Ghost Rider

ghost

1 : any faint shadowy semblance; an unsubstantial image; a phantom; a glimmering; as, not a ghost of a chance; the ghost of an idea

2 : the disembodied soul; the soul or spirit of a deceased person; a spirit appearing after death; an apparition; a specter

3 : to die; to expire

rid·er

1 : someone who rides on an animal such as a horse, or on a vehicle such as a bicycle or motorcycle

2 : a supplementary clause or amendment added to a legislative bill, insurance policy, or legal document

As a rule, the more bizarre a thing is the less mysterious it proves to be. It is your commonplace, featureless crimes which are really puzzling, just as a commonplace face is the most difficult to identify.

Sir Arthur Conan Doyle – Sherlock Holmes – “The Red Headed League”

I walk into the small eight-by-eight foot room with a single empty desk pushed up against the wall. Two men with guns strapped to their waists follow me in and sit down in the Spartan chairs to either side of the desk. Obviously the chair left for me is the “hot seat.” I don’t see a spotlight shining on the chair but there’s no mistaking the fact that this is an interrogation room and the men with the guns and badges have some questions for me today.

“Let the record show that Detective Jones and Detective Brown are present with Paramedic KC. Today is one, one, eleven at 1500. Paramedic KC, do you recognize this man?” He slides a picture across the table to me – actually it’s a mug shot with lines showing height behind a perturbed looking man facing the camera.

“Yes sir. He was my patient three weeks ago.” I’m starting to wonder if this is the time when I should ask for a lawyer. At least they didn’t read me my Mirada rights. I wonder if that’s a good thing or a bad thing. Either way it’s obvious that the conversation is being recorded by the way that they are verbally describing the occupants of this very uncomfortable room.

“Can you sign here please? This acknowledges that you recognize the person in the photograph and that he was your patient on the date written below.” OH CRAP! This is starting to sound serious…

“So, the man in that picture passed away three days ago and we’re looking into the cause as a possible homicide. Can you describe the circumstances in which you met this man and what transpired during the time you were with him?”

— 

Medic-40, copy Code-3 for the man who fell of his bicycle three days ago.” The radio crackles to life interrupting the enjoyment of my afternoon quad-espresso over ice.

“Medic-40 copy, we’re en-route.” Kevin flicks the lights on and chirps the siren to enter traffic headed in the direction of the call. Seriously? Code-3 for a three day old bike accident?

As we pull up to the Church’s Chicken I see a man sitting on a bench by the door with three firefighters standing around him. The guy has to be 450 pounds and from the rig I can see that he’s interacting so he’s probably okay. “Let’s leave the gurney in the rig and see if this guy can walk.”

“Exactly what I was just thinking.” Kevin and I are on the same page. Lifting a man that size on a gurney is a group effort and anything to avoid injuring ourselves is a good thing. Classic, a fat man sitting in front of Church’s, who would have thought…?

As I’m getting out of the rig the man stands up with the firefighters and starts to lumber towards us. Awesome, he walks!

Once he’s situated on the gurney, in the back of the rig with me, I start asking questions as Kevin starts entering information into the computer. It’s not exactly a stat call so we have time to sit here and do an assessment prior to rolling to the ED.

“Okay, so I understand you fell off of your bicycle three days ago. Why are you calling us today?” I’m taking a blood pressure and getting him hooked up to the monitor while I ask questions.

“Cuz it just kep gettin’ worser so I has to get checked out.” He’s pleasant enough and almost seems apologetic for having to call us. It’s a normal occurrence for us; people with no insurance put off going to the clinic as long as they can and then call 911 to get treated in the Emergency Department.

“What got worse?”

“All this swelling in my face. This ain’t normal for me.” I wiggle past him to the foot of the gurney so I can see his face straight on. Sure enough – now that I look at him straight on I see that his face isn’t symmetrical – his jaw and cheek are swollen on the right side.

