1 DEATH
Quote:
“The amazing miracle of death, when one second you’re walking and talking, and the next second, you’re an object”- Chuck Palahniuk, Fight Club
*Chuck hit the bull’s eye here. I read that he had volunteered in hospice before so I’m sure he has seen death. As for the word ‘miracle’…, well if you’ve ever read Palahniuk I think you will agree that the choice of word is most likely bitter sarcasm. On a side note, Chuck is a fucking rock star but that’s neither here nor there…
Watching people die and seeing dead bodies
after the fact is something almost anyone in the medical field is going to have
to encounter sooner or later. At the
same time, outside of a funeral setting it is something the average person will
never have to deal with. For paramedics
and EMTs it is pretty much guaranteed that you will see it frequently and
pretty early on.
Watching people’s bodies shut down for
good in front of you is a lot different than getting there and having them be
stiff. Most of the death I have seen has
involved the patients being dead before we arrived. Occasionally someone calls 911 soon enough
and we get there and they are still alive then crash but usually the people
should have called much sooner however we all die eventually and a lot of the
cardiac arrests we get are simply hopeless.
Death is often sanitized in American
culture. People hear about it and see it
in movies but most people don’t have to come face to face with it very often. Seeing the dead can be sobering and usually
has a surreal feel to it but it can also make you glad that it’s not you
yet. Seeing death can also make you
reconsider any self-destructive habits you may have especially when its young
deaths. An old person dying is natural
and people realize it will happen it is nature but when young people die it
always seems un-natural.
I haven’t technically seen a child die
but I have seen them with very little time left and close to death and that is
bad enough. I don’t want to see it
ever, nobody does, but that’s not realistic.
Most paramedics I have talked to tend to agree that pediatric calls are
the absolute worst as they hit you the hardest.
Still in extreme situations we have to stay calm and totally focus on
what needs to be done to save a patient regardless of how you might feel about
it emotionally. A lot of people couldn’t
handle it at all and eventually paramedics can burn-out which is when they’ve
just had enough. I am nowhere close to
burn out I am really just warming up but it does happen.
There are also the total nightmare calls
you here about that can be it for some people, such as a school bus full of
kids going off a bridge or something like that.
When a lot of people are hurt all at once from the same event we call it
a mass casualty incident, luckily where I live they are rare but from what I’ve
heard they sound like a nightmare emotionally, physically, mentally and
logistically. If let’s say 100 people
were all hurt then you would need a lot of responders and there would be tons
of work to do. Mass casualty incidents
can cause further problems though. Now
you have 100 patients, where are you going to put them all once they are ready
for transport? ERs do not have unlimited space, resources and staff and many
any not set up to take serious trauma or a lot of people all at once. In addition counties and states and countries
don’t have unlimited ambulances and people to run them so you can end up having
to call for help outside of your area if it is bad enough.
From the outside looking in paramedics can
be seen as cold or heartless in how we react to stuff that make other people
lose it. An example is some paramedics
and firefighters tell really offensive and crude jokes sometimes about our
patients later on. This might appear
cold but it is really just a coping mechanism.
In other words after you see some fucked up shit you have to be able to
shake it off somehow and joking about it can make it easier to handle. If we couldn’t handle the stress somehow we wouldn’t
be able to deal with the stuff we see from day to day over and over again and
effectively and wouldn’t be able to help patients. For squeamish people working a cardiac arrest
would be nearly impossible.
On one of my first ER clinicals a veteran
firefighter paramedic told us if you can’t laugh about the bad stuff it will
eat you alive. He also said that you
have to be crazy or retarded to sign up for emergency medical services which
could be true!
My
First Dead Body
One thing some people like to do is mess
with students and new people. One day I
was doing a ride-along at a fire department and we were eating breakfast and
one of the guys asked me if I had seen a dead body yet-regular dinner table
conversation at a firehouse. I hadn’t
but that day I saw my first one.
