Wrestling With Death

Apparently, as EMS providers, we all have the proverbial “slump.” I guess you could call it a “cold streak,” or perhaps, “a series of unfortunate events,” but then you have to worry about that Snickett guy suing you.

Early in my 911 career, I had a slump. I was an EMT for several years working critical care transport and BLS / inter-facility transport before I made the jump to 911/ALS (which is the industry acronym for “advanced life support”). During my time pre-911, I saw some people who were sick. I don't mean “I have a cold,” sick, I mean, “my patient has six IV drips running, an arterial line, an intracranial pressure line, and extra-ventricular shunt in his head, a foley catheter, a rectal tube, is intubated and on a ventilator,” sick. If you have no frame of reference for any of that, it's pretty goddamn sick.

The funny thing is (and not “ha-ha” funny), I never ran a code. Never. Not once did I run a code until I made the switch to ALS/911. Now, most EMT's never do a chest compression on anyone other than CP-Arlene until they work on a 911 box. CCT guys like me were supposed to have them periodically when people are just crazy sick and they have to be transferred to a different hospital, but they are unstable, and so they code during transport. Yeah, well, not me. I was a fluffy white cloud of good luck on a CCT box. It was a good omen for patients if I was on their transport crew. I worked CCT during the didactic portion of my paramedic program, but left when it was time to go and do my ER clinicals, specialty rotations and my field internship where I would function as a paramedic on an ambulance whilst being overseen by a preceptor.

Did my clincals. 150 hours in the ER. No codes.

Did my OR, PACU, ICU, psychiatric, pediatric, and geriatric rotations. 144 hours. Not a single code. Nada.

Made the move to 911, and worked there for eight months before my internship. Still nothing.

I went on my internship. About 150 hours in, I got dispatched to my first cardiac arrest call. I was nervous as hell. I scrambled through the county protocol manual to make sure I knew what I was doing, even though I had easily run hundreds of mock-codes in the classroom. I could recite the AHA algorithm for cardiac arrest in my sleep, but here, after hearing the tones drop, and the dispatcher squawk over the air, my mind was going blank.

We arrived on scene for a man in his 70's who had apparently arrested at some point in the early morning. His roommate or relative, which I can't honestly remember which it was as this was all a bit of a blur for me, went in to check on him. When they did, he was pulseless and apneic. They called 911 and began performing CPR on him until Fire or EMS arrived. Well, Fire got there first. When I arrived, the fire crew had already put a Lucas device (a CPR compression machine, which is totally bad ass, by the way) on him, and it was pumping away. He was already hooked up to the monitor on the which showed asystole, which is the ever so dramatic flat line you see on TV. The captain of the crew had tried to start an IO (intraosseous, which is fancy medical talk for “in the bone.” that's right: we drill a hole into your bones when we can't get an IV started) but he went into the wrong part of the lower leg and the line wasn't patent. He asked us if we had an IO kit, knowing full-well we did, claiming “the batteries died” in their IO drill, or some other bullshit excuse. He proceeded to drill the second needle into the same leg, in a slightly lower approximation of the same incorrect anatomical landmark as the first one, but this time he got lucky, and the line flowed freely. One of the fire medics announced he was about to “go for the tube,” meaning he was going to attempt to intubate the patient. I asked him if I might try as I was the intern, and he was more than happy to hand over his laryngoscope.

Now, I had intubated live people before. One of the requirements from my school was five successful intubations in the OR prior to your internship. I had gotten six, so I was pretty confident going out into the field that when the time came for me to drop a tube, I was going to absolutely nail it. What we don't think about when we are in the OR getting our boxes checked off is that the OR is, for lack of a better way to explain it: perfect. You have perfect lighting, perfect, positioning, perfect pre-oxygenation of your patient, perfect equipment, it's perfectly clean, people to hand you things, and the patient is perfectly still, and on a hydraulic table that you can position any way you see fit as you stand up on your own two feet.

This was a different scene altogether.

