He works in mysterious ways

It was a nice sunny afternoon in Oakland when the call came in for “man down”. I love that description, seems so sinister, yet rarely is. We pulled up at the same time as the fire department to a boxy, two story apartment complex that had the look of a converted cheap hotel. This one was badly in need of a new roof and paint. The external stairways and walkways were framed with rusty wrought iron railings and a decent amount of trash to navigate through. There were several older large black women dressed as if coming straight from church waving to us from the top step. Wool dresses, matching hats, purses and pumps. Color coordinated to the max.

We made our way up the rickety steps. They were center supported concrete slabs with spidery cracks veining the cement. The corners of most of them were chipped off, one was only two-thirds of a step. The center steel beam that held up the steps from below creaked and groaned under the stress of three firefighters, my partner and I plus all of our equipment trudging up the steps. I tried not to think about it. Much the way you don’t look at the cheap cotter pins that hold together a Farris wheel when you are stopped at the top.

At the door on the second floor, the church women met us. They were excited, sweaty and all talking at once.

“We just got home and she aint right” one said.

“I don’t know what happened, she was fine this morning” said another.

“Oh Lord don’t take her like this!” pleaded another one at the sky above.

We were calmly led to the back bedroom by the woman who seemed to have the most control over her emotions. On the bed we found an obese younger woman, approximately forty years old dressed in an old fashioned pale pink dress lying face up on the bed. Next to her was an empty bottle of opiate-based pain-killers. Another empty one was sitting on the nightstand. Just clues. Gotta keep your eyes and ears open and let the scene talk to you.

The woman was breathing maybe four times a minute and shallow. She did not respond to our shouts or when we shook her. I could tell she was not getting enough oxygen without testing her pulse oximetry.

“Let’s bag her” I said to the firefighter. “one every five seconds” I added.

As the firefighter repositioned her airway and began to assist her with her respirations, I continued with my assessment. Her radial pulses were weak and she was sweaty. Her pupils were pinpoint and she had some frothy sputum around her mouth. I noted it and moved on.

The engineer was just finishing getting the blood pressure.

“It’s really low and hard to hear…maybe sixty over palp?” he more asked than stated.

I could hear my partner asking questions in the background of the family.

“What medicines does she take? Does she have any medical problems? Any allergies to medications? Does she drink or take any illegal drugs? When did you last see her normal? Has she been sick lately?” All the right questions. Nothing obvious was sticking out. I kept thinking about the empty pill bottles, our only clue thus far.

“Let’s get a line going. Can you spike me a bag?” I asked the engineer.

“Sure” he said and got to it.

“Can you put her feet up please?” I asked the Captain who was standing at her feet.

“Copy” He got right on it.

“I’ll check her sugar.”

When you anticipate a patient needing medications or fluids and it seems as if they are going to be a stat patient, we will often start an IV on scene to get it going before we move. In the case of this patient, she was not only hypotensive, but I was suspecting an overdose. We would not be playing around too much here, it would be a stat transport as she was not doing well.

“I’m going to try some Narcan” I told the captain. I spun around and grabbed the box of Naloxone, better known as Narcan. Narcan is a wonderful drug that is a competitive opiate receptor inhibitor. It will bind to the opiate receptors and prevent the opiates, such as heroin, morphine, or methadone from having the effect of slowing down the breathing and ultimately killing the patient. The drawbacks are that it will not remove the opiates in the system, just block them so when the Narcan wears off, they will OD all over again if enough opiates are still in their system. Narcan also will take away the high instantly sending an addicted patient into acute withdrawal syndrome which could including seizure, profuse sweating, explosive diarrhea, abdominal pain and vomiting, heart attack to name a few, so we are careful with it. Only enough to get the respirations normal.

Just as I was preparing the Narcan, in walks a mousy woman in all black wearing a matching black hat with black roses and a short veil pinned up. She had thick glasses from the 80s that magnified her eyes. She was holding an old leather bible. It was clear by the way the rest of the family was acting that this was someone to be respected. Possibly an elder of the family or a holy person.

“Excuse me” she said in a meek voice. “Do you mind if I say a prayer?”

“Well ma’am we are working real hard here to save this young lady, pray if you need to it certainly can’t hurt”. The Captain reassured.

“Thank you” she said quietly and jockeyed for a good position at the patient’s feet.

I don’t understand what happened in the next few seconds, but this meek and mild old woman suddenly became aflame with the holy spirit. She turned into the shouting preacher complete with throwing her hands up in the air and punctuating the pertinent syllables in her sentences like she belonged in a travelling revival tent in the turn of the century south.