The first one shook me up a little. A young man probably not much older than me
(I am 25) had gone swimming at the beach and had drowned. He was just lying
there when we got there with life guard doing chest compressions. Another crew pronounced him before we could
try to work him. They had apparently
been doing CPR for a long time with no response at all and he had been in the
water for a long time according to his friends.
They ran an EKG strip and he was asystole which is a flat line like you
see on movies and TV, however unlike in fiction defibrillating (shocking) it
won’t do anything. We can’t shock all
dead people, well we can but unless they are in certain lethal rhythms it won’t
do anything.
A common misconception is that
defibrillation starts the heart but the opposite is true. We defibrillate 2 main rhythms called
Ventricular tachycardia (pulseless) and Ventricular fibrillation AKA V-tach and
V-fib for short. In these rhythms there
is electrical activity in the heart but its abnormal and not doing what it
needs to do to pump blood. The idea of
defibrillation is hit the heart with a ton of electricity and knock out all
electrical activity so that the heart can restart itself in the proper rhythm. Because asystole is the absence of electrical
activity so defibrillation won’t fix that.
With v-tach the heart’s ventricles (bottom large chambers of the heart
that pump blood) are beating so fast that they aren’t able to produce a pulse
and pump blood and blood is life. V-tach
can also be with a pulse but when live patients are in v-tach they are usually
in really bad shape. Other patients can
have runs of v-tach meaning they can go from stable to v-tach and back to
stable but if they know this they usually have internal defibrillators kind of
like a pace maker but not exactly. A
pace maker gives shocks to the heart if the rate goes too low to speed it back
up while defibrillators zap it when its going too fast or into a lethal rhythm. In the field we can externally pace people
when their pulse is too slow and we can cardiovert when it is too fast but they
do have pulses. Cardioversion is similar
to defibrillation but it is not done to dead people, what it does is zaps the
heart to slow it down versus knocking out bad electrical activity. I could get a lot more technical than that
but I don’t want to be dry.
Rollover
with Ejection
My first hand on cardiac arrest was my
first and only dead person who had a return of pulse after his heart had
stopped. He had been in a rollover
accident on a highway and had been ejected out of a window (where your seat
belts!). He had landed on the pavement. We got the call as a respiratory distress
(difficulty breathing) but before we arrived on scene they had updated his
status to cardiac arrest. When we got
there people were already doing CPR so we took over and they gave me the job of
chest compression while they got IVs and put in a breathing tube.
We loaded him up doing CPR and rescue
breathing while we moved. Rescue
breathing is done with a bag valve mask or BVM which is like a balloon you
squeeze that fills patients lungs with air every time you squeeze it when their
body cant breath for itself. Mouth to
mouth is mostly discouraged now as it is dangerous and its also
disgusting. The downside is that we were
using a basic tube which also cause air to be pumped into their stomach which
can cause dead people to throw up which is totally crazy when patients vomit
and can’t control their airway they can aspirate (breath in fluids) which can
cause asphyxiation and infection if they live-in other words they can drown in
their own stomach contents. What that
means is that we can’t say gross instead we have to work fast to suction which
also became my job or else we can compromise our patient’s airway.
Not too long into our trip we had been
doing CPR for a while and had given some IV fluids to replace blood loss and we
did a pulse check and sure enough he had strong pulses and a decent blood
pressure and this guys was very dead. Of
course unlike fiction they don’t just jump up and start having a conversation
with you they usually stay unconscious and still need a hospital badly and are
prone to crashing again. His heart was
working again and he was moving around a little but still was totally out and
we still had to breathe for him all the way to the hospital. Usually if their regaining consciousness they
will try and un-tube themselves and he made no effort. We transferred care with no change. He had taken blow to the head, had who knows
what for internal injuries and had lost some blood so he was still in bad shape
and I would honestly be surprised if he survived but I never found out. It’s not uncommon at all to drop off patients
and never here about their final outcome but usually you forget because many
days you can run calls one after another.
