That dead lady gave me the finger

Alright, you won’t often hear a Medic (capital M) admit it, but there are times you look back and maybe doubt your past decisions.  Call it reviewing, re-evaluating, whatever you want, but the bottom line is you are scratching the quiet itch of doubt.  Now, if you honest with yourself, you find things to do better next time, or learn something new.  And if you’ve been doing it a while, and learned from your past, more often than not you can reaffirm your actions and stick to your guns.  Almost nothing puts you through that mental review process more frequently than a call that ends in a code.  And sometimes, the Reaper is just yanking your chain.

The engine crew was already on a run when the call came in for a Stoppage of Breathing at the assisted living place across the street from the station.  As result, we got a BLS ambulance and engine from our second due sent with us for help.  The extra information says that it is a 93 year old female patient, call placed by the staff who found her.  We did not get the usual “CPR instructions are being given”, but there are nurses there, so that may not mean anything.  Oh, and the call is on the top floor, but you knew that already too.

Jen was with Cat, Kelly and I, and was, at the time, in the midst of an epic run of codes.  By epic run, I mean something like 7-9 of them in a three month period.  She had her own entry in the CDC’s Morbidity and Mortality report.  This is the same stretch that had the guy on the bike hit by the car. Anyway, getting a code with her at the time was anything but surprising.  

We do the usual “toss everything on the cot, and haul it up to the room” routine and get upstairs pretty quick.  As we head down the hall to the room, we see two of the staffers waiting for us.  Of note, they are in the hall, not in the room…guess there is no CPR going on here.  A bit of an exasperated sigh, and we are past them into the room.  On the bed is a 93 year old lady, looking for all the world like anyone’s grandmother, but dead.  She’s flat on her back, eyes open, mouth gaping, and clearly not breathing.  She’s been down a while and I can see that her pupils are glazing over as I do the mandatory pulse check.  “So, you just found her like this?” I ask the staff.  They tell me yes, it was on a check, but they just saw her, “not long ago.”  Of course.  It always seems that whenever we get a code at a nursing home, or assisted living place, the patient was always “Just seen”.  Sometimes it is clearly a lie, like the time we took a guy out in full rigor, this is not that obvious but more likely they just didn’t realize how much time had passed.  I have Cat setup the LifePak to document the findings, knowing she’ll be asystolic even before everything is on.  I’m looking to call this here and now, but not long prior to this, a medic in an area north of us called a DOA, only to have the overdose patient later wake up and make a full recovery.  Her butt was in a sling, and that case is still pending.  As a result, EVERYONE gets an ECG, and we document it all.  

I’m on my cell phone even as Cat grabs the LifePac and hitting my speed dial to the Doc at the hospital.  The doc answers quickly, and it is a doc I know, but is middle of the pack as in reputation amongst the Medics.  I explain what I have, an unknown, but reportedly “not more than 30 min” down-time, no CPR in progress on arrival, milky pupils etc.  Our protocols say I can only call it with lividity, rigor, or “injuries incompatible with life.”   She doesn’t have obvious lividity etc yet, so I have to call.  The lifepak is on as we are talking, and no surprise, she’s textbook asystolic.  “What interventions have you performed?” is the question I get over the phone.  I explained we have done nothing ALS, that the call is to not work the code.  He explains that he ‘can’t have you stop if you have not done it yet’.  “Okay doc, copy, work the code…” Cat gives me the you-must-be-shitting-me look “we’ve got a lot to do, will call when we are on the way.”  I think the doc heard the tone in my voice and he started to say, “You don’t have to work it all the way, just call when you’ve done things.”  Okay, now THAT is confusing.  

