Tag Archives: death

Dead Space

dead

1 – having lost life, no longer alive

2 – having the physical appearance of death; a dead pallor

3 – not circulating or running; stagnant: dead water; dead air

 

space

1 – the infinite extension of the three-dimensional region in which all matter exists

2 – an empty area which is available to be used

dead space – a calculated expression of the anatomical dead space plus whatever degree of overventilation or underperfusion is present; it is alleged to reflect the relationship of ventilation to pulmonary capillary perfusion

Walking back into the ED room to get a signature from the nurse I’m momentarily surprised at the level of commotion surrounding the man that was my patient just a few minutes ago. I look up to the overhead monitor that displays his vitals and see the obvious cause for excitement – asystole, the most stable heart rhythm in the world, is marching across the screen and slowly erasing the beautiful complexes of normal heart beats as it fills the screen with the flat line of death. The Paramedic Intern pulls a short step stool out from the corner just as the attending MD makes the call for him to begin CPR. Well, I guess my differential diagnosis was correct, small comfort considering he’s dead now.

There’s a question in paramedicine that is useful to the Paramedic in deciding a course of action on any given call – is this person big sick or little sick? The speed at which we can determine the acuity level of any given patient helps us in determining how fast we move through the call. On occasion the first look at a patient can tell you everything you need to know in terms of acuity. As I walked into the bedroom I could see that this is one of those times. My new patient looked up at me from the bed and it’s obvious that this is big sick and I’ll be moving fast today.

The firefighters arrived just a few seconds before us so they’re still attaching the monitor  leads and trying to get a blood pressure. I know what they’ll find based on the patient’s skin signs alone. The term – pale/cool/diaphoretic – gets overused in our business but it still surprises me when I see these skin signs manifest on a patient. A man of his ethnic background would be hard pressed to look pale so the fact that he looks ashen tells me all I need to know. My first thoughts on a call like this are about extrication. I want to get this guy out of here, into my ambulance, and start driving. Everything else can be figured out on the way to the hospital but the main priority is getting him from the bedroom to the ambulance. The problem is that he’s over two hundred pounds and there are three flights of stairs between me and my ambulance.

I send my partner back to the rig for a stair chair as I start to take in the vital signs and patient history to see if I can paint a picture of the last few hours that led to this big sick presentation. It seems that he and his wife were out running some errands and he started feeling sick about an hour ago. He vomited once and now he’s presenting with an altered mental status, very low blood pressure (72/48), fast heart rate (118 bpm), clear lung sounds, and skin signs that are screaming “heart attack” at me. Of course that was until I ran the 12-lead for the second and third time. The results keep showing nothing even remotely concerning in the cardiac department. In his altered state the only intelligible uttering I can make out from him is, “I…can’t…breathe…”

I put a non-rebreather oxygen mask on him and start the trek of three flights of stairs to the ground floor and the relative comfort of my ambulance where I can start to figure this thing out. The new stair chairs with the revolving treads make quick work of the stairs while preserving our backs in the process. It seems we’re on the ground floor in just a minute or two and headed towards the ambulance.

Finally inside the ambulance, I have decent light and all of my tools at hand so I can try to analyze his condition while driving to the closest hospital. I’ve already ruled out the possibility of a STEMI (S-T elevation myocardial infarction – a.k.a. heart attack), which would require a cath-lab, so I am free to head to the nearest hospital. As I check his 12-lead a fourth time – on the right side this time, still looking for the elusive STEMI – the firefighters decide it’s a good opportunity to leave. Figures. Looks like I’m on my own on this one.

With lights flashing and the siren singing a duet with the air horn I bounce down the road while starting two IVs in my quickly fading patient. Once that’s done I set up two bags of warm saline flowing wide open to drop as much fluid on him as possible and try to keep that blood pressure out of the double digits.

I slip the non-rebreather off of his face and put on a nasal cannula that has a receptacle for reading the exhaled breath and measuring the end tidal carbon dioxide (EtCO2). I actually do a double take as the reading comes back as 8 when the normal reading should be between 35 and 45. Hell, I’ve stopped CPR and pronounced people dead with higher EtCO2 readings!

A number this low just doesn’t make sense. I listen to lung sounds again and they are still coming up clear. I check his blood sugar to rule out a DKA (diabetic ketoacidosis)  presentation and it comes up perfect. Sepsis could possibly take the reading this low and explain the presentation but not with an onset of just one hour. There’s only one other differential diagnosis that is making sense to me right now and when that flashes into my head I’m more relieved than I can admit to see the bright lights of the ED out of the back window as my partner backs us into a spot by the double doors and I prepare to give my findings to  the doctors on the other side.

In these days when science is clearly in the saddle and when our knowledge of disease is advancing at a breathless pace, we are apt to forget that not all can ride and that he also serves who waits and who applies what the horseman discovers. 

Dr. Harvey Cushing

 

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.”


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.

