Saturday, March 27, 2010

The Bleeder

It was the first night without my regular partner in a while. She had transferred over to critical care transport on the day shift leaving me with what we affectionately call “mystery meat”. Mystery meat is when you don’t know who your partner is going to be. It is a bit of a gamble really. If you roll a seven you get a great partner who knows their job and can hold a conversation. If you roll snake eyes you get a lazy partner or maybe a dead fish that doesn’t speak for the entire twelve hours of the shift. This night I was lucky and rolled a seven.

Nadine was a tall, well-mannered young lady who obviously was a bit classier than the typical EMS worker. Her soft-spoken confidence spoke to someone who knew her job, but wouldn’t tell you so. We were having a good night of conversation between calls with the new Sade album playing softly in the background when a call came in for the west side. It was a shunt bleed.

When a patient’s kidneys fail, they are often offered dialysis as a way to prolong their lives. Three times a week they go a dialysis facility and a machine is hooked up to a port, usually on their arm. Their blood is cycled out of their body and through a machine that cleans their blood and removes excess toxins and volume. The machine serves as a form of artificial kidney for the patient. The port is called a “shunt” and is the direct line into their major veins and arteries. If this port breaks open, they will bleed out in a short time. It is a true life-threatening emergency.

“Have you ever had one of these?” I asked.

“Yeah, a couple, they can get real messy” she replied as we sped through the abandoned and darkened streets of downtown.

“I had one a couple months back and she almost bled out. The room was like a murder scene, blood everywhere”. I ran through my bleeding control protocol in my head quickly. There would not be any time for fooling around, we would have to go as soon as we arrived.

We pulled up in front of the run-down apartment complex at the same time as the fire department was arriving. There was a thirty-something woman standing in her pajamas waving to us frantically.

“Please hurry! Please hurry!” she pleaded. “We can’t stop the bleeding”.

“I’ll grab the trauma dressings and wrap” I yelled to the fire captain, ”You guys check it out”.

The captain nodded to me and they headed in with the frantic woman. I often worry about taking control like that, after all, technically it is the fire captain’s scene but it was clear the fire crew had just woke up and were in no mood to be leaders.

“Nadine, not sure what we are going to need, jus bring the gurney to the bottom of the stairs please, get some extra sheets, I’m going to run ahead with the trauma dressings”. She gave me a look that told me she understood. We were all in work mode now.

I walked into the apartment and was surprised at how many people were there. There were at least six adult women in this house not counting myself or the fire department. One was sound asleep on the couch. Sleeping through all this commotion. Interesting. I made a note.

As I poked my head into the back bedroom that everyone was pointing to, I saw our patient lying on the bed. The contrast of the bright red blood against the white sheets was startling. There was a steady stream flowing from her upper right arm and her middle-aged daughter was trying to hold pressure with a towel. I ripped open all the dressing packages and asked the firefighter to cut off her nightgown sleeve. It was completely blood-soaked anyway and was ruined. I asked the daughter to carefully pull away the towel and when I did a pulsing stream of fresh blood shot through the deep-red coagulated jelly that had collected around the site of the shunt due to the towel being on her arm. I quickly pressed a trauma dressing on her arm and began wrapping it as tightly as possible.

Around and around and around we wrapped the dressings until her now-oversized upper arm looked like that of a bodybuilder. Blood was still streaming out of the end of the dressing at her elbow.

“Squeeze here, and here, and lift it up” I directed the firefighter. “And get comfortable, you can’t let go until we get to the hospital”.

“Are you kidding me?” He asked. He was just a kid.

“Congrats buddy, you just got the worst job in EMS. Holding a bleed” I smiled at him. His captain winked at me, he thought it was funny. They love to see the new guys squirm.

The patient’s daughter was pacing around the room. She was worried and needed a job to do.

“Can you grab me a robe, some slippers, and her medical card” I asked. Having a task is very helpful for people who feel helpless. She disappeared into the other room, the tears stopped temporarily replaced by determination.

“Gurneys at the steps, need a stair chair?” my partner Nadine shouted from the front room.

“Awww crap” I thought to myself. Of course we would need one, I had forgotten we were on the third floor and there was no elevator.

“Yeah, good idea” I said a bit embarrassed I didn’t think of it myself.

“Good thing I brought one up” she teased. I love partners like this that think proactively.

