Sunday, December 11, 2005

A Blanket

It is during the tail end of a snow storm that has left ten inches in six hours. We are on the way back from the hospital after a call where we had to wade through deep drifts to get to a patient's farmhouse. The roads are barely plowed. We get called for a 93-year old woman unresponsive with shallow breathing. Updated to respirations at six a minute, now irregular and gasping. I say it's going to be a code. When we get there instead of trying to haul the stretcher through the snow, we grab the equipment and go right in. We have to walk through a narrow hallway, through an open living room, then down some stairs to the basement, then down another corridor and into a small bedroom where a man and younger woman stand, and there on the bed is an old woman who from the door I could see is not breathing.

I'm thinking great, 93 years old not breathing. She is dead. Has the family even thought about what they want us to do? I say (I really do say) "Have you thought at all about what you would like us to do if she stops breathing or her heart stops and she dies." I feel for a pulse. There is none. "Like now. Would you like us to resuscitate her?"

The man seems understandably flustered by my question, and hesitates and then says something to the effect of well, yes, yes we do.

"It's a code," I tell my partner who has followed me down the narrow hallway and into the bedroom. "Let's get her on the floor." We pick her up and place her on the floor so there is room for one person at the head and room between the end of the bed and the dresser for someone to do compressions. I hand one partner the ambu bag, then the other partner -- an EMT student, the young ex-high school football player, who has been doing so well riding with us -- I tell to do compressions, (Let's do the new CPR, I say, 30 and 2) while I get the defib pads out, hook them up to the monitor, then slap them on. I have them stop for a moment, and I quickly see the woman is asystole.

I tell them to continue and not stop, while I get out my intubation kit. I also hand an oral airway to my partner, and tell him to take out her false teeth. The bottom teeth come out, but the top, he says are nailed in.

I take out a number 8 tube. I see the epiglottis, see the chords, have a little trouble getting the tube to go into the chords, as the lady's teeth stick up and there is not a lot of room between the blade, the teeth and the side's of her mouth. I reshape the tube, making it straighter and I am able to easily pass it. The bulb syringe test works. No sound in the belly. Equal and strong on the right and left. Vapor in the tube. I tie it up with the commercial holder. I hand it over to my partner and say, keep it in there. Squeeze the bag 8 times a minute.

Then, instead of dropping some epi down the tube like I always do, I delay and go for an IV. As I am pulling out my IV kit I remember I need to attach the capnography. I attach the capnography device between the tube and the bag and then into the machine. I glance at the reading. It says 35. I am shocked. 35 is normal. It is also an excellent prognosticator. On the other hand the lady looks dead and is asystole.

I get a 20 in the AC. I have them stop CPR. Still asystole, then I tell them to resume. I take out a milligram of epi and say, "All right, let's see if the epi can do it's job," and I slam the epi followed by an atropine.

I look up at the monitor and see a funky rhythm.

Shock or not shock. I hold off because it looks organized.

I give another epi. We continue CPR. The young man is doing deep strong compressions. We're bagging nice and slowly.

When we stop again, it looks like there is a qrs complex, then some loopy ventricular like rolls, then a qrs.

I go so far as to hit the charge button, but I hold off.

There is a rhythm trying to break in.

And there it is.

No question about it.

"Check for pulses," I say.

"Strong radial pulse," my partner says. "Very rapid."

I look at the monitor. A Sinus tack at 132 that over the next several minutes gradually comes down to the low 100s.

93 years old and we get her back -- at least temporarily. As we package her up, I stay vigilant waiting for the epi to wear off, but she's hanging right in there. Good rhythm, good end tidal. Good BP.

We have a difficult extrication. We can't get the stretcher in the house. We have to strap her to the board, securing her head with head blocks. A police officer and I carry her down the hall stopping every ten seconds or so to ventilate her. The stair is a bitch. We have to pass her up nearly vertical. Her family waits in the living room. Suddenly they are yelling at us. "Put a sheet on her." "You can't take her out like that." "Let me get a blanket." "Have some respect for her modesty."

I am doing my best to keep her from toppling off the board. I hadn't even thought about her exposed breasts. I was concerned with just getting her to the ambulance. They are yelling at me. It occurs to me then that they have no idea about her condition. I normally try to involve the family, and keep them updated, but due to the geography of the scene, I was isolated from them. I remember what I read in Thom Dick's book, People Care: Career-Friendly Practices for Professional Caregivers..

"People don't remember much about our medicine. But they do remember how we make them feel."-Thom Dick

We have no sheets handy. Our stretcher is outside in the snow. I set her down because I don't want to drop her and it's time for more ventilation.

"She'll be cold," a family member says.

I want to explain what I have just read in the new AHA guidelines about the benefits of hypothermia and how keeping her from getting too hot is good for her. "Her situation is very critical," I say. "We need to get her to the ambulance." I glance at the monitor. Still holding her own. "We'll get her covered up." I nod to the officer to pick her up again.

Normally, on a code I always pause, and have the family say something to the patient, even though she may not be able to hear. I do it for the family to let them at least have a chance to say goodbye because most of the time the patient is dead by the time they arrive. But I am not even thinking about that now. I'm just thinking about getting her out to the ambulance through the snow before she loses her pulse.

We back out the door, and down the icy steps, and out to where to the stretcher is set up. There we bag her again, and throw a blanket on her. In the back of the ambulance, we switch her to the main 02, and head to the hospital. Everything status quo. The EMT student is bagging. I compliment him on how well he has done on the call, but I tell him we can't expect the woman to ever walk out of the hospital. At her age and given the condition we found her in, it just isn't going to happen. He nods and says nothing.

A moment later the woman moves suddenly. It startles both of us. And then we see her chest heave again. And again. And to my amazement she is breathing on her own.

"But then again," I say. "I could be wrong."

At the hospital, her pressure is 130/60. Her heart rate is 104. Her respiratory rate is 10.

The doctor congratulates us and I praise my crew. My regular partner has worked EMS as a volunteer for 20 years and this is his first save. The EMT student has just begun his career. I am still startled that we got back a 93 year old woman from asystole. She had to have stopped breathing just minutes before our arrival. I tried to use the new AHA guidelines. Good CPR, less ventilations. No drugs down the tube. Even unconsciously hypothermia. And while the AHA guidelines say our cardiac drugs have never been proven to help. I know she responded to the epi. I have seen it before. Epi IV has gotten me back many an arrested patient, or at least gotten them to the hospital alive.

But before I congratulate myself too much, after I have written the run form and dropped it off with the nurse, I glance at the patient's room and see two family members sitting in armless chairs by her side. Their eyes meet mine. They stare at me but give no expression. I feel like they are waiting for me to say something.

I approach, and bow my head slightly. They remain seated. "I am sorry about not covering her up," I say. I should have gotten a blanket."

"That's all right," the woman says. "Thank you."

"I wanted to get her out to the ambulance. I wasn't thinking."

"Thank you," she says. "Thank you for helping."

I bow my head slightly again, and then head back down the hall.

Lesson learned.