“Yep, that’s swollen all right. So this all happened in the last three days?” He nods his head and it looks like it hurts him just to do that. “Okay, let me feel your jaw.” I put my hands on either side of his mandible and he opens and closes his mouth, wincing in pain as he does it. No clicking that I can feel and the jaw seems solid – probably not broken – but it’s hard to say with all the fat and swelling deforming the normal jaw lines. I pull out my flashlight and look inside his mouth and I’m met with a putrid smell and green/yellow puss on the right side. Yikes!

“Looks like you got a pretty bad infection in there.” The infected teeth and the vitals that I got are starting to add up to a pretty sick guy, quite possibly a lot worse than he looks.

“I got bad teeth, you know, don’t go to the dentist all that much. I think when I got hit they got knocked loose a little. Then I start spitting that yellow stuff today so I called you.” Fair enough, but hold up…

“You got hit? I thought you fell off of your bicycle.” I’m having a very hard time picturing this man on a bicycle. I’ve gone to calls for a lot of bicycle accidents and I can’t remember anyone being over 200 pounds, much less 450.

“Yeah, you know, when I hit the ground.” Okay have it your way. I check out the side of his face with my flashlight and don’t see any road rash or bruising – just inflamed swelling and a bit of redness.

Either way, the damage is done, and all I can do is treat what’s in front of me so I start transporting him to the ED while I look over his fat skin in hopes of finding a vein for an IV. His heart rate is in the 130s and respirations of 32 with an end tidal carbon dioxide of 23. The temporal thermometer comes back with a fever of 101.7. Everything is adding up to sepsis but it’s still a little early so he’s not going into shock yet. At the ED they’ll drop a few liters of fluid on him and start some IV antibiotics. They’ll take x-rays of the jaw to see if the infection has progressed to the bone – if so he’s in for some pretty painful surgery. I can get the process started now and see about taking the edge off of the pain.

I crack open an ice pack and have him hold it to his jaw as I thread a 22 gauge catheter into the only vein I can find – in his knuckle. It’s too small to get very much fluid on board during my short trip to the ED but I leave it wide open just to start the process as I break open the morphine vial.

He’s a big guy so I’m sure he can take as much morphine as I’d be allowed to give him so I’m surprised as we’re pulling up to the ED he tells me that his 10/10 jaw pain is now a 0/10. Awesome! At least I did something for him.

As we push him into the ED a triage nurse that I don’t recognize is taking my report. “Fell off his bike three days ago? You can take him to the lobby.” There’s a nursing strike right now and this woman has a thick southern accent – she probably just flew in to help staff the hospital and isn’t too familiar with how we do things in this county.

“Yeah, can’t do it. I started an IV and gave him fifteen of morphine. If he’s not septic yet he will be in a few hours.” Sorry if I’m inconveniencing you by actually treating patients…

“You did what? Oh fine! Give him Hall-6.”

My last memory of him is sitting in the corner of the ED as he thanked me and waved goodbye.

“So you never saw a bicycle at the Church’s Chicken?” Detective Brown has been taking notes while Detective Jones asks some follow-up questions.

“No, didn’t see any bicycle. He said it happened three days ago so it didn’t surprise me not to see one. I still can’t picture a man his size on a bicycle but that’s what he said.”

“Anyone standing around him when you arrived?”

“Just the firefighters.”

“Okay, KC, I think that’s about all the questions we have for you. We appreciate you coming in.” What, that’s it?

“Can I ask what happened? I mean, why a homicide investigation?”

“Well, we’re still trying to figure out what exactly happened. I can tell you that he was treated at the ED and ultimately transferred to University Hospital for surgery to clean up an infected jaw. He eventually died at that facility from the injury. There were no medical malpractice issues but the cause of the injury is suspect so we’re looking into it.”