We loaded the patient into the chair and buckled her in for safety. I got on the bottom and one of the firefighters took the top. The patient only weighed about one-fifty. We could easily handle that. We decided to just carry her down instead of going step by step. I find it easier on the back with lighter patients than the up and down of dropping on each step. That way you only have to bend over once, not at each step.

Once in the ambulance I threw another dressing around the existing one and began the bizarre dance of working on the back of an ambulance around a fully necessary firefighter who was stopping the bleeding, but now serving as a roadblock to the front half of the ambulance. The patient was getting pale now and her eyes were starting to swim the way they do before you pass out.

Right out of the blue she vomited. And I don’t mean just a little vomit, more like the projectile kind you see little kids do.

“Don’t let go!” I coached the firefighter really holding back a giggle, after all this was a serious call. But it was funny to see this kid getting assaulted from every side. He was getting covered. His arms were already soaked up to the elbows in blood and now his chest and hair had vomit in them. Good thing he had a long sleeve pull-over on. That thing was going in the garbage when the call was over.

“What do you need?” It was Nadine. She had slipped in the side door and was going to help from the other side of the firefighter.

“Suction. She just puked all over.”

“OK, got it” she said as she turned on the electronic suction and began clearing the patient’s airway. Aspiration can be very serious and lead to life-threatening pneumonia. Nadine would try and clear as much as she could from her mouth.

As soon as her airway was clear and it looked like she wasn’t going to vomit anymore, we all knew it was time to go.

Our patient’s daughter who had waved us in was now standing at the back of the ambulance watching us work and coaching her mother to “Keep on living” and to “fight”. She was fighting tears and trying her best to bury her own fears and give all her strength to her mother.

“Where are you taking her?” she asked.

“The closest, it’s just around the corner.” I said.

“No don’t take here there, she’ll wait forever!” She pleaded. The hospital in question was a busy one and you could wait there for hours as it is often overrun with patients.

“Don’t worry, they won’t make her wait this time” I promised. The back doors closed. Bleeds don’t wait.

“Code three, shunt bleed, hypovolemia, approx 500-1000 mls.” I shouted up to the cab.

“B/P is 90/P, tachy at 128 bpm, pale and cool, starting IV now, GCS 14” I added.

“Copy” Nadine yelled back, signaling she understood.

The sirens came on and we bounced along down the pothole-ridden streets. Being that the firefighter couldn’t free up a hand to reach for anything on his end of the ambulance or risk spraying more blood on the walls and floor of the ambulance than there already was I had to get creative and contort myself around him. It was becoming like a disgusting game of Twister.

I got my vital signs, started and IV flowing wide open and put the patient on oxygen just in time to pull in. It was only a mile or so, felt longer.

We wheeled in fast with the firefighter in tow. His forearms had to be burning by now. Blood was streaming off his elbows and leaving a trail from the back of the ambulance, through the triage plenum, past registration and into the trauma room. We wouldn’t be hard to find.

For some reason, the resident doctor doing his rotations at the hospital kept hearing “shot” instead of “shunt”. Perhaps it was because he has seen so many gunshot victims. In any event, it provided a moment of levity as we did this round of Abbott and Costello.

“Where was she shot?”

“Shunt not shot”

“What? Yeah, shot”


“I know, WHERE was she shot?” he emphasized.

Funny stuff. But this was serious, we just bowled through him to the room where they take all the stat patients.

The code team at the hospital was ready for us. We quickly transferred her to the bed, the firefighter was still holding her arm through this exercise. Most of the team had gloves, gown, and face shields on now.

“OK you can let go now.” The doc said. He was ready to resume control.

“You sure, it’s gonna blow if I do” the firefighter said. He knew, he was holding it.

“Let go, we need to see what we have”

My partner, myself and anyone else in the room who had seen this kind of thing before faded back. I actually left the room to the other side of the glass. The new doc leaned in.

As soon as the firefighter let go and the bandage was off, the doc got covered with blood. So did the bed, the equipment, the floor, pretty much anything within three feet.

I laughed to myself. So did an number of the senior nurses. They saw it coming.

“Clamp it down clamp it down! “ the new doc shouted.

A quick thinking nurse put a B/P cuff above the shunt and pumped it up. It stopped. Half the people left the room. This emergency was over.

