One week later…
It’s morning at the start of my 48 hour shift as a paramedic intern. Having just checked out the rig I’m standing in the kitchen making coffee for the crew when the tones go off on the portable radios and the dispatcher comes up telling us the nature of the call and location. Taking a sad look at the stream of coffee just starting to drip into the pot I head out to the rig for the first call of the day.
Bouncing down the two lane rural highway with lights and siren I rush to put on my gloves before my palms get sweaty and make it nearly impossible.
As we take the side entrance into the mobile home park I get the feeling I’ve done this before. There’s the BRT and the neighbors in their bath robes in front of James’ mobile home.
I’m excited, this could be every intern’s dream – a call do-over. I’ll get a chance to ask the right questions in the right order, do my rule outs prior to medication administration, and not fumble while drawing up and connecting to the IV tubing. Redemption is within sight as I walk through the door.
Something is wrong. The fire crew isn’t taking vitals – they’re all just standing around the dinette. Seeing us walking in they part so I can see James. The fire captain shakes his head and picks up his clipboard. Walking out with the rest of the crew he looks at my preceptor and says, “DRT.”
I’m not sure what that means but I’m busy trying to figure out what’s going on with James. He’s sitting upright at his table, once again in boxers and flip flops, with a different bottle of wine sitting next to him with the ash tray overflowing with cigarette buts. One cigarette is still in his fingers, burned down to the filter. There is ash on the floor under his knee where his hand rests. He has new surgery scars on his chest with meticulously tied sutures.
I’d already seen a few dead bodies in my short career but never one that was my patient the week before or one that is my responsibility to pronounce. Okay, suck it up and do it by the book.
Tony has become a fly on the wall again, letting out the proverbial leash. I walk up and notice the mottled skin on his lower extremities, the ashen color of his face and torso, his glassy eyes with fixed and dilated pupils, lids still open from the fire fighter’s assessment. I grab his lower jaw as Tony had previously coached me. Rocking it up and down his torso follows the motion without the hinge of the mandible moving; rigor has already set in.
Now that I have hands on I notice how cold he is and how fresh the surgical scars are. He must have had surgery after last week’s trip to the ED. I place my fingers on his neck checking for a carotid pulse; nothing. I check for lung sounds in all fields and at the neck; no air moving. I place my stethoscope over his heart, no heat tones.
One last thing to do and I can leave.
I place the heart monitor leads on James’ torso; I need to record a six second strip of asystole (flatline) for my paperwork.
The room goes dark as I tunnel vision into the screen on the monitor. This must be what a vagal response feels like. Kneeling down to see the monitor better, or possibly because my knees just gave out, I hit print on the monitor. Where the flatline of asystole should be there is a perfectly spaced, consistent complex printing out of the machine at 72 beats per minute. What the fuck?!? That shouldn’t be there! Hell, that can’t be there!!
Now my vagal response has turned into SVT (supra ventricular tachycardia). I stand up to feel for a carotid pulse again. He’s cold and dead, there can’t be a pulse.
I move my fingers around thinking I may have the wrong placement and maybe I missed it. After ten seconds I’m positive there is no pulse.
As I pull my hand away from his neck my glove is tickled by fresh sutures on James’ left upper chest; the new surgical scar that wasn’t there last week. Underneath the skin is a small box the size of a matchbook. A pacemaker has been implanted to send out electrical impulses to the heart 72 times a minute in a futile attempt to stimulate dead cardiac tissue to contract, but it couldn’t overcome the damage that James had done with his habits and now it just served to trick the monitor into recording electrical activity in the heart.
My own SVT converts to a benign tachycardia and the lightbulb comes on: DRT means Dead Right There. I look over at Tony, who had never budged from his “fly on the wall” position. He saw the new pacemaker scars as soon as he walked in the door. I can only imagine his amusement at my momentary panic. Or maybe he’d already seen too many other interns react like I did and it was old hat.
On the slow ride back to quarters I’m going over the call in my head while sitting in the dim light of the back of the rig. I start to think about the coffee waiting for us and hope that it might actually still be drinkable. Then I look up at the radio in the front of the rig and wonder when the tones will go off again.