1 : a choice between two equally unpleasant alternatives
2 : also known as; between a rock and a hard place
3 : 1889, in ref. to John Morton (c.1420-1500), archbishop of Canterbury, who levied forced loans under Henry VII by arguing the obviously rich could afford to pay and the obviously poor were obviously living frugally and thus had savings and could pay, too.
Each player must accept the cards life deals him or her: but once they are in hand, he or she alone must decide how to play the cards in order to win the game.
“Damn! This might be a real call…”
We pull up to the house just as the fire engine stops and three firefighters bound out – headed for our rig to grab the house bags. It’s one of those tribal customs that we all follow and no one ever knows when or how it started. If we use our bags in the house we don’t have to restock the fire department’s bags so when we arrive at the same time as fire, they always walk back to our rig and carry our bags into the house as we bring the gurney. But it’s more the haste of their movements that I’m reacting to at the moment. If this call were just the call for the altered seventy year old that my MDT told me it was, they wouldn’t be moving so fast. I’m thinking there might be a little more to this than my dispatcher led me to believe.
Kevin and I walk up to the front door with our military EMT ride-along in tow. Standing in the small foyer of the house I see the fire medic bent over and feeling for a carotid pulse of a man who is laying in the back hallway. “Yeah, it’s code-blue – bystander CPR was in progress until just a second ago.” Okay, cardiac arrest – looks like we’re working a code today. It’s my call so I ask them to move my new patient to the foyer so we have some room to work. As they carry the very large lifeless body my direction, I open up the drug box and set up the monitor. I’m going to work everything here in the foyer and see where we go from there.
Working a code is something like the altered reality of visiting the Twilight Zone for a few minutes. I have an omni-present yet tunnel visioned perception of the world where I’m acutely aware of minute detail yet still processing and interacting with my peripheral surroundings. While attaching the monitor I’m handing a BVM (bag valve mask) and NPA (nasal pharyngeal airway) to the military ride-along. For now I’ll keep him on the head to manage the airway and breathing for the patient. Later on I’ll switch him to compressions, but I want the experienced firefighter doing the first few – all too important – rounds while I figure out IV access, spin up some drugs, and evaluate the monitor for any shockable rhythms. With my mind prioritizing all of these tasks I delegate to the crew and somehow manage to listen to some random family member standing behind me, who’s telling me that he saw his father collapse and did CPR until we arrived.
Kevin thinks he has a good shot at a vein and goes for it while I have them stop CPR so I can feel for a carotid pulse and check out the monitor – no pulse and the flat line of asystole on the monitor. “Resume CPR.” I hand the OPA (oral pharyngeal airway) to the camouflaged sergeant who’s breathing for the patient right now. There was a day when I would have immediately laid down at the patient’s head and intubated while holding CPR to get that all so important tube, but the recent data seems to de-emphasize the intubation so I’ll cross that bridge in a few minutes when I figure out where this code is going. Besides, I wanted the sergeant to get the feel of inserting the nasal and oral airway adjuncts as they will be the primary ones that he uses in the future and it’s the right thing to do for the patient at this stage in a code.
Kevin looks up in frustration. “I didn’t get it, the vein collapsed on me.” After only five minutes of down-time, even with CPR, the blood volume in the vein has reduced making it deceptively hard to hit with a needle.
“No worries, I’ll drill him.” I pull out the bone drill and sterilize my target area on the lower leg where I’ll be using the electric drill to drive a metal catheter into the bone marrow and give us access to my new patient’s veinous system for drug administration.
While I drill, Kevin cuts off clothing, the rhythmic bounce of CPR rocks the lifeless body beneath me, and the army sergeant squeezes the bag every few seconds, providing life-giving oxygen. I can still hear the man’s son in my ear talking about how his father wasn’t feeling too well today and how he has a lot of medical problems – surreal Twilight Zone.
There’s too much fat on the leg and my drill never even reaches the bone. I stifle the automatic profanity that comes to mind – family members are standing over us and they don’t need to see frustration on our faces as we attempt a resuscitation. Reaching back into the drug box I pull out the bariatric bone needle and attach it to the drill. While I drill his leg a second time I explain what we’re doing to the son who’s floating over my shoulder. With the larger needle secured in the bone I attach the bag of fluids and inflate the pressure bag to force saline into the veinous system. I turn around to hand the bag to the son – I want to give him a job so he feels like he’s doing something. He did a good job by providing CPR until we arrived so I want to include him in the process. Looking up at him for the first time I’m momentarily stunned. Damn! He looks familiar but I can’t place him. I’m fairly certain I’ve never been in this house before. Whatever; work the code.
The second round of CPR is done and I do a pulse check while staring at the flat line of asystole on the monitor again. “Resume CPR, first Epi going on-board.” I inject the drug into the line and pump up the pressure bag a few times to push it into the system. I help Kevin in cutting off clothing and spin up the next drug so I’m ready to inject it at the next break in CPR. The firefighter who’s been doing compressions sits back on his haunches, after his latest two minute cycle, as I put two fingers to the patient’s neck. I’ll be damned! That’s a faint pulse. I look over at Kevin, “Confirm that pulse for me.” As I put fingers into the femoral artery and Kevin feels at the neck. A quick glance at the monitor shows a string of perfect complexes marching across the screen. Kevin and I lock eyes and simultaneously nod to each other: confirmed! The sergeant looks up at me, “He’s breathing by himself!”
Looking at the sergeant, “Track him with assisted breathing but don’t force it.” To the other two firefighters, sweat pouring off of my very competent CPR go-to guy, “Let’s get a board and some straps in case we have to resume and let’s get transporting. I’ll be going Code-3 to St. Closest.”
The voice of protesting anguish comes from behind me as the son is in tears. “Oh come on man, anywhere but there, don’t take him to that death trap!!” Okay this guy’s face is really starting to bug me, I know I’ve seen him before, but I can’t place it. And he knows our system because that ED is known for its less than stellar performance.
“Look, he’s got a pulse and I can’t risk losing it by driving too far. St. Closest is less than a mile away and I can’t bypass it by four miles – doing Code-3 – to get to Hilltop. You’ve got to believe me – it’s the only option!” I actually considered it for just a half a second but if I lost pulses during transport I will have put this patient in serious jeopardy and I’d have a lot of explaining to do to my medical director. I just can’t risk it.
The son is distraught but he’s not going to go toe to toe with me on the subject. I feel a little bad for forcing the issue against his wishes but I’ve got a dozen other things to do right now that take precedence so we carry on with the transport.