Now that I’m committed I pull my cell phone out and punch up the direct line to the University Emergency Department and give them a detailed description of what’s going on and what Josh’s condition is right now. The RN on the other side understands the situation and tells me that we’ll be going directly to the pediatric unit and she’ll have cardiology standing by when we get there.
The rest of the trip is somewhat uneventful as all of our tasks had been completed and it’s just a matter of monitoring Josh and reacting if anything were to change. Towards the end it’s obvious that he is starting to decompensate. He is more lethargic than before, he’s nodding off more frequently, and we have to keep him stimulated with questions and idle talk. His heart is starting to fatigue from the accelerated pace it’s been keeping for the last 45 minutes. His initial rate of 178 has now dropped to 52 and throwing consistent premature atrial contractions (PACs). Josh’s heart was bouncing from bigeminy PACs to trigeminy PACs. This means that he has normal conduction beats interspersed with abnormal beats in which the electrical conduction starts in the wrong place on the heart. This makes the contraction ineffective.
If his heart rate drops any more we’ll be turning on the external pacing pads to override his faulty electrical conduction with stronger electricity that his heart can’t ignore. It’s really an unpleasant thing to watch as someone is rhythmically shocked every second to force the heart to do its job. If I have to do it I already have the sedative ready so I can at least take the edge off of Josh’s pain, but I can’t risk sedating him too much as it will encourage the decompensation that has already started. Nothing to do now except continue the IV fluid bolus to keep his blood pressure up. We even have the pressure bag on the bag of normal saline, compressing it to push the fluids in faster.
Looking out the back window I can see we’re on University campus grounds as the large stadium and athletic fields pass through my limited field of view. The siren has stopped the constant wail and now only chirps at intersections as the cars pull to the right to let us pass. Unlike in the hood, the people here actually know what to do when the flashing lights appear in the rear view mirror.
Pulling into the ambulance bay I see the once familiar Emergency Department at University. My first ever code-3 return was to this ED. Three weeks into my new career in EMS I was working as an EMT doing inter-facility transports in this county. A skilled nursing facility (SNF) called us for a resident with a fever. Upon finding the patient in her room it’s obvious that the SNF called for a basic transport rather than calling 911 so they are not tagged by the county. The woman was septic, hypotensive, and altered. Our protocols said that if we had a transport time less than 10 minutes to the ED that we were permitted to take the patient in code-3, rather than call for an advanced life support (ALS) unit. That was the first time I called up to the driver telling him to light it up. Five years later I’m taking a crashing 8 year old for a 40 minute code-3 drive. It’s a different world yet still very much the same.
We unload Josh and wheel the gurney towards the receiving entrance. The ED charge nurse sees us coming and redirects us to the pediatric unit. There’s a team of six people waiting by the first critical room for us. As we unsnap all of our wires and transfer Josh over to the bed I’m giving a basic run down of how we found him, how he changed during transport, and an overview of his medical history. The pediatric cardiologist sees the 20 foot roll of EKG strip on the gurney and starts from the beginning, evaluating each printout and 12-lead sequentially captured during the last 40 minutes. Mom has her stack of papers and starts talking to doctor who she recognizes and is familiar with Josh.
As I’m about to leave, I look over at Josh, nurses busy connecting him to their monitoring equipment, I wave to him across the room, he gives me a thumbs up.