I work in a diabetic town. There is one particular section of lower middle class homes along the avenue that runs north out of the city that seems to be diabetic central. Many of the older residents came to the United States from Jamaica, and while they continue to enjoy their home cuisine — jerk chicken and pork, curry goat and ox tail, all served with generous portions of rice and peas (kidney beans)cooked in coconut milk with fried plantain on the side, they no longer exercise or walk the great distances they did and their relatives in Jamaica continue to do in the course of an ordinary day. Consequently obesity, HTN, high cholesterol and diabetes is a common medical history for these residents.
We have quite a number of frequent flyers, although to be accurate, they don’t really count as flyers because we rarely transport them. A son or daughter or niece or nephew or grown grandchild finds their elder family member in bed cool and clammy with snoring respirations. They call 911. When we arrive we find their sugar to be low, put in an IV and give them an amp of D50. They wake up, and refuse transport. They forget to eat lunch, their relative fixes them some food and promises to watch over them and to followup with their doctor. The refusal is signed after all the necessary cautions and urges to go to the hospital for further evaluation. We pack up our bags and leave.
There is this one house that has a small garden in the front yard guarded by a small marble toad. I always see it on the way in to the unconscious and on the way out from the diabetic refusal. I have always been comforted by sight of the toad. You work in a town long enough and there comes a certain comfort factor. You feel like you are a part of the town, a part of something. You get to know the neighborhoods and the people and the rhythm of the life. I say good bye to the old woman and she and her niece thank me or whatever other relative is there and I walk out past the toad and back to the ambulance and my job of looking out for the people of the town — at least while I am on duty.
Recently I discovered a poem called Jamaican Song by James Berry, which I now read often to my little daughter. It goes like this:
Little toad, little toad mind yourself
mind yourself to let me plant my corn
plant my corn to feed my horse
feed my horse to run my race
the sea is full of more than I know
moon is bright like nighttime sun
night is dark like all eyes shut
Mind-mind yu not harmed
somody know bout yu
somody know bout yu
I am writing about all of this because the other day we got called to the same street off the avenue for a cold stiff body in a warm environment. I saw the toad in the garden as I walked in the yard, carrying only my monitor. In the front room I heard a discussion of where she wished to be buried. I went into the bedroom and examined the woman on the bed. She wasn’t cold and stiff. Soon my partner was rushing back into the house with my field pack as the first responders and I had now gotten the woman on to the floor and were doing CPR. When I intubated her, the ETCO2 reading was 100 — indication of a respiratory cause of the arrest.* Within two minutes it was down to 20. When I checked her sugar it was 40. We tried epi, atropine and of course, D50, but we couldn’t get her out of asystole, so after twenty minutes, we called the hospital and got permission to presume her.
I can’t remember the number of times we had come to her house and brought her around with a simple IV and D50. Always there had been someone who had found her and called us, but this time the discovery was too late. No one was watching over her. Likely, her sugar low, she turned her head the wrong way and occluded her airway. Her heart continued to pump CO2 to her lungs, but since she had an airway obstruction, none of that could be ventilated off. After maybe five minutes, she likely bradyied down to asystole. The grown granddaughter arrived maybe twenty minutes after that and called 911. Not that that explains cold and stiff.
After the code was over, we removed the tube and IV and peeled off the electrodes. We put all our medical waste in a red biohazard bag, gave our condolences to the granddaughter. Her grandmother had lived a long life (she was in her 80’s, well-loved, but had been sick lately. Although I didn’t say it, it was hard not to think of the old woman and how she used to smile, and thank us for helping her again and how she always invited us to come see her for family dinner on Sunday when she promised she would have heaping portions for us of oxtails with butter beans. And then we would walk out past the small garden, feeling like we had helped.
Little toad, little toad mind yourself
mind yourself let me build my house
build my house to be at home
be at home till I one day vanish
The sea is full of more than I know
moon is bright like nighttime sun
night is dark like all eyes shut
Mind-mind yu not harmed
somody know bout yu
somody know bout yu
***
*ETCO2 (each bar is 30 seconds, the first bar is intubation with CPR, ventilation starts with second. Initial reading 100.)