After this call the back of the ambulance
and my uniform was a bloody mess. We had
to clean blood and vomit and who knows what else off of nearly every surface
and piece of equipment. I was so covered
that they told me to go home shower and change. I changed out of my uniform at the station and
wash it there as they recommended, nobody wants to take something contaminated
home with them because you don’t want potentially infectious clothing where you
live and it is just gross. I wasn’t
thinking it was gross at the time because I was on an adrenaline high. It was my first hands on cardiac arrest and
we had got a pulse back which could be counted as a save but some people say
it’s not a save unless they walk out of the hospital healed, I say if their
alive when we drop them off we did our job since hospitals sometimes think we
are just a meat wagon which is fine because we have nick names for hospitals
that imply they kill people too. One
joke some medics use is if you lose a patient you killed them, even if you did
everything right mainly because ball busting is common among paramedics and
firefighters and because it just helps lighten the mood.
A very shocking part of CPR that is
actually quite common is breaking ribs.
I have broken ribs on patients twice that I can remember. You know it happens because you can feel it,
sometimes here it and there are times when you can actually see it. We are taught that if you aren’t busting ribs
you probably aren’t pushing hard enough with your chest compressions. It isn’t to say that breaking ribs is a good
thing or that we want to break ribs but that you have to push hard in order to
manually pump a dead persons heart and the amount of force it takes to do that
often will break ribs.
Broken
Chest
The worst case where I broke ribs was
brutal. We got a call for respiratory
distress at dentist office meaning a patient wasn’t breathing well. We got there and that was an
understatement. The patient looked like
hell. He was an elderly man with cancer
and had been on chemotherapy. Being old,
having cancer and going through chemo makes for a nasty triple cocktail for
very brittle bones. He was clinging to
life. He was barely breathing and his
pulse was around thirty and plummeting. We quickly loaded him onto the stretcher and
rushed him to our ambulance after putting him on high flow oxygen. Right about when we put him in the ambulance
his heart stopped and we lit up the truck and raced to the hospital and got to
work.
I started chest compressions after putting
an IV and one arm and another medic put one in the other. I started cracking ribs almost
immediately. About at the same time
another medic was ventilating him and just by holding the patients jaw (a
needed step to form a proper seal with a bag valve mask and properly ventilate)
and the jaw broke. It was so brittle
that just broke from the medic trying to breath for him. Anyone whose never seen what cancer and
chemotherapy can do to the human body might see that and think the medic was
being rough of course the hospital didn’t think anything of it, the guy looked
like a holocaust victim-skin and bones.
By the time we got to the hospital we had given him multiple doses of
cardiac arrest drugs, if I remember right we gave him two doses of epinephrine
and atropine, neither did anything. It
seemed like his whole ribcage was destroyed.
As we transferred care and I continued CPR while we were waiting for the
doctor to pronounce him dead the bone fragments of what was left of his chest
were starting to stab into my hands. If
we had continued for much longer Im sure the fragments would have broken
through his skin, my gloves and into my flesh which would have been a nightmare
because that would have been a great way to get infected if he had anything
blood borne we didn’t know about. At
about that time the doctor decided enough was enough. You can only do so much for a cardiac arrest
before you have to call it quits because at a certain point if you’ve done
everything you can and made no progress you have to accept that they aren’t
coming back and you have to move on.
Rigor
Mortis
Another cardiac arrest I had involved a
middle-aged woman. She was lying on the
floor of her house with a distraught family member, husband or boyfriend or
whoever he was standing by begging us to help which never makes things
easier. We through the drug box at her;
meaning we gave her everything we could.
First thing first we checked for a pulses or breathing and put the
monitor in her to check for a rhythm-no pulses or breathing and a flat lined
EKG.