A brief interjection here.  I am NOT in the habit of not working codes.  I’m considered fairly aggressive on the street, and I’m not going to use age, status, or medical condition (outside of being dead) to determine working a code or not.  Hell, my only two walk-out-of-the-hospital saves that I know of are a drug dealer (see S.’s blog) and a terminal cancer patient.  I’ll run the code with about no chance at all, just in case the big man upstairs wants someone back.  But, this lady is D-E-D Dead, and there is nothing else to be done about it.  I know of only one medic that can get this lady back, and last I heard he gave the slip to a couple of Roman Centurions about 2000 years ago.  This was just one of those cases where I was not going to go around protocol and say I saw something I didn’t (rigor etc) just to avoid the call.

Okay, so, we are working it.  It’s a training run, but if we are going to do this, it will be done right and by the numbers.  The engine and the basic come in to see us pumping chest and getting the BVM to the O2.  I had gotten past the unique pleasure of cracking the lady’s ribs with the first few compressions and started to hand compressions off to Jen and Kelly.  The basic unit lead was in EMT-I class, so with her, Kelly out of I class, Cat and I, we had silly ALS help.  The staff of the place wasn’t much help and was struggling to get paperwork in order for us.  Typical too.  I make the call to run the code BLS to the unit, and we are moving that way fast.  There is good compliance with the BVM, and we had her on the cot before the other unit got there.  The patient and the folks doing CPR head to the elevators, and I follow on another one.  There is limited room, and we could not all get in at once.  The team is solid, and I’m not adding anything to that point.  

We transition smoothly to the unit and get setup fast.  Everyone is kinda got that amped-up code groove going and I take a moment to calm everyone.  “Okay, everyone understands how this one is going to end right?”  I get nods from Cat and Kelly, and a little confusion from the rest.  “She’s dead, and nothing we do here is going to change that.  Let’s do this right, get everything done, and don’t poke each other…okay?”  I can feel the back of the unit calm and everyone gets going.  I have the intubation kit out and work with the lead from the basic to get going there.  Kelly offers to get the IV, not a trivial deal on the arm of a person with no blood pressure, and I tell her to give it a shot.  It’s good experience, and she’s pretty good with a needle.  If she doesn’t get it in the time it takes me to get the tube, I’ll have Cat try or I’ll just go for the EJ (IV access in the neck veins) from up here at the head.  Cat gets Kelly going and after the basic ventilates, I take a quick look into the trach of the patient.  Yeah, she’s been down a bit.  I see right away that there is none of the usual ‘goop’ you find in there.  She hasn’t vomited, she isn’t full of mucus etc and all in all, a very clean airway.  (okay, if you aren’t a medic, you may no know that that is a compliment.)  I know I have an EMT-I student next to me, and this is a good a shot at experience as she’s going to get.  (I can’t let her get the tube by protocol, no students get field intubations until after certification etc…kinda stinks, but thems the rules.)  So, I lean back and motion with my head for her to take a look.  She leans over fast and sees her first human airway.  “Cool, not like the dummy” she says.  “okay, so this is not a total waste” I think to myself.  Jen is on my other side, and giving me the raised eyebrows, so she gets a quick peek too.  I have the tube all set to go and pass it quickly, seeing it going through the vocal cords and into place.  I’m well under my 30 seconds for the intubation, so I have the student look in to see what that looks like too.  “Tube placement visualized by two providers” I think to myself and grin.  My documentation will show that this part was nailed.  I hear that Kelly hit the line, and Cat is pushing the first round of meds.  Compressions are going smoothly, and I listen to confirm placement of the tube I already know to be in place.  The Capnography is flat, but then, she’s dead so I have great ventilations, and no respirations.  (Air in and out of the lungs fine, but she’s been down to long for her body to exchange the O2 and CO2 in her blood).  You get that same effect when you intubate a tree.  