Over the next few hours this patient would receive as much fluid and blood products as she could take to replace the volume she had lost. The emergency was over and she would live to see another day.

I cleaned myself up, finished my report and went out to the ambulance bay. Nadine was out there scrubbing the back of the ambulance.

“We better go delayed” I said, meaning that dispatch would be told we were out of service for a while to clean up.

“Already on it” she said with a smile. Again, a step ahead of me. When the little details are taken care of, it really takes a lot of stress off a paramedic, especially on stat calls.

“You hungry?”

“Starved, let’s go eat.”

Tuesday, March 16, 2010

Ed the Killer

Tonight I met a killer.

He was sitting in handcuffs in the back of a police cruiser with no shirt on. He was wearing nothing but baggy jean shorts, tattoos, and a fresh coat of sweat. This was peculiar because it was a cold and damp January night. There was steam rising off his slick shaved, scarred scalp and blood trickling down from the corner of his eye into his carefully manicured pencil thin moustache. He had a split eye the way you see boxers get when they are punched too many times in the eye area. He was mess, but determined to control the situation.

“Hey man,” I opened with, “I’m not a cop, I’m a paramedic and I don’t care what the hell happened, I just want to check you out and make sure you are not hurt. Is that OK with you?”

“Whatever, I aint sayin’ shit.” He replied with a dead forward stare.

I questioned him over and over again and he just kept throwing out inappropriate answers to common questions. Name. Date of birth. Address. All came back with non-sense answers, just as the police had told me when I first rolled up. I sensed he was not actually mentally altered, but more enjoying this game of cat and mouse with the police and now me. He wanted us to think he was crazy and give up, which would land him in the hospital and ultimately the psych ward instead of jail. But he was different from the typical nut, his eyes were too sharp and calculating, not vacant. This was a ruse.

“Look buddy, I’m not trying to come down on you, but if you don’t start answering these questions appropriately, I am going to have to assume you have brain damage and you are going on a backboard and getting an IV. When we get to the hospital they are going to have to go through all kinds of tests and scans for possible brain bleeds or concussions. They usually start with a finger up the butt. That’s the best part. It gets worse from there.” I was lying, but he straightened up and from that point forward answered all questions appropriately. Of course he still wouldn’t budge on why he was bleeding or what circumstances led up to us meeting this chilly winter night.

I approached the police officer, leaving the patient in the patrol car.

“So why is this guy being written up on a 5150 again and what do you know about him?” A 5150 is a psychiatric hold you place a patient on when you feel they are a threat to themselves or others. Usually the person needs to make suicidal or homicidal statements or attempts to qualify. In this case, the police didn’t want to deal with him so they were throwing him over the fence to the ambulance crew to take away instead of taking him to jail. Probably because they had nothing to hold him on and he knew it.

“Says his name is Ed, no ID. Neighbor called saying they found him sitting on the curb all sweaty and bloody so they called. He’s going on a 5150. He’s a danger to himself” the cop stated in that bravado way cops talk.

“Did he say anything to make you think that?” I dug a bit deeper.

“He’s just not making sense so he’s going with you guys,” the cop replied, punctuating the sentence by ripping off the duplicate of the form and handing it to me with a smile. He was obviously irritated with where I was going with this and the conversation was over.

“OK, I’ll take him,” I conceded, as if I had a choice. It wasn’t worth the battle. It wouldn’t be the first time I have taken a healthy, mentally sane person to the hospital on a 5150 hold and Lord knows it won’t be the last.

En route, the patient did not talk to me much but was generally cooperative. I kept prying. His body told a rough story of life lived hard. He had gang tattoos all over him and obvious scars from bullet and knife wounds of various ages. I wanted to hear the story from his mouth.

“Can you run the siren?” He broke his silence in an almost a childlike tone. “I like the siren” he smiled through bloody gold teeth.

“Sorry Ed, it’s not that kind of emergency”.

“Well then take me out of these restraints.” He tugged at the leather restraints on his wrists and ankles.

“Sorry again man. It’s procedure. Just go with the flow and it’ll be over soon. You’ll be out in no time.” I half lied. I knew there was no way this guy was going to be a treat and release. They would hold him to run warrants and photograph his tats and try and get some info out of him. They would try. If he was lucky, he could slip through on the psychiatric path and the law would forget about him Seventy two hours later, if he could prove to doctor he was sane, he would be free. In the meantime he would have a safe place to sleep and eat. Not a bad deal. Beats jail.