Necromancy Revisited 2/2

Walking through the door I fight the adrenaline-induced tunnel vision. As team lead it’s my job to keep the big picture in sight and not focus on the minutia. I have four EMTs following my lead as we make it into the lobby. My boots make sucking noises with each step I take on the blood-soaked carpet; spent bullet casings litter the ground. With the smoke still clearing from the room I can smell residual cordite from the weapons fire mixed with explosive residue. I almost trip over the body in front of me because of the low visibility.

A quick check for a pulse and a reposition of the airway tells me he’s non-viable – blast injury to the torso and GSW to the neck. I pull a black ribbon from my triage waist pack and hand it to the EMT behind me. “Black tag – keep moving.” My EMT ties the black ribbon to the wrist of the dead body behind me as I continue in to the room.

With the smoke clearing more I can see the extent of the room. Vinny’s men are holding down the corners where they have a visual to every angle; two of his men have fallen into ranks with my team and two others are securing the egress route at the front doors. Vinny gives me a head nod – letting me know it’s secure and giving my team the floor to do our jobs.

In a loud voice I address the room. “If you can walk I need you to exit the building now. EXIT NOW!”

Nobody moves. Hell, nobody even says a word! I focus in on the six people sitting on sofas in the corner. I’m fighting with balancing the big picture and noticing the minute details – macro vs micro, the eternal battle of EMS. Micro wins out when I notice that everyone in front of me has their hands and feet duct taped – they’re incapable of walking out of here because they are bound hostages.

Six people with big round eyes are following my movements as I quickly scan them for injuries and I hear the muffled screams from under the duct tape. That tells me enough for now. Turning to the next EMT behind me; “Cut the tape on the feet, clear them, and get them out of here.” I want to quickly reduce the number of people in this room so that all I have left are wounded, and I want to keep the hands bound in case any of these hostages are tangos in disguise.

Moving on I see a man convulsing on the ground with a blood saturated shirt. While I reposition him to check his airway bright blood erupts from his mouth missing my leg by inches. Bright red blood – probably from a perforated lung – gives me an idea of where to look for the wounds. I rip his shirt off and see the entry wound to the right side of his chest. Feeling around his back I find an exit wound near the right scapula.

I turn to the next EMT behind me and hand him two occlusive dressings to seal the wounds, as well as a red ribbon from my triage pack. “Chest seal front and back; keep an eye on his airway. He’ll be one of the first out.” I move on in my clockwise lap of the room.

There’s a man laying supine on the ground, eyes open, not following me or reacting to me when I give him a knuckle rub to the sternum. There’s a mid-axillary GSW to the right flank with no exit wound. A quick listen at the neck with my stethoscope tells me he’s still moving air for now. Shrapnel is embedded in his torso with minor bleeding. I’m getting closer to the blast sight and this guy took more of the blast. Turning to the EMT behind me; “Compression dressing to the flank, he’s critical.” I hand him a red ribbon and move on.

Moving closer to the blast site I find a secretary wedged under her desk. Damn! She looks familiar! She’s screaming and tracking me with her eyes. Arterial spray is coming from her arm and her entire torso is covered with embedded shrapnel. I slide her out from under the desk and turn to the EMT behind me, “Tourniquet to the arm. She’s delayed,” and I hand him a yellow ribbon to tie around her wrist. She’s still screaming as I continue my clockwise lap.

Closer to the blast sight now I see the man laying on the floor screaming and clawing at the blood saturated carpet with his fingers. The source of his discomfort is fairly obvious as I almost trip over a leg that used to be attached to him. I pull a tourniquet to hand to the EMT behind me when I realize I’ve run out of help. Fuck! Micro wins out for a moment as I apply the tourniquet and tie a yellow ribbon to his wrist. Macro takes over again as I walk away from him. Sorry sir, some people are more critical than you are today.

Coming around to the front of the room I’m by myself as my team is caring for the people left in my wake with ribbons tied to their wrists. Two more bodies laying in front of me have further saturated the now ruined carpet. A quick check for vitals tells me there is nothing for me to do here. Judging by their military style clothing I’m thinking Vinny’s operators are very good at their job and left the tangos non-viable. With black ribbons tied to their wrists I walk off.