I was in a double-wide that looked like an episode of that show, Hoarders, there was a desk lamp that barely gave off any light, the guy was on the floor with his head up against his dresser as he lay next to his bed, with a Lucas device pumping away on his chest, I was on my knees, and though I didn't see any cats, the whole place reeked of cat piss. I swapped blades to a Miller 3, which is kind of an old-school style straight blade, but it works for me and got into position. I went in for my first attempt, and it was a hell of a lot different than the OR: every time the Lucas device compressed his chest, his head and neck moved. There was vomit everywhere. I had to approach his head from the side because of the way he was positioned on the floor. Somehow, by the grace of God, and some plain old dumb-ass Irish luck, I landed the tube. Lung sounds were present, and there was no gastric inflation. My first field intubation was a success. After that, the rest of the code for me, as a first time lead medic, was just to order the drugs, and have the fire medics push them. We worked the code for about thirty-five minutes, meeting the county requirement for drug cycles, and we even went as far as to push calcium and sodium bicarbonate as a last ditch “kitchen-sink” attempt, but to no avail. We pronounced the time of death, cleaned up our equipment, covered him with a blanket, picked up our trash, restocked the fire crews jump bag, and left, off to the next call leaving the shift supervisor on scene to wait for the coroner.

My first code was a failure. I thought, Well, I got that first big one out of the way. The next one will be the one. I'll crush it.

A couple of weeks later, I had another code, just before the end of my shift. She didn't make it.

The following week, we had a woman who was hit by a truck. She coded in the back of the ambulance during transport. Regardless of our efforts, and the efforts of the trauma center, she died.

A month after that, I had a code almost exactly like my first one. We got his pulse back for about thirty seconds, but lost it just prior to transporting him. We never got him back.

A little while after that, a woman was found unresponsive in a skilled nursing facility. We worked her for almost an hour, but we never got her back.

A week after that call, we had witnessed arrest of a sixty-year-old man. We worked him for thirty minutes on scene, defibrillated him four times, and briefly got his pulse back. We transported him to the closest ER where they worked on him for the next hour, until his family members decided to end the resuscitation efforts.

I went from feeling like the guardian angel, to feeling like the grim-reaper himself. I knew we were doing everything right. I knew we followed the protocols correctly. I knew we worked with good crews and good hospitals. What I didn't know, were the statistics. The cold, hard, brutally disconcerting statistics. According to the American Heart Association, over the last five years, the survival rate of people who have had a pre-hospital cardiac arrest, meaning they went into an arrest somewhere other than in a hospital, was between... are you ready for this?

Nine To Twelve Percent.

That's it. Seems crazy low, right? That's the national average. Nine to twelve percent. The numbers are better in the hospital, which are right around twenty-four percent, but still... It just goes to show you, life's not like the movies, right? We don't see a flat-lined monitor, grease up the paddles, and shout, “CLEAR!” before we defibrillate someone, and they have a huge convulsion right before the several dramatic seconds of waiting before we have a blip on the monitor and suddenly the patient is alive again and on the road to recovery. If only it worked that way. Sadly, more often than not, it ends with us cleaning up our mess and laying a blanket over someone before we call dispatch to tell them we have a coroner's case.

So there I was, in a slump. I needed a win, bad. I needed to feel like I knew what the hell I was doing. So, I waited for it. And I waited. And I waited. And it didn't happen. It took quite some time for me to get my first field save. I expected it to be this hugely defining moment where I'd feel like the 2004 Red Sox and I'd broken the curse of the Bambino. But I didn't feel that way. Don't get me wrong, it felt great; I felt like I had broken my losing streak. I felt relieved that against the odds we got him back, but I knew that, statistically speaking, I probably wouldn't get the next one back. Or the one after that. I had just come to grips with the fact that my workday isn't always going to have a happy ending.

Sometimes, which is really most of the time, we do everything right on a code, literally everything, but we don't get the patient back. Running a code is like being in a wrestling match with the biggest, meanest, scariest wrestler you can imagine. Most of the time when you step into his squared circle, he wipes the floor with you, sometimes kicking your ass so badly that you don't know if you can ever step back in the ring again. But sometimes, every once in a great blue moon, the stars are aligned, you manage to pull some crazy maneuver out and, nine to twelve percent of the time, you manage to win. This time, I fought death, and I won. I brought a man back from the edge of never. I wanted to feel like a hero, and for a brief, perfect, shining moment, I did. I was a hero.

Until the next code.

Click here for The American Heart Association's website showing cardiac arrest survival rates