“Wife says patient stopped breathing.”
I know this one is going to be a code.
Just yesterday we were dispatched to a “Cardiac arrest,” but it wasn’t a code. It rarely is when it comes in like that. People don’t know their terminology. Every time we get dispatched for a cardiac arrest and it turns out to be an alert breathing patient, I want someone to trace back who talked to who, and just who was it who first said, “cardiac arrest,” then grab that person by the lapels, shake them and say, “Stop it.”
But “patient stopped breathing,” that’s a pretty good bet. That and “Patient not responsive and turning blue.” “Pt fell and is gurgling.” “Wife can’t wake patient up.” Those are always codes.
If it’s not a code, that’s good, but if it is a code, well, I’m game. It’s been awhile since I’ve done a code – a couple months. There just aren’t as many workable codes as there used to be. One of the reasons is all the DNRs these days. When I started they were rare, and we worked a lot of people who were dead, just not stiff and dead. Now, we don’t get called as much and when we do, we rarely work them(older people) if they are asystole when we get there, unless they are very warm and were seen alive within the last ten minutes. I always check the jaw first. Any sign of rigor there, and I don’t bother. Dead is dead.
The other reason there are fewer codes to be worked is there are so many more medics on now. It used to be the medic cars were held back in reserve and only sent on the bad ones, and often were sent to intercept with the basic units who found their patients not breathing when they arrived. I rarely did less than one a month, often one every week. I had several days where I did two on the same shift. One day I did three.
I don’t mind working codes. Now I’m not taking about the occasional code from hell where the person is four hundred pounds and puking and I can’t get the tube right away or IV access. I’m talking about your basic run of the mill code. Patient drops, you get there, you shock’em if you can, drop a tube, sink an IV, push some drugs, load’em and take to the hospital. Maybe get a rhythm and a pressure back, maybe not.
Codes are a challenge — a combination of skills and choreography. They are an exercise that you need to go through with some regularity so that when one salvageable one happens, you are at the top of your game and can maybe actually make a difference.
This call is just down the road. And we are there at the same time as the cops. Within 5 minutes of the dispatch.
There are three mangy dogs with huge teeth that the crying wife pulls away as we charge into the house. We find the man on the living room rug by his chair. It’s dark in the room and the light from the overhead lamp in the adjoining room is to dim to see well enough. I fumble with the monitor, rip open a set of electrodes and go to attach them to the monitor cables, when I am momentarily confused. The connection ports are identical. I see then that someone has already ripped open a set of electrodes and left them open in the side pocket and it is their ends that I have grabbed, not the monitor’s defib connection. I grab the right connection now and slap the pads on. I glance at the monitor. Asystole, I order the cop to resume CPR and my partner to get out an ambu bag, while I go for the tube.
The man is in his seventies. He looks just like he is asleep. He is warm. His mouth is very pliable. I get my gear ready. It always amazes me at how long it takes me to get ready. After giving a few breaths with the ambu-bag to check compliance, I turn the Ambu-bag over to a cop, then have to do the following:
1) Unzip the side packet of the Pacific Pack.
2) Take out the ET kit.
3) Unzip the ET kit and spread out the kit.
4) Unzip and inner pocket and take out a) the ET tube holder b) the bulb syringe and c) the Easy Cap C02 reader.
5) Open each of those 3 packets and set them beside the patient.
6) Take out an ET tube and stylet, open each package, then
7) insert stylet in tube and shape it,
8) take out 10 cc syringe and attach to ET Tube,
9) take out and snap together the laryngoscope.
That all seems to take forever.
“I’m tubing,” I say, and the cop stops bagging.
I go in with the 3 Mac — my favorite blade. I sweep the tongue to the side and peer in. No chords. Nothing recognizable. I pull out, stick a pillow under the patient’s head, reposition, and go back in. Nothing. I try laryngeal manipulation. Still not seeing anything. I pull out and decide to try a bougie. I go back in, this time I crank a little more, and suddenly I see the bottom of the chords. I pass the bougie, slide the tube over it, and confirm with the bulb syringe. It’s good.
Now some epi down the tube, quick glance at the monitor, still asystole. I move around to try an IV on his arm. I get an 18 on my second try in the forearm. Slam a few more rounds of drugs to no result, and then look around for the board which one of the cops has brought up.
I think wait a minute, maybe I should just work a few more rounds here, then call it, but then I remember he was a fresh drop, and doesn’t quite fit our resuscitation cessation criteria, so we get him on the board, kling his hands together over his stomach, and carry his heavy weight through four rooms, then down steep stairs to the drive.
His children have arrived now and I tell everyone what is going on. We are breathing for him and making his heart go, but he hasn’t responded, and he likely will not make it. This maybe their final chance to say goodbye.Maybe I have not phrased it right because instead of telling him they love him, they all shout for him to hang in there, keep fighting, don’t leave them alone. Not the message I expected.
We get him in the ambulance and have one of the cops drive. I tell him to go slow, but we are soon yelling at him to slow down.
My partner flies through the air backward, slamming his back into a corner that fortunately is padded.
He swears. I’m worried he is hurt. “Are you all right?”
He grimaces and swears again, but goes back to doing compressions.
“Easy!” I shout to the officer. “Easy!”
They declare the patient dead at the hospital. I fill out the ET form and drop it in the box.
The cop apologizes to my partner. He looks very sheepish. “Sorry dude,” he says, “I looked in the mirror and saw you go flying through the air.”
My partner’s okay – just a little sore, and we leave the hospital after cleaning and resupplying our gear.
I have in my pocket a copy of the initial strip. I look at it closely in the light of day. It looks more than a fine v-fib, then asystole to me. I should have looked closer. It was dark, I didn’t have my glasses on. The monitor wasn’t set up as close to me as I would have liked. Did it make a difference? I don’t know. He’d already been down six minutes. Still.
The code was uneven. It was a spring training code, a back after a layoff code.
Unfortunately, that kind of code doesn’t cut it.