Finally, I’ve made a full circuit of the room and have a mental tally of the wounded and an extrication plan to get the most critical out first. Walking up to the man with the through and through GSW I see that my team has him ready to go. “Okay, he’s first out.” Looking to Vinny, “I need two SWAT for a cary out.” Vinny nods his head and points to two of his operators who rotate their M-4s to a back cary position and immediately jump in to help two of my EMTs roll the man on a combat cary tarp.

Just then I hear the call from across the room. “I need ALS over here.” It’s one of my EMT’s kneeling next to the unresponsive man with the mid-axillary GSW and blast injuries – he must have run into a problem that needs a paramedic. “I lost lung sounds on the right side,” he tells me as I kneel down and check his findings.

“Good pick-up. Grab a tarp, he’s next out.” I open my waist pack and pull out the enormous needle. Finding my landmarks I insert it to his chest, pull the needle while leaving the catheter in place, and re-check lung sounds. He’s breathing on both sides now that the collapsed lung has been vented with a pulp-fiction style stab in the chest.

As I stand up and look at Vinny, “Two more for a cary out.” Two camouflaged operators appear with two of my team and a tarp. As they’re working him I walk over to check on the man missing a leg.

One of my EMTs is with him and has check to make sure the tourniquet is doing its job. “Okay, this guy is next.” The first team of two EMTs and two SWAT head my way and roll the recent amputee onto the combat tarp. As they pick him up I check his shoe and see that it matches the one on the severed leg. I pick up the leg and put it on the tarp next to the patient. “Make sure the leg stays with him.”

As I make it over to the secretary under the desk I motion the second returning cary-out team to me and get her rolled onto the tarp. The two EMTs and two SWAT operators pick her up and I kneel down to look into her eyes. “I’m glad we got a chance to save you this year.”

We’re heading to the double doors guarded by Vinny’s men and she stops screaming and gives me a smile.

A man in a reflective vest steps out from a glass office. “END-EX, END-EX, secure all weapons!” End exercise.

Once again we have completed the yearly joint training exercise where SWAT teams from across the world and EMS teams work together. As always the realistic wounds and Hollywood quality makeup is unnerving to look at. The blood in the injuries flows and sprays just as it does on the streets and the actors are true to character. Despite knowing it’s an exercise the adrenaline flows very much as it does at a large unknown incident. The SWAT operators and tangos are using simunition shot from real service weapons and the explosions were controlled pyrotechnics with all kinds of bark yet very little bite. The man who got a needle stuck in his chest was a very elaborate mannequin with moving eyes, chest rise and fall, and accurate lung sound generation. If left alone for too long he eventually stops breathing. Once the computer recognizes the needle-decompression it restores bilateral lung sounds. 

Exercises like this train us for the things we hope we will never see. I performed my duties better this year than I did last year and it helped me to recognize areas where I need improvement. The SWAT and EMS interaction is invaluable for the safety and efficiency of all participants. The sooner life saving measures can be taken on scene the more people we can save. Three recent mass shootings come to mind where this cooperation would have made a difference. 

And yes, I did recognize the secretary from last year’s exercise – she was one of the first black tagged victims/actors. We never get a second chance to make a save on the streets, but it was nice to get a second chance here.  

Necromancy Revisited 1/2

nec·ro·man·cy

1 : the practice of communicating with and learning from the dead to predict the future

2 : see also – necromancer; one who practices divination by conjuring up the dead

re·vis·it·ed

1  :  to visit again

2  :  to re-examine (a topic or theme) after an interval, with the view to making a fresh appraisal

The phone is ringing in the bank manager’s office, which is odd. The last time the hostage negotiator called the phone rang at the teller’s window. Thinking that possibly there has been some progress on getting his demands met, he walks to the ringing phone and picks it up with his left hand as his right hand holds down the “dead man’s switch” – a button that needs to be pressed to keep the bomb from going off. If he takes his finger off the trigger, his vest will explode.