Alright, wow, smooth code I’m thinking.  Everything went great, worked the first time, and everyone knew what to do. Nice, smooth.  As much as I abhor a Custer-Fluck, I do admire a group just doing what needs to be done.  The student goes up front to drive and the hospital is only about a mile and a half or so away.  (Which is why we weren’t already rolling).  Quick checklist in my head:  Airway check, compressions check, IV in, drugs in, oh yeah monitor….still asystolic and textbook flat.  Time to call the doc.  “Hey doc, Okay, CPR in progress, asystolic at the start, Tube in, IV in, one round Epi, one round atropine, still asystolic. Pt eyes continue foggy, request permission to call it.”  He asks me how long it has been.  I check my pager…holy cow, I was Dispatched 20 min ago.  “20 min” I tell the doc, and he says to call it.  I give the wave-off to the team in the back of the unit.  “okay, 2 min out” to the doc. Hang up and yell up to the driver so we can just drive, no need for the lights.  (We were still in the parking lot)  Now that means that 20 min ago I was watching TV.  We got the call, got across the street, up the elevator, to the room, talked to the doc, talked to the staff, ran the CPR, got down the stairs, to the unit, ET, IV, drugs and another call, in 20 min.  That’s silly quick and just another case of the mantra: Smooth is fast.  Doing something right the first time, under stress, even though you think you are going slower to be careful, is actually much faster than rushing and messing up.  I’ve noticed our EMTs picking that up, and it’s fun to watch.  Again, a good team is everything.  

We get to the hospital and wait in the bay for the doc to come out and declare the death.  It takes a while, something like 15 minutes, the ER was busy and it took him a while to come out.  Some time during this, the Rescue Chief comes by to see how things went.  He finally comes out, listens to her chest, sees our leads and declares death.  We go into the ER and I work with the Charge Nurse to get someone to the morgue so we can take the body around.  This takes about another 10 minutes to arrange, but finally we can drive around, “downstairs”.  The Chief gives the wave and starts to leave.  

The morgue entrance is in a parking garage type structure that is under construction, so it takes a bit to maneuver the medic unit to the door.  We get the lady transferred onto the pan, after moving another resident and get started to leave.  I’m helping back the unit up around some obstacles when one of the ER staffers comes running out, eyes WIDE open and gesturing madly.  “Your patient is MOVING” he all but yells.  Aw, hell.  Visions of the medic north of us in my head, and grateful for all of my ECG tracings, I stop Cat from backing the unit.  I grab the LifePak from the unit and call back the Chief on my Nextel.  He comes screaming back into the garage in his buggy in a flash.  Me, Cat, Jen and the Chief head for the door to the morgue.  Inside, there is a patient rep, a nurse is just running in, and the patient on a table.  I rush in to see what’s up.  The rep is pointing and agape, not a good sign.  “Don’t touch her” I get from the Chief “that is the Hospital’s patient, not ours”.  Good, clear headed thinking on his part, and he’s exactly right.  We’d handed off care, and the ER doc examined the patient and declared death…this is not my patient.  About that time the doc is walking in.  “She’s moving her finger” the rep says and we all stop and stare.  Sure enough, she’s moving.  Her index finger is moving off and on, kind of a “Come here” move.  “You HAVE to be kidding me” I think as she does it again.  The doc is in now, and listens to her chest.  We are all silent as he leans in, and the finger twitches once more.  “It’s okay, just a reflex from the drugs” he says.  Well, that makes sense, and I’ve heard of such things, but never seen it.  It seems that the Epinephrine, given to help stimulate the heart muscle was causing twitches in her finger.  Let me tell you, hearing it is one thing, but seeing a lady who has been dead for at least an hour or so give you the “come here” will cause you to suck the underwear right up your butt, and I’m not too big a man to admit it.  I’ll know it if I see it again, and I damn well better not see it again too. Grin.

We pack up and go to write the report, and I un-pucker my backside.  I document he heck out of this one though, and have plenty of tracings to show the call.  We clean up and chuckle, knowing that we took a plain old code, and a practice run at that, and turned it into ‘one of those calls’.  To this day, I wish I’d just let her stay in bed, and none of this would have happened.