“Lord!” she started with a dramatic pause letting all the air leave her before springing back up “It is not time to take this humble servant!” she said impossibly loud with an elongated “ssssssss” on the “this”. “She has so much more of your work to do! Do not take her today, I beg of you. Give us more time. Do not take her. Not like this. Not like this! Not like this!” The repeated part got louder and more dramatic with each pass. The other women were starting to grunt and nod in agreement getting more involved in this impromptu prayer meeting.

She was throwing her body onto the legs of our patient and wailing. She was throwing elbows to keep us back. The prayer was much more than we had expected. Her arms ran from the tops of the patient’s thighs down her legs and she chanted and pleaded with her maker to reconsider what surely must be a mistake.

It got to the point where we were not able to get to the patient to do our job anymore. The little prayer had turned into a full-on sermon complete with theatrics, call and answer, and singing. It was time to shut this down, or at the very least get some room to work.

“Ma’am please, I understand you need to pray, but we need to work here” the captain reasoned. “If you don’t let us help your friend here, she will die. And soon.”

“You can’t save her, only the Holy Spirit can make that decision” she retorted sternly in the captains face “Do you hear me boy?” she redirected her eyes up “You can save her! Only you!” she shouted at the cracked ceiling with the old fashioned fixture on it before swinging her hips to block the path of the captain the way a defensive guard does underneath the basket. We gave her another ten seconds of sermon time before we shut it down. This was getting ridiculous.

“Let’s go” the Capt said nicely as he forcibly removed her, pinning her arms to her sides.

“I’m not done! I’m not done! Hear me Lord!” she yelled over her shoulder as she was lifted out of the work zone.

“Well you can finish from over there” the now-miffed Captain stated gruffly.

With the would-be prophet out of the way, we got back to work. I quickly started a line and pushed 2 mg of Narcan and stood back to witness the chemical miracle that Narcan is, from a distance. Sometimes people come out of this violently or start projectile vomiting. I didn’t need that.

Nothing.

I looked over at my partner. “Get the stair chair, we need to roll”.

By the time the chair was there, I pushed an additional 2 mg and had delivered a 500 ml bolus of normal saline. Still nothing.

We all looked at each other, this wasn’t right. “Come on!” I thought. “Everything is pointing to overdose, accidental or otherwise. What the hell is going on here?” I thought silently in my head. Protocols were flashing before my eyes, but no answers.

“Suggestions? Ideas? Anything?” I asked my fellow rescuers. They were as dumbfounded as I. We all at once decided to get her out of here. At least do something we know how to do that will benefit the patient.

We managed to get her lifeless, slumped over body strapped onto the stair chair and get her down from the second floor and into the ambulance. It took all five of us and we were pretty shot by the time we got her down.

I grabbed the fire medic to ride with me and we took off code three to the hospital. It was just a short hop, maybe three minutes total transport time. I was grateful for that. This would soon be over and she would have a higher level of care available to her.

Once at the hospital, we told the doctor the whole deal and how we suspected narcotic overdose but the Narcan wasn’t working. Of course he ordered up another 2 mg of Narcan, guess he thought I must have done it wrong. I wasn’t offended, he needed to see it for himself. It didn’t work any better than the previous two doses. I left the patient with the team who was now aggressively searching for a cause. Younger people don’t usually just present like this. There has to be something.

About five hours later I returned to the hospital and they told me she had passed. I was a bit confused. The doctor filled me in. She had had a major vessel in her brain spontaneously rupture. This caused enough brain herniation to pinpoint her pupils and reduce her respirations which ultimately killed her. He told me there was nothing we could have done differently.

The lesson I walked away from on this call was two fold. The first is obviously to keep an open mind and think outside the box. Everything is not always as it seems. The second is that there is no end to people’s arrogance to think that if they just say one more prayer or shout louder, their God will hear them and reverse a medical situation. Prayer is a powerful tool and provides comfort for many in times of need, but when it gets in the way of saving someone’s life, it is another thing all together.

I am reminded of a joke I once heard in a sermon. Here it is modified to fit the scene.

A woman’s friend is dying in a bed and she calls 911. She yells out to God to save the friend. The paramedic tries to save the friend but she jumps in and says “No, God will save her.” Then the fire captain picks up the gear and tries, and she likewise beats him back citing God will save her. Finally an EMT jumps in and tries but is again beaten back similar to the other two. The friend dies right in front of them despite her pleas to God and she is distraught.

Many years later when the woman dies she goes to heaven and meets God and asks “Why didn’t you save my friend when I pleaded for your help? Have I not always been your humble servant?” God took a deep breath and said “What more did you want, I sent you a Paramedic, a fire Captain and an EMT!!”