop is disconnect at the top, then the bottom, and pulled away cleanly. As her clothes are cut, there is the faint stench of vomit. A nurse wraps a tourniquet around Lillian’s bicep, and crouches under the glare of the trauma room’s spotlight. The light is adjusted until a blue streak appears under her skin. Many tubes of blood are drawn and an intravenous line is connected.
“Let’s intubate her,” G says, leading an intern to the head of the bed beside me. The oxygen mask is lifted away and I yank the oral airway; it’s gross – coated with yellow bits and a thick trail of spit. Her teeth are clenched, and if I try to pry them open, I may lose a finger. I call for paralytics, plunge them into her I.V., and her body relaxes. The respiratory therapist hands the intern a laryngoscope – the metal blade that will lift away Lillian’s tongue so he can put a tube into her trachea. G waves it off. “Let’s use the Glidescope instead,” he says. “It’s right here, and this looks tough.”
I nod, and wheel the high-tech camera over to him. The intern slides the camera into Lillian’s mouth and her vocal cords appear on screen. It’s like a video game, and the young doctor makes it look easy as we watch the tube slide between the cords. Oxygen is connected and health returns to Lillian’s skin. Her oxygen saturation climbs from the seventies to the mid-nineties. She is stable for the moment. I strip my gloves and ask G if I can leave. He nods. As I fling the white latex toward the garbage, I notice Andrew*, a paramedic that I know mostly through Facebook. His face and hair are drenched with sweat, and his skin is flushed. He’s shaking his head in disappointment – in disgust. I ask him if he’s ok. “I’ve had better days,” he says. I pat him on the shoulder and head to my car.
Andrew is forty-ish, married, and has been a paramedic for a decade. In most professions, his day could be described as “the worst day of my life.” But this day has happened to him before. It’ll happen again, too.
His first call that morning was a woman in her sixties. She was without breath or pulse, lying on the stairs of a cramped home when his crew had arrived. There was no space – and a dozen family members were there – crying, hoping, praying, wailing. They intubated her, performed CPR, but she was long gone. The family begged the crew to transport her cold, stiff body to hospital. The doctor walked in, spent less than 30 seconds, and said “I’m sorry.” The next call was from a woman with a history of anxiety – when they’d arrived, she was standing there – chatting on a cell phone, her index finger pointed toward them “wait just one second.” The third call was a construction accident – a hefty worker knocked unconscious into a trench – a real trench – damp, muddy, and deep. And after that, it was a kid – a kid – with a cardiac defect – sweaty, pale, his heart rate over two-hundred – high enough to make even the most seasoned professional short of breath themselves.
Just two hours remained in his shift – not even enough time to finish the day’s charting – when a text came from another crew: “Cardiac Arrest. Unconscious.” The patient was in a house, on a rural road, just minutes away. It wasn’t his crew’s call, and they could have returned to base, and finished up. But the other crew had sent the text – a nudge – ‘if you’re not too busy, do you mind?’
A week after taking care of Lillian, I looked up the address and drove by the house. I’d intended to park, and take notes, but as I pulled up, a band of anxiety tightened my chest. On a street where houses are separated by forest, this house is set far back from the road, piles of junk obscured by overgrown weeds. The windows and doors don’t match, appearing as if they were rescued from recycling. I didn’t stop, and I can’t imagine how fast and hard my heart would pound if I’d been asked to go inside.
When Andrew’s crew arrived, another ambulance and a fire truck were already there. Narrow halls and splintery floor boards led to a tiny bedroom – just enough room for a queen bed and a side table – where Lillian lay, eyes closed, on her back. She looked dead. Her boyfriend was talking to a firefighter, hands in his pockets, shrugging. He was led out, just to make room for Andrew’s crew. Lillian’s faded t-shirt was covered in vomit, and her pants were soaked at the mid-section. The stench was instantly inside Andrew’s nose – behind his watering eyes. The mattress was tattered and soft, and sunk in the middle under the weight of her body. She sucked a shallow breath and gagged, as the first crew suctioned her mouth and tried to oxygenate. Just as the airway was clear, she gagged and heaved, as vomit spilled down her cheeks and into her lungs. Her pulses were strong, so they concentrated on her airway, turning her head to the side as she vomited again. The liquid flowed under her, into the pit under her backside, caking her clothing. Her blood pressure was normal, as was her blood sugar. There was no simple fix. No shot of sweet jelly under her tongue to wake her up. Her oxygen saturation was in the seventies. As Andrew held the oxygen mask to her lips, he felt turbulence in her chest – there was barf in her lungs – and she needed a secure airway. Immediately.