“What do you want?” With the anticipation of talking to the hostage negotiator on the other end he’s already setting the tone with an aggressive stance yet no one answers him. Looking up from the phone and out the window he sees a tiny puff of smoke on the adjacent building that is quickly followed by a round hole in the window and spider web crack lines extending to the frame.

That was the last thing he saw as the bullet from the police sniper travelled through his head. He releases the “dead man’s switch” as he falls back, but he never hits the floor – his vest explodes, sending shrapnel and body parts throughout the building.

From forty yards away, staging with my police escorts and the rest of my EMS team I see the fifty-foot ball of fire come out of the window. Crap! Now I have hostages with blast injuries. This is going to be a very bad day!

I walk into the command post to meet the SWAT team leader and get the briefing prior to the assault to attempt resolution of the hostage situation. Camouflaged SWAT members are checking gear and loading weapons as the commander calls for our attention.

“Okay gentlemen, this our latest intel.” The SWAT commander is pointing to a rough floor plan drawn on a white board. “We have three tangos holding approximately ten hostages. I’m getting real-time intel from sniper teams who are in place now. They report the leader has an explosive vest and the FBI SWAT team just raided their home base and found bomb-making material. The good news is that it’s just a black powder device so we’re not dealing with high-yield C-4. The bad news is that we don’t know what the triggering device is or how it’s connected.

“In approximately ten minutes your SWAT team will rappel down from the sixth floor to the mezzanine level. You will then stack along the west wall at which time we will call the phone in this office. It is our expectation that the tango with the explosive vest will answer the phone, at which time our sniper will take out the target. We are told that a single shot from a .308 will weaken the window and allow entry. You will take your team through that window and eliminate the additional tangos. Remember, you have a room with approximately ten civilians.

“Once you secure the room you will call for EMS. They will be staging down the block and enter through the front door. You will provide force protection while they address any life threatening injuries and extricate any wounded. EMS, remember you are entering a warm zone which was hot just a minute prior. I need the SWAT team leader and EMS team leader to come together on how to work together and extricate any wounded with all haste while staying safe. That is all gentlemen; you have ten minutes.”

The SWAT commander walks out on his way to the forward command post as the SWAT team leader, Vinny, and I look over the rough floor plan together. Vinny’s a serious man dressed in his camouflage uniform with an imposing M-4 rifle slung over his shoulder.

Vinny is pointing to the floor plan on the wall and walking me through their method of clearing the room. “Once we have the tangos down I’ll set an internal perimeter and secure egress through the front doors. I’ll alert you via radio that it’s clear to enter. We’ll give you two operators, with your team, on force protection. How are you going to work the room?” He’s a no-nonsense, straightforward kind of guy who seems to know his business.

“That sounds good. I’ll start on a clockwise lap of the room to get a patient count and identify the first out critical patients. As I tag the wounded I’ll spin my guys off on treatment and facilitating egress. I’ll want to stage the wounded for pick-up and transport to the left of the entrance. We have rigs staging, ready to do a drive by and transport to the hospital. It would help if I can use some of your guys to help cary people out. If any of the wounded are heavy it may take four people to get them out.”

“Easy enough, I’ll send you two operators at a time when you need them. Otherwise we’ll stay out of your way and let you work on the wounded. You good?”

“Yeah, I’m good, stay safe.” A blue nitrile fist hits a tactical glove fist and we return to our respective teams for final preparation.

From my vantage point, a half block away, I see ten ropes fall to the ground on the west wall of the building. In a silent rappel, ten SWAT operators slide down the ropes and fall into a stack formation at the corner of the building.

The radio on the officer next to me crackles to life. “Sam one in position.” It’s Vinny on his throat-mic, telling the commander that he’s ready in a whisper.

