Quiet and Comprehension

There is a certain profundity that is expressed by silence in the face of screaming tragedy. Quiet has a potential to permeate the soul deeper than any cry could, hit harder than the fiercest blow. With somber sadness and a quiet reverence for a life gone in only a few seconds, my partner and I stood over the body of a woman who was alive and working at the machines only ten minutes ago. Now, her skull was gruesomely crushed, open and split onto the cold concrete. The factory, usually buzzing with activity and clanking machines, was totally shut down. The hundred or so workers who manned the iron from nine to five were frozen in their positions, standing in awe. Their smudged faces peeked out from yellow hardhats, betraying a contorted mixture of disbelief, shock, awe, fear, and sadness. Silently, we all stared at the result of an accident that brought the entire factory, and this woman’s young life, to an abrupt halt.

She was assisting on a large iron press, we were told in whisper. The machine exerts several tons of pressure, and through some miscommunication or some other horrific lapse, this woman was caught underneath it on a downward stroke. The result was the worst traumatic injury I have ever seen: a crushed skull and brain matter spread out in a fanning pattern. The face was an unrecognizable mash, attached loosely to a body that lay lifeless in an awkward, contorted position. We didn’t even check a pulse. There was no point.

We conducted our business under our breaths, passing word to the police officers that the patient would be presumed dead having sustained injuries incompatible with life. Firefighters wordlessly began surrounding the workstation with a large opaque tarp, shielding the entire area from the tearing eyes of her coworkers and friends. I was able to get demographic information from some of the factory management, and then quietly made my escape back to the ambulance.

My partner and I stowed our gear and climbed back into the truck. Looking at each other from driver’s seat to passenger, we couldn’t come up with anything other to say than “holy shit.” Silently, we drove back to the ambulance bay.

I’ve been to the scenes of many recent deaths. Car accidents, shootings, various cardiac arrests. Outside of health facilities there seems always to be some distraught family member or friend, loudly exclaiming their grief in either cry or yell. It used to bother me to see the faces of these anguished people, and it was usually with them – not the patient – that I empathized. For some reason or another I don’t usually find myself sympathizing with the dead. They’re gone, and in most cases there seems to be plenty of grieving going on anyways.

…But not this call. It was deathly quiet. The silence was so thick that it had to be managed, considered as its own passive obstacle like knee-high sand. We waded into that factory though oppressive quiet and took in a scene that few should have to bear witness to. We saw a hundred hard-hatted faces, watching and silent as if they were waiting for the woman to take her next breath and spring from that contortion. It was a frozen moment of time, lasting an hour, where consideration and re-consideration of events past left little room for outward emotion or cry. It was unreal.

We were brought in to talk with our supervisors who worried whether we were okay. They were extremely accommodating, asking if there was anything we wanted or needed. They said they knew that the scene was pretty gruesome, that it is tough for anybody to see a body so mangled and dead like that.

But it wasn’t the gore. It was the quiet. Seeing that person lying there frozen where she last moved herself was an extremely powerful experience that I don’t think I will soon be rid of. It was as if the clock stopped immediately after that machine banged downward, and though the area surrounding that small space shuffled and blurred in the background, our dead patient remained in sharp focus, preserved in powerful tragedy on the precipice of comprehension.

…And all we could manage to say was “holy shit.”

The Squeaky Wheel

I guess this is what I get for complaining about my chest pain patients. It was my first time with such a standout case, and even though I would have liked to do a few things differently, everything seemed to go well. The cath lab told me he had a total occlusion of the RCA which was stented within record few minutes of us rolling through the ED doors. The patient, smiling, signed my paperwork from his ICU bed.

Credulity

He didn't even have chest pain. No shortness of breath, either. Just weakness and a little nausea without vomiting. He noticed it earlier this morning and though it bothered him, he let it go in hopes that it would resolve on its own. He had had a heart attack about three months ago and stents put in, but even still he remained doubtful that this was very much at all. "Probably just the heat," he said. And I agreed.

Nevertheless I thought I'd ride with him to the hospital instead of driving. Maybe he could use a little fluid I thought, or perhaps some medication to control his nausea and make him a little more comfortable. I hadn't teched a call all day and my own boredom probably played as much a role in this decision as any particular sign or symptom. What the hell, right?

The twelve-lead ECG was full of noise from the bumpy ride despite my best efforts, and there was a bundle branch block that further obscured the view. What I could see, though, were some ST depressions in the V5 and V6. They were maybe a two millimeters or so, and I had my doubts that they were much more than a reflection of all else that was wrong on that strip.

Besides, I have been down this road before. ST depressions in a few leads, inverted T waves, small elevations: they get scoffed at in the ED. Especially without a really good story, these minimal, inconclusive ECG changes often bring nothing more than eye rolls and a condescending pat on the back. "We'll look into it, good job." I've heard it many times before.