Once at the hospital, we were stuck in the triage plenum, a room with locking doors on either side where the ambulance crew waits while the ER staff are preparing a bed for the patient, or in this case, when they don’t have one available. You can wait there for hours on a busy night. Tonight was a busy night. The ER was buzzing; people were swarming in every direction with equipment, clipboards, and gurneys. A triple shooting had just come in and two of the victims didn’t make it. The third was in critical condition and all hands were on him so I had to wait. I was fine with the wait until Ed started talking.

“Man, you like this job?”

“Sure, it’s fun.” I replied into the screen of the laptop I was writing my report on.

“So you like tying up people and being the cops’ bitch?”

“It has its good days and bad days.” I replied flatly. I knew where this was going. I was not taking the bait and addressing the slur.

“Do you ever think about this stuff at home? I mean do you have nightmares about all the people you kill?” He asked. I think he was serious so I bit.

“Come again?”

“All the muthas who get smoked because of you askin’ all these questions. Trying to get people to talk. When someone talks, someone dies. Fat Face is a killer and didn’t even know it.” He chuckled. “That’s OK, I am too. We are a lot more alike than you thought, huh….”

I stopped typing. Ed had my undivided attention. This was the kind of perspective I was looking for. I just wasn’t sure why he was turning the tables on me as a perpetrator. I don’t wear a badge. I don’t wear a gun. I don’t chase the bad guys, I just patch them up after the excitement is over. He continued, now aware that I was listening.

“Man you are out here in this game and completely unaware of the game you are a player in. How is that possible?” His tone and cadence were now ratcheting up. He was feeling it. We both were. “I know, I know, just doing your job. Right? WRONG! Your job is getting people killed. And not just killers like me…mothers, kids, brothers, we get the family if we can’t get the guy. I do it with a gun, and you do it too with your bullshit snitch questions.”

He was rolling now, and I was not going to stop him. Morbid curiosity assured that much. The bulging veins on his forehead and neck backed up his harsh words.

“You have no fucking idea what you are doing out there. Every day I smoke mutha fuckas and you come pick up their almost-dead asses and drag them here. But you never see me on that gurney, do you? Look at this tattoo. Look at it and read it!”

“1 8 7 – Fuck a ho, kill a bitch.” I read. Charming. “That’s nice work, where did you get it done? San Quentin?” It wasn’t nice; I was trying to change the subject and feign interest in his ink. Maybe we could stop talking about “smokin’ bitches”.

“It’s professional, this aint no jailhouse gank.” He was more amused than offended. “You stupid. Now you look at this scar from where I got shot.” It was a dull red scar from the bottom of his rib cage to below his belly button. He wore it like a badge. “Every time, you see. Every time. Ev-A-Ree time I get shot but I keep living and the other mutha fucka dies. That’s what happens. You can’t kill me. I do the killing. I end up here and they sew me up. I don’t die but the other guy does. Every time. Just like those guys in there.” He was pointing towards the direction of the trauma rooms where the dead gunshot victims were lying. He knew this place.

“Mmmmhmmm,” I was now looking through the little window out to the rest of the world. The world that was not in this box with this maniac.

“You listening to me fat face?” Apparently I had a new nickname. “I will fuck you in the ass and kill you if I want to. It’s the way it is. I decide! Let me outta these restraints and we’ll see what’s what.”

“Whatever you say.” He was getting overly agitated now, I didn’t want to probe further. I was done with my little foray into his world. I wanted back into mine.

“We have a bed for you” The nurse popped in not a second too soon.

“Hear that Ed the Killer?” I teased. Two could play at the nickname game. “You have a bed.” I had a new sense of confidence. I was back in a routine I was comfortable with and had the support of the staff there. It would be OK form here on out.

“Haven’t you been listening to me?” he snorted. “I don’t need a bed, I need to get outta here so I can get back to work. I have mouths to feed and people to smoke.”

I left Ed the Killer with the nurses in the psych section of the emergency room. Ed was not a psych case, he was a killer. A triple shooting had taken place 3 blocks from where he was found about 15 minutes prior to finding him. It was likely he was involved somehow. I didn’t understand how the connection was not made, but police work is not my job. I take patients to the hospital regardless of their indiscretions.