“Tac-com copies, Sam one. Sniper two, do you have visual?” The tactical commander is getting ready to put things in motion.

“Sniper two, clean line of sight, we are go.”

“Tac-com copies. All teams we are go in ten seconds. Out.”

After waiting for what seems like an eternity, everything happens at once. The sniper fires and the sound of breaking glass is quickly followed by a huge explosion; a fireball comes out of the broken window. As soon as the flames recede, Vinny’s team moves around the corner in lethal stack formation and enters the building. A few seconds later the rapid fire of the M-4 can be heard from the inside of the building. Short bursts of six shots followed by another short burst of eight shots. Some sporadic returning fire and then the final burst of six shots echo out of the building.

The radio crackles to life again. “Three tangos down. Initiating final sweep now.”

The officer next to me leads us up to the forward staging area just twenty feet from the front doors. I can see movement through the windows as the SWAT operators are clearing the room and securing weapons. Smoke is still pouring out of the office window where the explosion came from. Two SWAT operators force open the front doors and secure the egress while the radio crackles again; “Code-4, EMS is clear to enter.”

“Copy. EMS coming in now.” I lead my team towards the front doors.

 

 

Impalpable 2/2

We’ve been driving for twelve minutes with lights and siren and we’re still miles from the call location. Our ambulance travels further into the hills on this foggy morning, in a desperate attempt to find the curvy ridgeline road where a bicyclist has been hit by a car. The update came in a few minutes ago that CPR is in progress and the Parks Department Fire Rescue is on scene.

I’ve been going over CPR ratios with my military EMT student who is anxiously peering into the front compartment. He’s twenty but looks like he’s twelve with a fresh, bootcamp buzz cut and black-rimmed glasses.

We can tell we’re getting closer as passing bicyclists are pointing back up the hill as we go by. We round the bend to find firefighters doing CPR on a man in the middle of the street. I walk up to the scene carrying my monitor and suction with my student in tow.

I set my monitor on the uphill side of the patient because blood is flowing downhill at every compression. I tap the firefighter who’s doing CPR on the shoulder and ask if my student can get some compression time while I start assessing the injuries and looking for a pulse. The firefighter pulls back and I feel at the bloody neck for a pulse while listening with my stethoscope for heart tones and breath sounds.

Nothing.

“Resume CPR.” My student starts compressions on the chest like a machine and I have to remind him to count it out for the others while I’m attaching electrodes. I’ll get an electrical reading of the heart on the next pulse check but I already know what I’ll find.

I suction out the mouth, which is a reservoir of blood that just keeps filling on every compression. The firefighters have been doing this for ten minutes and they know as well as I do that this guy isn’t coming back. As I’m waiting for the next transition of CPR the lieutenant shows me the helmet. The top is actually concave! Usually I see scrape and slide marks on helmets from a bicyclist. The concave nature of the helmet tells me a lot. I kneel down to feel the section of his head that corresponds to the helmet damage. Palpating the bones of the skull I feel them give away to depress into the brain. I look up to the lieutenant, “You can cancel the helicopter, we won’t be transporting.”

He walks away while talking into his radio as I have my student stop CPR so I can document the flat line of asystole – showing that the heart has no electrical activity – with a long printout from my monitor.

I switch my student into the airway position and show him how to use the suction while another firefighter picks up the compressions without losing a beat. Walking across the road to the guardrail I pull out my cell phone and hope for a signal while I stare at the hillside disappearing below me in the fog. After a few rings I hear a voice on the other end.

“Medical control, this is Dr. French.”

“Good morning Dr. French. This is paramedic KC on Medic-40 calling for base orders to discontinue resuscitation efforts on a traumatic arrest.”

“Okay, Medic-40, go with info.”

“I have a 43 year old male involved in a head-on bicycle vs. auto. BLS Fire has been on scene for fifteen minutes. The patient was pulseless and apneic upon their arrival. An AED was applied with no shock advised. They proceeded with CPR until our arrival. My monitor is showing asystole in three leads. I have a compromised airway that refills with blood upon every compression. I have a concave bicycle helmet consistent with impact to the car’s bumper and skull crepitus corresponding to the helmet damage.”

