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Thursday, April 24, 2008

Common Threads & Awkward Circumstances

by Steven P. Velasquez
April 23, 2008

Once again the common thread that interconnects us all has revealed itself in a most surprising way. One can debate the existence of this "thread" but the next logical question would be for that person to explain life's coincidences that often manifest as more of a "perfect storm of events," than a benign set of circumstances that are easily explained away.

The Response

While working one of my jobs the other night, my partner and I were eager to hit the road and get a meal. As our luck would have it, we were dispatched to a local nursing home for a cardiac arrest with CPR in progress. These types of calls are often anti-climactic and severely lack the intensity and drama often found on your TV shows. It's often someone who has been quite ill, has not one but many disease processes working against him and his aging set of organs, and they have simply run out of gas – so to speak. They're dying. Many times, even with a rapid response and a bag full of medicine, they are too far gone; they're not candidates for resuscitation and they are pronounced dead in the field by Paramedics with a supervising physician via radio or phone. After answering enough of these types of calls, it often feels like more of the rule vs. the exception. This, of course, does not translate into delayed responses, lackluster care or absence of desire to assist the ailing victims.

Code Blue

As we arrived and were greeted by the nursing staff, we encountered a man in his 70's who has stopped breathing and had no pulses. The local EMS agency was already on scene performing CPR and using an AED (Automated External Defibrillator). "Were any shocks delivered?" I asked. "No, no shocks" they gasped as they compressed the patient's chest vigorously. A long litany of questions follows during this process as we setup our equipment to either confirm death or perform advanced resuscitative measures. The nurse stated that he had no DNR (Do Not Resuscitate order) indicating that all measures to sustain life should be attempted. A quick glance at the ECG revealed asystole or a "flat line" indicating the absence of any electrical activity in the heart (we all will have this rhythm sooner or later!). So far, the circumstances seemed to jibe with the description above. I expected to call the doc, report our findings and receive a time of death. Oh, and then dinner!

The patient lacked one or more of the qualifiers for pronouncement of death though. He had last been seen or spoken to within the past ½ hour, his body was still warm and pliable with no evidence or blood pooling due to lack of circulation. Our doctor instructed us to continue the resuscitation, give some life-saving drugs, and call back with any changes for further direction. Translation? Get busy and, uh, no dinner! My partner intubated (placed a breathing tube in his lungs) and I began an IV so we could administer fluids and medications. After only one round of drugs (1 Epi and 1 Atropine), the patient had a return of spontaneous circulation (ROSC). Initially I thought "Eh, it's just the meds doing their thing; it'll wear off!" Nope! We had nice heart sounds, strong pulses, his mottled (blotchy) skin color seemed to improve and his carbon dioxide levels were in the 40's (definite sign that the body is still producing energy). My partner and I exchanged a look of, how do I put this nicely? "Holy Shit!" Internally I thought "Jeez, this guy must really want to live." We began to move the patient to the stretcher and that's when my world was turned upside down.

The Helmet

As we moved the patient, I noticed a firefighter's helmet on the floor. I asked "where is he a firefighter?" The EMT's replied "he's a firefighter and an EMT from Union City." The words struck me like a giant's kick in the gut. Without seeing an ID bracelet, his chart or re-examining his face, I shouted his name and choked back my tears! "You know him?" they asked. Now, if this were a movie and I was the protagonist, this would be the scene where I grab the EMT by the lapels and shake him growling "You treat him like family – got it? Family!" But dramatics aside and with the absence of my camera crew, I gently told the crew (voice shaking and tears building) the following:

"I want you each to remember your very first time that you ever entered your EMS building. Who was the person that greeted you and introduced you to the place? Who was it that told you 'that's the driver's seat – you won't use it. That's the siren – you don't touch it. This is the radio – you never talk on it! I will?' Whomever that person was for you, this man is for me."

I'm currently in my 21st year of service. Two decades ago when I first joined Union City, this man was already in his twentieth year of service. He served in the US Navy during the Vietnam era, was a charter member of the Union City Volunteer Ambulance Corps. in 1972, was the gatekeeper of the place that would lead to my future career and now I, in a dramatic role reversal, was his gatekeeper between here and the ever-after.

The Location

My "routine" mentioned earlier was suddenly and dramatically turned upside down. The room seemed to elongate and the voices sounded slower than usual. I was caught in a vacuum of time and space. Where I was geographically was about 40 miles away from Union City. How did he wind up here? And, talk about a bunch of circumstances, how is it that he's here on my night to work, in my primary call area, I'm not on another call, I'm not at the furthest distance from where he is etc… etc… "God? Can you hear me? Why me? How?" All these questions and more raced through my aching head.

His Care

We covered him in blankets to preserve his body heat and moved to the ambulance. My partner and I double-checked all our IV's, tubes, machinery etc… This man who spent his life serving so many, caring for the sick, treating the injured, protecting life and property as a volunteer firefighter and until her passing – caring for his mother -- was now in my care. His last hours on this earth were under the care and supervision of one of his own. It was time for him to receive that which he gave so much of.


My partner and I stayed in the ER with him for the next few hours. His next of kin had arrived shortly after we did. She was his best friend and the only one who took care of him. I remembered her as a new EMT and cop wannabe. She now looked like the cast of NYPD Blue as she arrived in a business suit with a 9mm strapped to her hip and a gold badge? "Are you in the detective bureau" I asked? Humbly she replied that she was the new Lieutenant Commander of the night shift in that bureau. There was obviously much catching up to do.

We stayed, spoke to, reminisced with and comforted her. We stroked his hand gently and told funny stories of some of his antics from the past. We quipped that if he regained consciousness, he would probably kill me for not letting him go peacefully. Truth be told, his nurse told us there was no DNR order when in fact, there was. I shudder to think of how I'd feel had they produced a DNR and I had been forced to stand idly as my friend died before my eyes. I suppose I'd feel much worse than I do right now though that's hard to imagine.

My friend lasted through the night and was transferred to the ICU. I withhold his name so as not to betray medical confidentiality of one of my patients. I left work Tuesday at around seven. After running some errands, I called his next of kin to see how he was doing. She was just leaving the hospital and conveyed that he had passed on just a short while ago. She thanked me greatly for providing her with a window of time to wrap her head around these sudden and tragic events. She was afforded a chance to say goodbye. She stood by his side as his heart finally slowed one last time, as he crossed the gate from this life into the next.

And with that, another page of history gets woven into the fabric of life. Take nothing and no one for granted my friends.