By Peter Stebinger
KCD 357 to the Jerico Fire Department, ambulance needed for an unresponsive patient.
Unresponsive patient; this could be anything. An unresponsive patient could include an amazing list of possibilities and symptoms – someone who has died, someone who has fainted and will be awake and talking to you when we get there, and everything in between. An “unresponsive patient” could be suffering from a diabetic emergency, infectious disease, kidney problems, suicide attempt, you name it.
It’s absolutely one of the most common reasons to be dispatched. In the ambulance, we generally talk through what we’re going to do as we’re on our way – who’s going to grab what bag, who’s going to move the stretcher, who’s going to park the ambulance.
| More: Compassion and skill: Mindfulness in EMS
Compassionate care
On this particular day, I am responding with a nurse – we’ll call her Anne – who works in a hospital, as well as a driver. Anne is a really good EMT who has been in the department probably 10 years longer than I have. I value her wisdom and her practicality.
We get to the address, pull into the driveway. Anne and I grab the oxygen bag and the basic medical kit and head into the house while the driver turns the ambulance around. We knock on the door, announce ourselves and are called into the kitchen. When we get to the door of the kitchen, we see a very small, very frail man sitting in a chair with a strap around his chest. He is slumped over, face down on his tray in a plate of food. There are two individuals sitting there absolutely silent, looking thunderstruck. One of them is the person who has called us.
Knowing that a person who is slumped in that position probably has a compromised airway and may not have breathed since he slumped over, Anne walks up to the to the patient and checks his pulse at his neck, saying, “we have no pulse.” His color is terrible. I look at the two people are there and say, “what can you tell me?” They tell me that they were visiting their friend, an end-stage cancer patient who hasn’t been eating much. He was talking with them and then he slumped over in his chair. They then called 911 and here we are.
“Pete, help me get him out of his chair. We’ve got to undo the strap and we’re going to lay him down on the floor and we’re going to start CPR,” Anne directs. We get him out of the chair and I walk out and call for the stretcher and longboard. I help the driver to bring them in. Anne has started CPR.
We get the oxygen mask on him after we start the airway and then we put him on the longboard. After strapping him onto the longboard, we lift it and him onto the stretcher. As we are wheeling him out, we ask, “what hospital should we go to?”
“He likes Charlotte,” they say.
“OK.” It’s a few minutes closer than the Level One Trauma Center we usually go to and a lot of people in our community like it. So, this looks like a good call. We load the patient in the back of the ambulance. As we start moving, our driver checks on the location of our assisting paramedic.
Anne says, “Pete, I think I just broke every single one of his ribs.” When this happens with a frail person, and it does happen during CPR more often than we like to talk about, it means every single compression after that one will have an awful squishing sound. And that was true in this case.
I’m at the patient’s head, providing oxygen.
Then Anne asks if we can switch positions. I nod and we begin changing at the end of each cycle of assisted breaths and compressions. As we’re switching positions, Anne says to me, “Pete, are you praying?” I say, “Yes I am, I’m praying a lot. I’m praying that God will do what needs to be done here.”
Anne looks at me and she says, “Pete, I know you’re a priest, and you’re our chaplain, and I need to know is it OK if my prayer is that we don’t succeed.”
Our patient isn’t anyone I know, but I know he has loving friends and family. I can see the ravages that cancer and chemotherapy have played on our patient’s body, who needed to be strapped into a chair to be able to eat his food.
And I just wasn’t sure the right thing to pray and hope for was, but in that moment, that prayer was as good a prayer as any I might offer. “Anne, I’m really OK with that; I think I might even be praying that myself,” I say.
Stopping CPR
We see the paramedic ahead of us and stop. The paramedic gets on board and starts hanging IV bags. She takes a look at the patient’s veins and says, “I don’t think we’re going to get any IV lines here, continue CPR.” We tell the medic where we’re headed and she hooks up the EKG. It’s a flat line; the patient is in complete asystole. Even our compressions aren’t really moving much at all.
That means a paramedic isn’t going to try to shock the patient because there’s no shockable rhythm present. Anne and I keep trading off compressions, probably about every 3 minutes, because the squishy sound is really, really hard to deal with. We do compressions as well as we can and because we are hooked up to the paramedic’s monitor, we can see how well our compressions are working. So we try to make them deep and consistent to move his blood as best we can.
We get to Charlotte and we move the patient into the cardiac arrest room. The doctor hooks him up to the hospital monitors before she looks at us and says, “I am going to call this code. Does anyone wish to continue CPR?” It was not a question she needed to ask us, but one which I thought was kind. The paramedic, Anne and I all shake our heads and I say, “no doc we’re OK with stopping CPR.” She calls in her nurse to document the time of death. I offer to say a prayer for a person who has just died. My offer is welcomed by all present.
Everyone gets our best effort
You have to decide very early on in emergency medicine that you’re not God. There are a lot of situations in which doing less and letting a patient pass quickly might seem like the right decision, but we remind every member of our service that we do absolutely everything that we can do every single time, no matter what. We are not making decisions about how much care to give a patient. Everyone gets everything we have available.
I have told many families whose loved ones have died in our care, that every single resource available on the planet to save their lives was utilized, and all those resources were not enough to save the life of their loved one. And the families have been universally grateful.
I’m OK with the wide variety of prayers that are offered by myself and my colleagues – who have a wide variety of faiths – for our patients.
Still, the bottom line is we bring our best skills and our best tools, and all the resources of mutual aid and great hospitals to every single call, every single time. And I am able to sleep at night resting in that truth.