“Yeah, that sounds non-viable. Is that your assessment as well?”

“Yes sir, that is the consensus on-scene.”

“Okay, let’s call it: time of death zero nine forty three. Have a better day.”

“Thank you sir. You too.”

While on the phone I’ve been standing next the the guard rail at the side of the road and the fog lifts to reveal the hillside extending for miles below me with the city by the water and bridges extending across the bay that disappear in the marine layer. The view is breathtaking and I’d love to be able to enjoy it but I have other business to attend to.

Turning back to the task at hand I give a discrete nod to the lieutenant who’s standing over the CPR efforts. He unfolds the yellow rain blanket and covers the dead body laying in the middle of the road. As the rest of the scene comes into focus for me I see five men in matching bicycle spandex uniforms standing at the side of the road. Underneath the yellow blanket lies their missing teammate who was wearing the same uniform. It looks like I still have some work to do and it’s one of my least favorite aspects of the job.

“Hey guys, come on over here and let me explain what’s going on.” They are crying and shaking from the cold of the morning. I send my student back to the rig for blankets as I position myself with my back to the guardrail – this focuses them away from the bloody mess in the road and gives a majestic backdrop to the difficult speech I’m about to give. They huddle close as my student is draping blankets over their shoulders.

“We’ve been working on him for over twenty minutes now and he wasn’t responding to any of our efforts. I had a conversation with a doctor and we both agreed that it was time stop and pronounce death. What I can tell you is that he had very severe damage to the head and extensive internal damage to the organs. It’s very likely that he died upon the initial impact. I wish that there was more that we could do but his injuries were incompatible with life. I’m very sorry for your loss.”

Impalpable 1/2

im·pal·pa·ble

1  :  incapable of being felt by touch

2  :  not readily discerned by the mind

3  :  the quality of not being physical; not consisting of matter

I have wrestled with death. It is the most unexciting contest you can imagine. It takes place in an impalpable grayness, with nothing underfoot, with nothing around, without spectators, without clamor, without glory, without the great desire of victory, without the great fear of defeat.

Joseph Conrad

The morning sun illuminates the interior of the church in a kaleidoscope of color from the stained glass windows. I slowly walk up the center aisle towards the coffin that is on display at the front of the sanctuary, with a backdrop of systematically aligned vertical pipes from the organ. A nine foot crucifixion is mounted to the wall and the eyes from the depiction of Jesus seem to follow me as I make my way up the aisle. The candles along the wall are giving off the slight smell of burning wax that mixes with the occasional whiff of recently burned incense. After what feels like a very long and somber processional, I finally reach the front of the church and kneel – as if accepting communion – and place my stethoscope in my ears.

“Hold CPR.” A firefighter rocks back on his heels with sweat dripping from his brow as I feel the neck for a pulse and listen to the chest for respirations and heart tones on the pale, lifeless, body laying in front of me. No heart tones and I can’t feel a pulse, yet I catch the occasional autonomic gasp for air as the body attempts to breathe even when all of the control centers of the brain have been turned off by death. I look at the monitor and see the organized complexes of pulseless electrical activity (PEA) march across the screen, each having failed to stimulate the heart to form a contraction. “Continue CPR.”

The flash chamber of the IV fills with blood as the needle finds a vein and saline is pushed into the body by a pressure bag which is pumped up on the IV bag to force the saline into the vein faster. The standard medications are pushed into the IV tubing at regular intervals in accordance with our county’s protocols, as a CPR machine replaces the tired firefighter and applies perfect compressions at the push of a button. The floor of the church is littered with the remnants of our resuscitation effort: the purple and gray medication boxes, various wrappers, etc.