“This is where the call goes to complete shit,” he says, as he recounts the case. “We’re supposed to make things better, but now, things get worse.”
As Andrew suctioned vomit from Lillian’s mouth, his partner tried to intubate her. He lifted away her tongue, but just as he saw the vocal cords, and tried to pass the tube, vomit flew out of her mouth like water out of a garden hose set to ‘jet’. They turned her again, but her body sunk into the soft bed and she clenched her teeth. There was no firm stretcher, no fancy camera, no bright lights, no drugs to paralyze her. On her side, they tried to hold the oxygen mask to her face, but could barely maintain their grip, as slime covered their fingers and crept into the gap between glove and sleeve. They couldn’t open her mouth, and could hear the vomit choking her, as she gagged, coughed, choked, and gagged again. Their only strategy was to roll her – from her back, to her side – over and over – as if emptying a bucket. Drenched in sweat, their plastic face shields were fogged so badly, they ripped them off.
As Andrew’s partner tried to pass a tube again, her shoulders sunk into the soft mattress. They had to move her. They placed the partitioned scoop on either side of her and tried to connect it, but the mattress was so soft that it got caught in the scoop as well. After three attempts, they threw the scoop to the side.
Her oxygen saturation continued to fall, and she was comatose now; the only thing that made her seem alive was the continued gagging and vomiting. Andrew tried a nasal airway – a tube passed through the nose and into the vocal cords. After the first pass, her nose opened like a tap – blood – that flowed back toward her throat and down to her lips. The nasal tube roused her slightly, and she tried the breath on her own, spewing blood everywhere – onto Andrew, onto his partner – onto everyone in the room.
The fire crew connected the scoop and placed it beside her on the bed. Then, like dragging a bag of soil at a garden centre, they pulled her onto the scoop and strapped her down, and threw sheets over the soaked mattress to dampen the smell.
And then, on the scoop, Lillian arrested; she lost her pulses. They had to get her out of the room, into the hall, where they could start CPR. Andrew managed her airway but his legs are short, and he could barely keep up; his raised shoulders felt like they could fail at any instant.
An intravenous line was attempted. But she’d spewed so much, that masks were back on, and the paramedics could barely see through the plastic; they could hardly hold the needle with their slimy gloves, or their sweaty hands. And there was no light. CPR was started, and within seconds the pulse returned. They lifted the scoop – and Lillian – and brought her to us – racing down rural roads to the highway, sirens blaring, and lights flashing.
As the paramedics sit in a cramped room and make notes, Lillian is taken to the CT scanner. Her head is normal – no stroke, no bleed. Her lungs are suctioned and her chest x-ray shows patches where vomit is settling into her lungs and making her septic. Blood work returns, and it’s mostly normal. Then, the lab calls. One of her blood levels is out of whack; toxic. It’s her alcohol level. It’s through the roof.
A central line is passed into her femoral vein. Antibiotics, fluids, and steroids are given. Sedatives are continued so Lillian won’t fight the tube that feeds her lungs with nourishing oxygen. And by the time I’m putting my pajamas on at home, Lillian is transferred to the I.C.U., where her boyfriend is told that she may not survive.
“In my mind,” Andrew tells me, “I felt like we just killed this woman. If I could do this call again, there would be differences.”
The problem, though, is that the next time, it could be worse. This is truly the Front Line. The patient could be stuck in a crawl space; a man with a knife could be in the room beside them; There could be two patients in the same small space – or ten.
And he didn’t kill her, he saved her. And two weeks after her illness, she was out of the I.C.U., fully recovered, and back at home.
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* not their real names
I love your writing Raj,and your blog should be required reading for every Canadian. It is painfully informative and eye-opening. More people should be aware of how the medical system copes under sometimes very difficult and trying circumstances.
As a paramedic, I appreciate you writing and taking note of the crappy environments we sometimes have to try to work in. A lot of doctors don’t seem to understand just how difficult it can be out there. Thank you.