Some hours later, I was at the psychiatric hospital talking with another crew as we waited to unload our patients. The psych center only takes one at a time and the lengthy admissions process ensure we have plenty of time to chew the fat with the other ambulance crews. One of the other guys was telling me about their patient they had just brought in. A transfer from the hospital psych unit. Apparently they had a live one.

I told them about my deceptive killer I had earlier and said the name Ed.

“What a coincidence, our guy is Ed too” said the EMT.

“No way!” I looked at my partner. We had to look. We went around to the back of the ambulance and peeked in the window. Sure enough it was Ed. He was smiling back at me. With those gold teeth. He had convinced the hospital that he was in need of psychiatric care and was going to be able to hide out at the psych center. He had succeeded in his plan.

After that shift I was driving home. The commute offers me a bit of solitude to decompress and prepare to enter what I call “the real world”. This day I was rehashing what Ed had said to me earlier. It was sticking with me for some reason and I had to work through it. In his insane ramblings there was a bit of truth. Newton’s law states that for every action there is an equal and opposite reaction. I believe that law can also apply to social situations. There were actual consequences to all of my actions, as clearly as there were to Ed’s. I sometimes take the job lightly, not considering the world I am operating in, where a moment of weakness can mean your untimely death or someone else’s. Is it possible that in our zeal to do what is right, to tell the truth, to try and help people we could actually be making it worse?

Not a chance, I decided. I didn’t choose the life Ed or his targets chose. They chose that life and understand the consequences of that choice. Likewise I chose my path and it is a path that leads me to the other side of the fence from Ed and his pals, the fence that separates us from the killers.

copyright 2010 Jon Kuppinger

Thursday, March 4, 2010

Life in the Minutiae

It was a Sunday morning in Oakland. The sun was coming up over the mountains and was blinding to the bloodshot eyes of vampires like me that work the night shift in the city. The rising sun often came as a welcome reminder that the night was over and our shift was coming to an end. A kind of new beginnings signifying the end of a rough night of weekend calls. I work from 9:30 PM until 9:30 AM. Getting off shift at that hour of the morning is challenging because the morning is a time when the call volume is very dense. In a matter of a few short hours our system quickly becomes depleted of available resources. It makes sense when you think about it. Early morning is when you have people first arising and realizing that their loved ones (or themselves) have a problem. Compound this with the large amount of people who get up and pass out in the bathroom or just get up to fast and have strokes or heart attacks and you have a busy timeframe. My partner and I have learned to anticipate that we will get a call too close to our OD (short for off-duty) time and will get held over. It’s OK if you learn to embrace the extra overtime money you will receive.

Today was such a day.

The call came in for a particularly affluent portion of the Oakland Hills called Piedmont. Piedmont is where the doctors and lawyers and anyone else who has done well in Oakland lives. Most of the houses are multi-million dollar, three-thousand square foot plus houses that are built into the mountainside with outstanding views of the San Francisco Bay and all of it’s well known landmarks. The Golden Gate, Alcatraz and the Trans-America pyramid are all clearly visible from this perch, when the famous fog gives you a break. Since the more affluent types of people rarely call unless it is a good reason, your guard is generally up a notch when you head up the hill.

We arrived at a well-kept, modern house on a very narrow canyon street that the ambulance fit down, but blocked traffic both ways. The house was built vertically so that you had to go up two flights of outdoor stone steps before you even got to the front door on the ground floor. From there the house went up another three stories. It was a code 2 call, which means that the dispatcher had determined that the patient was a “less urgent” patient and we would be responding alone without the fire department as is customary on most medical calls.

Our patient was found lying on the upstairs bathroom floor in good spirits. He was an approximately fifty year-old man in good physical condition. Apparently he had passed out earlier when going to the bathroom, but was feeling much better right now. His spouse was a MD and had fully assessed him and did not find any pertinent findings but had a gut feeling that he should go with us as a precaution. She would follow in her personal car. We were fine with that. All of his vital signs were near textbook perfect and the patient was not orthostatic, meaning that there was no drop in blood pressure with changes in position from lying down to sitting to standing. This would be a finding we would expect for a patient who passed out due to a lack of adequate blood flow to the brain. Also his blood sugar was at a perfect level. We were stumped, and our guard was down. After all, it was probably nothing and this would be an easy call. Good way to end the shift.