The hospital flipped out. The nurse's eyes widened when she saw my strip, pointing at the tiny ST depressions as if they were tombstones from the widowmaker itself. She rallied all her resources, worked the patient up and yelled for the doctor who came quick-stepping into the room as I shrank farther towards the corner. Right about this time the patient's family arrived at the patient's room. I had met them earlier at the patient's home and before I left I told them not to worry, that I would take care, and that they should drive safe. We left the driveway without lights or sirens, and I thought I had made a calming impression on the otherwise edgy and nervous relatives.

So much for that. They sensed the tension and the doctor wasn't helping. "The ECG does not look good at all," she said. "I don't like it one bit." The doctor explained the next few steps in quazi-technical jargon that whipped the family right up into a frothy frenzy, and in just a few minutes I wanted nothing more than to make a quiet escape to review the strips again for myself.

They looked the same as they had earlier. Just a few minimal changes. The same stuff that I've brought in plenty of times before and been disregarded and tossed aside. "Oh, that's cute," they'd infer. "Look how thorough the medic is trying to be." I squinted at the paper and looked as hard as my eyes and education could decipher. Nothing impressive. Not even close, really.

A little bit of experience has raised my index of suspicion for acute coronary syndrome to perhaps a ridiculous level. It seems when I print off twelve leads these days, the patient better have huge ST elevations and the most convincing story I've ever heard if I am going to truly consider ACS with any seriousness. T wave inversion? Hah. ST depression? Yeah right. Don't get me wrong, I'll pass the asprin and nitro out like I am supposed to, but as far as actually believing the patient? As far as being willing to present this to the ED as a heart attack? Not on your life. Doctors simply do not want to hear a paramedic's evaluation of the minute. Its cath lab or shut up about it.


But not this time.

Blood Ran Cold

I never want to have that feeling again. That cold rush of fear that runs up and down my spine, instantaneous and unexpected at the utterance of just a few words. Normal one second, the next I am sweating and anxious, shifting my weight from foot to foot and staring intently at the scene ahead.

My patient is dead. He is spread out on the cot, naked and surrounded by nurses and doctors performing CPR, looking over my cardiac strips, pushing drugs, yelling out commands. The scene is organized chaos, but my focus is set upon just one person there, at the head of the stretcher.

Its the doctor saying that my tube is in the esophagus.

The feeling of fear and shame was so intense, so immediate and powerful that I still remember it with utmost clarity today. Surely any paramedic who has been in a similar position can sympathize. I was taken by surprise, having run this cardiac arrest for more than thirty minutes to the best of my ability, exhausted from the effort and glad to turn over care to the emergency department, only to hear this.

The doctor ordered an intubation kit and the nurses scrambled to comply. I caught a few eyebrow-cocked glances from those in the room. An unrecognized esophageal intubation is probably one of the worst things a paramedic could possibly do, and there I was, helpless in front of my jury, waiting for the verdict from a white-coat at my patient's head. My god I didn't know what to do. My blood ran cold and I just stood there, my mouth half open and staring at the scene as it unfolded. What the hell do you mean my tube isn't in??

The doctor put the laryngoscope in the patient's mouth and almost immediately made the claim again. "Yup," he said, "It's in the stomach." I remember the words exactly.

He asked for another tube with an outstretched hand and a nurse quickly complied. With my tube still in it's place, the doctor directed his new tube slowly, deliberately. It bent upward. He tried again, and again. Each time the tube would contort out of place and resist forward motion. He tried moving the blade around, lifting higher and harder. No luck.

I stared at my monitor printout. It listed the end-tidal CO2, which showed readings in the high teens and twenties for the entire trip. I remember listening to the lung sounds and hearing them clearly. Positive in both lungs, negative over the epigastrium. I SAW the tube pass through the cords, and it fogged up with my first few squeezes of the BVM. The patient's stomach remained perfectly flat for thirty minutes of bagging through that tube, and I re-checked the position at least three times on the way into the ER. God dammit, I was sure about that tube.

...But the doctor continued to insist that it wasn't in. He went back with his laryngoscope and dug harder, peering into the mouth from only a few inches away, squinting his eyes and contorting his face. The tube continued to bend on each of his attempts.

A nurse tapped me on the shoulder and I almost jumped. I was so focused on the events at hand, I didn't pay attention to anything else going on in the room. Now it was the doctor getting the half-cocked looks, and the nurse tapping on my shoulder whispered in my ear. "Don't worry about it," she said, "thats a good tube."

It was. It took the doctor a few more tries before he gave up, pronounced the patient dead, and signed my paperwork acknowledging that I had a good tube. He never said a word to me about it and carried on with whatever else he had to do.

Exhausted, relieved, and trembling, I found a quiet corner to write my run form. Its amazing how quickly things can turn around on you with this job.