A drowning

The dispatch is to a nursing home for congestive heart failure.  The fact that the staff called 9-1-1 instead of a private ambulance company could suggest that the patient is critically ill... or simply that the private ambulance company they called gave them a wait time for the next available ambulance that was too long.

We roll into the parking lot behind the nursing home.  I pull the stretcher out of the ambulance–one of my partners had already loaded it with the jump bag and monitor– and start into the facility.

As soon as we round the corner onto the patient's hallway I can hear it; the bubbling, gurgling sound of air being forced through water.  Walking into the patient's room, I find an elderly female supported by a police officer and a nursing aid, struggling to breathe despite the oxygen she's receiving through a non-rebreather mask.  I don't need a stethoscope to identify the sounds.  Heart failure has caused a backup of blood in the vessels that travel through the lungs.  The pressure builds until it forces fluid across the gap between the pulmonary vessels and the alveoli, coating the surfaces that allow oxygen to pass into the blood with fluid.  

The patient is pale.  Her chest heaves with each breath.  She can't get any words out in-between breaths.  "She's a DNR," the nurse tells me.  In her mid-nineties, the patient has declined resuscitative efforts in the event of cardiac arrest.  I glance at the patient.  I can see the exhaustion in her eyes, and hear the fluid that fills her lungs.  I can't help but feel a sense of relief upon hearing that the patient has a DNR.  All the drugs in the truck won't bring her back from this.  

We orchestrate a quick initial assessment.  She's a little normotensive for someone in CHF, but there can be no doubt about the diagnosis.  Surprisingly, her oxygen saturation remains in the mid-nineties.  She's winning the fight... for now.  The rhythm strip we print shows a wide complex tachycardia.  "Let's get going," I say to my crew.  We slide the patient onto our stretcher.  As my driver and I buckle the safety belts, the other EMT goes out to the truck to prepare an IV setup to facilitate the rapid administration of the drugs she needs in order to improve her breathing and alleviate the strain on her heart.

"You guys are fast," remarks one of the police officers.  I'm consciously moving quickly.  I know we can't save this woman, but hopefully we can make her more comfortable.  

As we load the patient, I overhear traffic on the police radio: "ANY CAR TO CLEAR FOR A CODE?"  One of the two officers says the two units will clear and respond to the cardiac arrest.  "Good luck," I tell him as he jumps into his cruiser and peels out of the parking lot.

In the truck, we get the patient set up on monitoring equipment.  I wrap a tourniquet around the woman's arm; by protocols we won't be able to administer the medications we need to before having an IV in place.  Feeling around the inside of her elbow, I find a few acceptable candidates for line placement, but I make a classic rookie mistake.  I slide my fingers along a large vein that cuts diagonally across her AC, and while it was the biggest, it was not the best.  When I try to glide the catheter below her skin, I am met with scar tissue that makes advancing the catheter difficult.  Pushing too hard, I shred the vein.  With her other arm, she lifts the oxygen mask off of her face, and gasps two words.  Even without hearing the words, I know what she's said: "I'm dying."  "Keep breathing," I tell her, "you're doing a good job."  I find a better vein and get the IV.  "We're going to give you some medications to make it easier to breathe."  We put a nitro underneath her tongue, and push 120 mgs of Lasix through the IV.  Already on the way to the hospital, I put more electrodes on her chest and print a 12-lead EKG, which reveals a left bundle branch block–a blockage in the electrical pathways that coordinate the heart's beating.  I drop another nitroglycerine tablet underneath her tongue and call the hospital to let them know we're coming before we complete the short 7 mile trip to the emergency department.  While congestive heart failure patients often praise our treatments as making them feel "born again," quickly clearing fluid from their lungs and surfacing them from the depths of hypoxia, this was not to be the case with my elderly patient.  As I suspected, her body had been subjected to too much abuse.  When I ask if she feels any better, she is barely able to shake her head "no."

When we wheel the patient in, we're directed to the back of the ER.  Nobody looks at the woman on our stretcher, although her gurgling breaths reverberate throughout the unit.  We have the patient moved onto the new stretcher before a nurse wanders over.  I give her the story as I help her get the patient hooked up to the room's blood pressure cuff, pulse oximeter, and cardiac monitor.  As soon as I finish listing the treatments we've given, the nurse walks away, leaving me confused.  The patient is in critical condition.  She needs treatment.  Not to save her; she's beyond saving, but to make her comfortable.

I realize that the 24-year old cardiac arrest victim that the police left my scene to respond to is being transported to this hospital.  When a different nurse comes over to get some additional information, I decide to get some information, too.  "How many doctors do you have working right now?"  I ask.  "Just one," she tells me.

"No residents?"

"No, we don't get residents."

"What about a PA or NP?"

"The PA goes home at 3 PM," she tells me with an painful, "what-can-you-do" expression.

"This sucks," I tell her.  "At Rhode Island [hospital], she'd be on CPAP, she'd have gotten more lasix, maybe more nitro, and definitely morphine.  She'd have been seen within 5 minutes of hitting the door.  Now, the doctor will be tied up with the code for at least half an hour before he'll even lay eyes on her."  

"I know," she says, "it sucks."  

They shoot a chest x-ray that the doctor ordered before the code arrived.  I go back into the room to finish writing my report.  The nurses and radiology tech are gone.  The patient pulls the oxygen mask away from her face.  She's tiring, taking increasingly large breaths, and she doesn't want the oxygen.  I think she is going to go apneic while I am right there; she will stop breathing and I'll have to watch as the monitor records her death.  With her other hand, she reaches out to me.  I take her hand.  "Keep breathing," I tell her, "they're going to give you more medicine soon."  I glance at my watch.

I move to her other side so I can sit and write.  I continue to hold her hand.  When I slip away to attach my 12-lead EKG to the run report, she extends her hand towards me again, and again I take her hand.  I finishing signing everything a little before the doctor finally comes in.  He doesn't introduce himself to the patient or even speak to her.  I suspect that he also knew she was dying–and why should he bother attaching himself, even if it means negating the most basic human courtesy?  Half an hour after we arrive, she receives treatment I could have initiated myself in many other states: CPAP and morphine.  The doctor orders 4 mgs.  About 6 too few, I think to myself.  I can tell she doesn't want to fight anymore, but can't suppress the urge to keep on breathing.  As soon as the respiratory therapist straps the CPAP mask on, the patient tears it away.  She vomits, her lungs overflowing with fluid.  I say goodbye to the elderly woman and leave.

I would have preferred to stay.