We assisted the patient down the several flights of stairs. He did fine and did not complain of any dizziness or pain at any time. His color was good and his coordination was normal. I was walking down backwards in front of him in anticipation of him falling. He found this odd.

“Jon, you don’t need to do that, I’m perfectly fine”.

“Steve…”not his name, but we’ll call him Steve to protect his identity “I have had people fall out on me that seem right as rain. I’m not taking any chances on these steps”.

Steve shrugged me off and continued his descent from the castle to the ambulance.

Once in the ambulance we talked about football, his job, and the neighborhood. All small talk to pass the time and make the best of an awkward situation. After all it is a bit unusual for one grown man to be poking and prodding another in the back of a van. I did all the checks I do on everyone and everything checked out. My partner Megan started the slow roll to the hospital through the windy canyon streets.

When it came time to start an IV, he was very nervous about the needle.

“I hate needles” he said.

“Nobody has ever told me they like them” I joked back at him “but most people are surprised by how quick and painless I make it. So who are you calling for the Super Bowl?” I kept him talking about things to keep his mind busy and off what I was doing.

He bore down hard when the needle broke his skin. I was a little surprised at how intolerant to pain he was. Most guys in his condition don’t even flinch. His teeth were gritting and his face was turning red. He was starting to slow his own heart rate down from the internal pressure and I wasn’t too excited about that, but a guy like him would recover fine.

“Aww come on, it’s not that bad Steve, just breath in through your nose and out through your mouth.” I coached. “Steve? STEVE?! STEVE!!!”

He was staring straight at me when the lights went out in his eyes.

I looked at the monitor and saw his heart rate drop by tens. I heard a sports announcer from the seventies in my head:

“Sixty… Fifty… Forty… Thirty… he… could… go… all… the… way! Twenty, Ten, Five, TOUCHDOWN!”

Steve was now gurgling with no cardiac activity on the monitor. His face was turning purple and the lights were out in his eyes. He began to sweat a profuse sweat we call diaphoresis. This was really bad.

“Shit!!! Megan! GO! GO! GO! GO! GO! CODE 3! GO!”

My partner Megan lit ‘em up and hit the gas. Getting back down to civilization on these windy, narrow streets, and doing so with a quickness, was going to be a trick. A trick she was up for, but none-the-less a trick.

“What do you have?” She yelled back, part morbid curiosity, part need to know, trying not to take her eyes off the road.

“No pulse, asystole, not breathing” I was really yelling now more in disbelief than anything. “Just go! PLEASE LET’S GO!”

“We are going” she said. We were going, I was whipping a horse that was already charging. It was time to stop yelling and start working. I couldn’t figure out how to communicate how quickly I wanted to be at the hospital now. Working a code blue alone was a nightmare. It’s a hassle even with a team.

“Steve! Come on man, wake up!” I gave him a brisk sternal rub that would have woken the dead. Nothing.

I don’t know what made me look out the back window. Maybe it was that feeling you get when someone is watching you. I saw his wife in the car behind us trying to keep up and straining to see what was going on with all the commotion in the back of the ambulance. I was like a tornado bouncing from cabinet to cabinet pulling out equipment thanking God I had done my rig checkout that day. There was so much to do. I pulled out my shears and cut his shirt from the neck to the belly button in one fast motion. I slapped the defibrillator pads on him and passing by his head to grab the BVM I instinctively bumped his O2 to high flow. CPR was going to start in a second and I wanted everything out that I would need. My mind was reeling, my heart was pounding in my ears, and I was a bit stunned. I was alone back there, but I could do this. I had no choice. Of course I could do it.

“What do I tell them? What do we have?” Megan broke my trance with a solid question. You don’t just fly into a hospital, you need to tell them you are coming and what kind of a mess you are about to drop in their lap so they can gather the appropriate resources.

“He just coded” I gasped, “I don’t know if this a seizure or a code or what” I felt for his carotid pulse on his neck. Nothing. No pulse. The gurgling had stopped and he was in a blank, dilated, motionless stare.

I ripped open a nasal pharangeal airway (or NPA as we call it) and lubed it up. He was going to need a secure airway and did not have one. I glanced over at the monitor and saw a ripple here and there. IVR. This was not good. This guy was healthy. We were just talking. He was a walking and talking guy with no complaints thirty seconds ago. What the hell was going on? My mind raced for answers as my body automatically ran through the well-rehearsed algorithms on autopilot.

