Code

My alarm went off this morning at 0515 and I jumped out of bed feeling like I spent the night waiting instead of sleeping. Today, under the watchful eye of another, I got to be a paramedic.

We had been doing routine ALS all day. Calls that my paramedic partners groan over at work... the dizziness. The probably-not-CVA. The BS difficulty breathing. All those kinds of calls that demand ALS only in order to protect liability. I was excited enough though. I got to start IVs, to perform complete assessments and direct treatments. Our dizziness got a full cardiac workup. The potential CVA got a careful neuro assessment and a rapid transport. The difficulty breathing got some coaching and a sympathetic ear: exactly what she needed. I made a difference, and while I felt good about it, I ached for a "real" call. Something that I can really stretch my legs and test out these new toys.

At 1615, I got my opportunity. We were dispatched priority one to an address 10 minutes south for the "man down unresponsive." My medic preceptor jumped out of his seat, eager for me. "Oh man, thats an arrest!!" It was. Halfway to to the scene we hear the radio crackle over the sirens: "Medic 3, be advised CPR in progress."

Shivers go down my spine. This is it. A confirmed code. The ultimate ALS call, and its my first day. My partner sinks the throttle closer to the floor, and we pick up speed. My heart follows pace and my previously calm demeanor flies out the window. I've been on lots of codes before. Medical codes, dialysis codes, hospice codes, traumatic codes, pedi codes. They are all the same as an EMT. You assist, you work under the guidance and care of someone who knows better than you. Today, though, I am the one who is supposed to know better.

I envision the scene ahead of us: frantic volunteer EMTs pounding CPR into a body on the floor. A BVM squeeze and air rushes through puffed-out cheeks into the lungs and belly. The first few drips of sweat falling down as they wonder where the hell are they??. The arrival of ALS brings a wash of relief as skillful, practiced hands carry advanced equipment ready to make the patient better.

My own hands fiddle endlessly with my stethoscope as we race towards the call. I try to act cool and collected, but my nervousness betrays me to my preceptor's notice. He asks me if I'm nervous and I admit that I am. He tells me its okay. If I'm not nervous, he says, something is wrong. Its a good thing. Excitement and fear combine within me and I feel a rush of energy. I think to myself that this is something I havnt felt since I first started working as an EMT... I notice I am tapping my feet as I chastise myself. Keep your cool, dude. You know how to do this.

As we approach the address we decide that I will go after the airway while my partner will get the line. A game plan set, we pull into the driveway and switch off the siren, simultaneously unbuckling seatbelts and opening the doors. "We're out," my partner says on the radio.

I grab the big orange bag that I learned this morning has the airway kit. The EMTs are in the building still with the patient, but someone runs out to us and says they are already packaged and will be in the ambulance in just a minute. We decide to set up in the ambulance and be ready for when they come. I throw the big bag on the bench and dig towards the pocket on the right underneath the yellow pack. There I find the laryngoscope wrapped up with a full set of shiny blades. I remember back to 3 months ago, when I did my rotation at the OR to get experience intubating people. Which blade did I use? The curved one, the Macintosh. A four. I find it and click it in. White, tight, bright. My partner is setting up drugs. Remembering setting this equipment up lots of times for my paramedic partners, I run through the routine, assembling the rest of the necessary pieces. A 7.5 ET tube. Stylet. 10cc syringe. End tidal Co2. Tube holder. C-Collar. I'm ready.

The patient is coming out of the building, wheeled on a stretcher surrounded by a cluster of volunteer EMTs. One of them is riding the stretcher, frantically pumping on the man's chest. Another struggles to maintain a seal against the mouth with a BVM. They lift the stretcher up and slide it into the back of the ambulance, the patient's head slowly rolls towards me.

He looks dead. There is vomit around his mouth, pooling in his nostrils. He is a big man and I worry that he may be a tough tube. Just this time, I say to myself, let it be easy. Let me get this first one and then I can start doing the hard ones. Please just let me get one under my belt first.

I put my hands on each side of the man's head and tilt forward and up, into the sniffing position that we were taught in school. I let go to grab my blade and the head falls right back to where it was. No good. I try again, this time holding his head in place with my knee as I grab my equipment. I open his mouth with my thumb and forefinger like the nurse anestetist taught me in the OR, slowly sliding the curved blade in above the tongue. Sweeping to the left I am able to open the man's mouth inch by inch. I hear the blade click against the teeth very slightly and I freeze for a second. Dont do that again.

I am able to wiggle the blade into what I think is the vellicula and, lifting upwards, I peer into the mouth. There is a mass of tissue inside, wet with vomit and saliva. Nothing looks familiar. I look harder, and recognize the epiglottis. I need to lift higher. I pull harder on the handle and watch as the flap of skin raises slowly, revealing the dark triangle shape of the trachea behind it. There isnt much space and I cant see very much, but I grab the tube and slide it in slowly. The tip of the tube passes through the cords and I feel the plastic bump along the ridges of tracheal cartilage. I'm in.

I pull the blade out of the mouth and click it closed on the backboard. I look up at my partner with a hopeful smile. "Youre in?" I nod and say I think so. I grab a tight hold of the tube and yank out the stylet. Pass me that bag, I say to the EMT, gaining confidence. I attach it to the top of the tube and give it a single squeeze. Warm, moist air enters the tube as I let go of the bag, fogging up the inside of the tube. Fuck yeah. I'm in.

We confirm the tube with lung sounds. Full and equal bilaterally. Negative over the epigastrum. End tidal CO2 reads 19 already. I secure the tube down and begin pumping air into the man's lungs. Relief washes over me, but this time I am able to suppress signs of it. I act as if I knew I was going to get the tube all along. Of course I got it!

"Nice tube" the medic says after confirming the placement, "I'm impressed."

We work the rest of the code smoothly. The monitor reads V-Fib and we shock. Four times. Epi and atropine are pushed into the veins, followed later by Bicarb and once, when the rhythm looks like V-Tach, 300mg of Amiodorone goes in. We run though the entire list of things to do, following the protocols to a T. Both my partner and I are floating. He got a nice 16 gauge catheter right in the AC by anatomy alone. Nice stick, I tell him. "Hell yeah," he replies.

We arrive at the ED and the doctor confirms my tube. My partner announces to the recessutation team that this is my first day and I got the tube on the first try. Smiles all around. Someone claps me on the back.

The doctor takes a better look at the patient. He studies the monitor and listens to our story. Shaking his head, he issues the order.

"Stop recessutation guys. I'm calling it. 4:48pm."

So much for our toys.