A man in a white shirt and gray hair is leaning into our little clearing here in the middle of the church and trying to get close to the patien’s head. With tears streaming down his face and a cracked voice of anguish he’s pleading with my new patient not to die. “Mom, you’ve got to come back to us. You can do this. It’s not time yet. Please mom, come back…” I take the IV bag from the firefighter and hand it to the man in the white shirt.

“Sir, can you hold this for me? Hold it up high and make sure it keeps flowing. Thanks.” He continues to plead with his mother not to die but at least he’s standing up and out of my way as I prep my intubation equipment. I tend to think that CPR and drugs have a better chance of bringing her back – more so than pleading – but it seems to make him feel better to be doing something so I’m okay with getting him involved by giving him a job. This is obviously one of the worst days of his life and he’s going to remember it vividly for as long as he lives. He came here to say goodbye to a loved one and watched his mother clutch her chest and fall to the ground not ten feet from the casket of another family member.

Kneeling in the aisle of the church, under the watchful gaze of Jesus, I bow my head – as if in prayer – and insert the laryngoscope into a lifeless mouth. The autonomic reflexes of the body are still attempting agonal respirations as I expose the vocal cords and pick my landmarks to sink the tube into the trachea. Like a surfer sitting in the line-up waiting for the perfect wave, I watch the vocal cords come into view every eight seconds or so. On the next rhythmic exposure I sink the tube home and inflate the cuff while securing it to my new patient. The firefighters begin strapping my patient to a back board to facilitate transport to the ED.

At the next break in CPR I’m feeling for a pulse and watching the monitor as the rhythm changes to the erratic zigzag of ventricular fibrillation. The drugs and perfect mechanical CPR have created an electrical change in the heart – or possibly she’s deteriorating as the heart can no longer create an organized complex. Either way this code just turned into a mega-code and we’re going to chase the rhythm with electricity and different drugs in the hopes of restoring a perfusing heart beat.

I push the charge button on the monitor and the high-pitched whining sound increases in volume until the modulating alarm tells me that it’s ready to deliver a shock.

“Clear.” The simple word is repeated by the others as they move slightly away from my patient. The son is a little confused as he stands holding the IV bag next to me. I reach up and take the bag from his hands and set it on the ground. In the background the monitor’s alarm impatiently reminds me that it’s time to deliver a shock. I let the son know, “You’re fine right there,” and I push the button.

Electricity courses through my patient’s body and her muscles contract and release tension as her arms splay to her sides. Nine feet above me the lifeless eyes of the crucifixion stare at our futility and the religious parody taking place on the floor of the church. Have I not tortured this poor woman by stripping her to her undergarments, stabbing her in the hands with needles, strapping her to a board, affixing a mechanical compression device to her chest, and finally sending electricity through her body only to create the mirror image of the crucifixion on the floor of the church?

The CPR machine is still doing its tireless job of compressions on my patient’s chest as we put her on the gurney and prepare to leave the house of God to go find the house of Science. Jesus’ eyes seem to watch our little procession of first responders push a gurney past the empty pews towards the back of the church. At His feet lies a casket with another dead body in it.

A priest in full robes stops us at the door. He says some words in Latin that I don’t understand and moves his hands in well rehearsed motions – passing on a blessing for my patient as the rhythmic noise of the CPR machine circulates blood in a lifeless body.

We exit the church and head toward the ambulance, walking past easily one hundred people standing around in black suits and dresses. All I can think as we slowly roll towards the ambulance is that it’s likely that all of these people will be back here in a week to pay their final respect to my patient.

We enter the ambulance and I have two firefighters with me – one squeezing air into the tube and one taking care of the monitor and CPR machine. I’m prepping drugs and reassessing my patient as the doors close and the four of us are finally alone  – away from our somber audience.

As the rig accelerates away from the church I look through the back window to see mourners start heading back inside. Parked alongside the church in the spot that we just vacated, a black hearse waits for its occupant so it can begin the slow transport to the final resting place.