Just as I was sliding the NPA into his nose he popped awake.

It was just like a light switch had been thrown on. His eyes suddenly became animated and his facial muscles regained the composure that makes Steve look like Steve. This is the oddest thing to see. It’s like the return of somebody’s soul to their body. Like a robot that had been switched on.

“Kaiser Oakland, go ahead” I heard the radio crackle from the front. It was time for the report.

“He’s back, we got him back!” I yelled into the cab. His heart rate did the reverse run like an end zone interception. “Zero, Ten, Twenty, Thirty”

Steve opened his eyes and took a deep yawning breath like a little kid just waking up from a nap.

“That was weird” Steve said in a dry, even tone. That was weird? This was his response from the grave? He really looked like a guy waking up from a refreshing snooze.

“Steve, you scared the hell out of me” I was reaching for his neck to check his pulse. It was back and strong. He was breathing normally. All his vitals quickly returned to normal.

“What happened? I felt like I was drifting off to sleep. Did I pass out again?” He was curious, but not concerned.

Meagan was eavesdropping on this exchange. “What do I tell them?” We were getting close to the hospital.

“Crap I don’t know, he just had two minutes of asystole with no breathing and now he’s back like nothing ever happened.” I was stabbing at the dark “I don’t know. Give me a second to get a blood pressure and take a sugar.”

His vitals were back to textbook levels again. What was going on? Did that just really happen?

“Steve, what did you see?” I asked. “Was there anything peculiar or different?”

“Not at all. I just felt sleepy.”

This gave me a huge sigh of relief. Perhaps death was not this awful thing to fear? I thought about my relatives who had recently died. Maybe it was as peaceful for them too. That would be nice.

Megan’s chaotic ring-down was an accurate description of how baffled we were I don’t fault her a bit. What do you tell someone when you don’t know what the heck is happening? The situation was radically changing even as she was talking into the mic. She ended it with a cringe anticipating the eventual laughs and jabs from everyone who heard it.

When we arrived in the ER we were quickly brought into a room with a team waiting. I had to tell and retell the story of what happened to no less than five different doctors. They all wanted to hear it straight from me because something must have been lost in translation. Healthy people don’t just die for a few minutes and come back unaware that anything had transpired. I talked with the ER doc, a cardiologist, the ICU doctor and his resident, and the patient’s family doctor who just arrived with Steve’s wife the doctor. I printed out EKG trend strips and re-enacted it over and over. They all were hunting for an obvious flaw in the assessment, but I had been diligent with this one and left no stones unturned.

Steve seemed to be doing fine in the hospital bed. A little anxious and confused about all the hub-bub but overall doing well considering a few minutes ago he was dead for all intents and purposes. I was another story. All this insanity on the tail end of a busy night had my nerves shot. I had already run a freeway accident, a “hot stroke”, and a near arrest patient on a ventilator. I was feeling the sting in my limbs and chest that you get when you go through repeated adrenalin cycles without rest in between. It feels as if your bones were replaced with metal. That’s the only way I can explain it. I was happy that Steve was alive, but still completely confused about what had just transpired. I was curious from a clinical standpoint but I was also personally invested being that this happened to a patient in my care. Was there something I could have seen or noticed to arouse my index of suspicion? More importantly, how do I make sure this doesn’t happen again?

I debriefed with my partner and retold the story about ten more times to curious hospital staff and fellow EMS workers we ran into. We were done for the day and ready for some much earned rack time. On the way back to the barn Meagan and I laughed, cranked the stereo, and talked about who was going to beat whom to bed first. We were shot. Later that day I couldn’t sleep so I called a senior medic friend who related to me a similar story. It sometimes feels good to hear a common story. He also reiterated the mantras from medic school regarding that this is exactly why we take every call seriously and perform due diligence on every patient. If I had not been careful with this patient and gathered all my information first and eggressed from the residence without the proper precautions this could have been a very different call. What if he coded and stayed dead and I had no line or no baseline vital signs? What if I had talked him into staying at home?

I know this call will change the way I look at patients, if only for a while. The hum-drum day-to-day grind will eventually again deviate my sense of normalcy, but in the meantime, I need to find that balance between paranoia and being slack. Living life in the minutiae.

Copyright 2010 Jon Kuppinger