I started CPR. Pop, pop, pop, ribs breaking under my
hands. Another medic started to
ventilate her with a BVM. They wanted to
tube her and I volunteered. They asked
me if I had tubed anyone before and I said I had so they let me try. I moved to behind her head so I was in
position to intubate. I opened the
airway kit and pulled out the “blade” which is used to help us visualize the
trachea’s opening. It is a metal device
with a light on it so you can see down the through. You have to be careful or you can break
people’s teeth with it. There was white
fluid pooling in the back of her throat, I don’t want to know what it was. We suctioned her throat out to clear her airway. I gripped her head so I could open her mouth
and put the blade in. I tried to open
her mouth but it wouldn’t budge. Rigor
mortis had locked her jaw shut. I gave
her some more ventilations and told the other medics she was locked shut. They decided to put in a combi-tube which is
blind insertion. We had to force the
tube in and one of the balloons broke on her teeth since her mouth was barely
open and that wasn’t going to change unless we broke her jaw which we would
never do deliberately. With a broken
balloon we couldn’t get a good seal so the ventilations were weak but better
than nothing at least we were getting some oxygen to her lungs.
At this point we had given her two rounds
of epinephrine (adrenalin), two rounds of atropine ( ), one dose of D50 (sugar; she had low blood
glucose), one dose of Narcan (an opiate antagonist; used to reverse narcotic
overdoses which never hurts and every cardiac arrest is a potential overdose),
one dose of sodium bicarbonate (an electrolyte that reverses metabolic
acidosis; in English when you die your blood starts to turn acidic which
creates a hostile environment for cells) plus some saline which can help with
hypervolemia (fluid loss or shock) and a ton of CPR. After all that there was no change and we had
to call it; we had to pronounce her dead.
We told the guy we were sorry but she was dead. Never passed away, moved on, in a better
place or anything else always DEAD. You
have to make it crystal clear that the patient is dead and the only way to do
that is to use the word dead. He didn’t
like that, not that anyone could blame him since he had just lost someone he
obviously cared about. He was in shock I
imagine he thought we were going to save her.
“She’s dead?!” he said and
cried and we apologized. He didn’t
believe it I know he said some other stuff too but I can’t remember what. We
left him there, we had to we can try to comfort them a little but we have other
places to go and don’t really have a lot of time to help someone grieve. The cops would bag the body for the coroner
to come pick up. We aren’t really
trained to do it either we aren’t therapists.
Work them and forget them then move on and do it all over again.
I think she was hopeless when we got
there. A locked jaw is a bad sign and a
medic probably would have been justified in an immediate pronouncing of
death. It wasn’t my call and still was
good experience. We did everything we
could and did everything right. But
rigidity is usually an indicator that they have been dead for a while and once
the brain is gone it’s gone.
He’s
watching TV!
The arrest that made us laugh a little was
totally hopeless. We weren’t laughing at
the death itself in this case but just the setting. We arrived at a trailer park. A neighbor had called because they said this
guy wasn’t looking so good. We got to
the trailer. A man was sitting in the
recliner with his feet proper up watching TV.
He was very dead. I didn’t even
see his face but from my angle he looked totally peaceful. It took the lead medic about half a second to
pronounce him. The air conditioner was
on and he said the guy’s skin was room temp- dead. He had to have been dead for a while because
his whole body was the temperature of the air conditioning and that doesn’t
happen quickly. However once I had a
patient in an ER who was alive enough to talk and move around who was in severe
hypothermia due to I believe pancreas failure if I remember right. She was icy which makes me wonder about this
guy. But he was totally lifeless. He didn’t twitch at our arrival and didn’t
show any responsiveness at all and he was stiff-rigor. The medic was confident that he was
gone. He was a medic I worked with a lot
on clinical rotations who I trusted completely and who had a ridiculous amount
of experience and taught me a lot. It
was a discretion call and everyone trusted his.
The reason we laughed was because the guy
seemed totally comfortable. Of all the
ways you can die there are much worse ones out there since it didn’t look like
he had suffered at all. Nobody said his
face was grimacing and he wasn’t locked into an uncomfortable position. I imagine he probably fell asleep and had a
blood clot go to his brain and never knew what hit him. He most likely died in his sleep.
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