 

 


Dia de los Muertos 2/3

Leaving the urban areas behind I accelerate into an increasingly empty freeway as the lights trail off, replaced by trees and scrub brush hills. There is solitude in the darkness, yet the open roof allows judgment from above as I navigate the quiet freeway home. With a crescent moon overhead I see the airliners strung out in their landing pattern like white Christmas lights hanging in the sky. I feel the rush of wind as I pass the big rigs hauling goods to far off destinations. Cold wind is still on my face, and I have a tightness in my chest when I breathe deep, so I allow my breaths to become increasingly shallow – it’s just easier that way. I wonder what he thought just before he took the last breath of his life.

“It’s Jimmy, looks like his asthma is acting up again.” Kevin pulls us up to the bus stop where Jimmy is sitting down and sucking hard on the Albuterol treatment provided by the fire medic.

We’ve seen Jimmy every few weeks over the years. Sometimes it’s drunk in public, sometimes it’s his asthma, or weakness, or hunger, or just a little cold. On occasion we even get the calls from the cell phone heros who think he’s dead yet keep driving so we have to show up and wake him up in the morning. Although he’s usually not in any serious distress he does have every chronic problem in the book: hypertension, CHF, diabetes, asthma, COPD, previous heart attack, etc. He’s an urban outdoorsman (a.k.a homeless), and a frequent flyer. It seems like he’s been in the county forever. The fire medic doesn’t even bother with a hand off because we all know him.

As I load Jimmy into the rig I hear the fire engine accelerate away from us. Jimmy’s having a hard time holding the Albuterol treatment so I convert it to a mask for him as I tell Kevin to start transporting – I’ll do everything en route to the ED because he’s looking pretty serious.

As I lean Jimmy forward to listen to his lungs I can actually hear the fluid level increase – filling up his lungs as I work my stethoscope higher on his back. FUCK ME!!! The asthma exacerbation triggered a flash pulmonary edema episode. Uncontrolled high blood pressure and congestive heart failure are pushing blood into the most porous organ in the body – his lungs. He’s drowning in his own fluids!

Just as I pull out the CPAP (continuous positive airway pressure) and affix a nebulizer to it, I see Jimmy’s head slump to the right. Fuck! Can’t use CPAP on an unconscious patient.

Looking out the window I see that we’re basically on the same block where my last patient checked out on me. I tell Kevin to upgrade to Code-3 and let them know we’re coming in with respiratory arrest. I switch the nebulizer over and attach it to the BVM (bag valve mask) and squeeze the football to try to oxygenate the lungs that have decided they are going to stop working tonight.

One minute later we’re at the ED and I’m watching his heart rate slowly drop; 60, 50, 40. “Start compressions.” The doc states the obvious – Jimmy just coded. Fifteen minutes later they are throwing the “Hail Mary” drugs at him in an attempt to counteract years of abuse to a body plagued by addiction and street life. Twenty minutes later I’m finished with my paperwork and the ED tech, Nick, walks up. “Man, I hope you’re going home now because I’m tired of working codes tonight.”

“Yeah, that was my last call, I’m done. It’s the end of my week – no more patients fixin’ to die on me.” I wave at him as I head out the doors. “Have a good one.”

Dia de los Muertos 1/3

Dí·a de los Muer·tos

1 : the day of the dead

2 : a holiday, particularly celebrated in Mexico, which focuses on gatherings of family and friends to pray for and remember friends and family members who have died

The fabric roof recedes behind my head in silent automation and reveals the stars in the heavens in all their glory. A moment of solitude and infamy which is quickly interrupted by the speeding commuter train on its elevated track, with its onslaught of light and noise, rushing off to unknown destinations. At the end of my shift I sit behind the wheel of my personal vehicle and take a deep breath – finally it’s over – and listen to the engine cycle into a familiar purr to tell me that it’s ready for the drive home.

I recline the driver’s seat to stare straight up at the infinite expanse of the universe and wonder where the three dead souls have gone this night. It wasn’t my fault, I mean seriously, how am I supposed to reverse multiple years of abuse in the fifteen minutes I’m with a patient? Well, the last one was probably my fault, I pushed him a little too hard, but even still – it was his time to die. 

Any why does it always come in threes?

Precision German engineering growls back at me as I depress my foot and accelerate away from the deployment center. Cold wind rushes past my face and street lights streak overhead as the flappy paddles on the steering wheel cycle the gears up in a desperate attempt to distance myself from the memories of a day from hell. Three hundred and thirty-three horses are unbridled at the on ramp to the freeway, with a rapid acceleration, as the increased g-force pushes me into the seat. The cold wind bites at my short sleeves and exposed skin – it’s a little too cold for a convertible ride so late at night – but I did it on purpose knowing full well what to expect. I wonder if that’s what a cutter says as she drags the razor blade in ever increasing depth across her forearm? Does pain and discomfort somehow remind you that your alive and in that revelation then become a celebration of life? Or is it time to check myself into Emergency Psych Services on a 5150 – should I start to worry when the madness actually starts to make sense?

“Medic-40 copy code three for the OD on the transit bus. PD is on scene, Code-4, you’re clear to enter.”

We’re only a few blocks away and Kevin puts us behind the bus and fire engine in just a few minutes. As we walk up to the bus I see a man in his early thirties surrounded by county sheriff officers and firefighters. He’s looking at me in this kind of thousand yard stare as the fire medic shows me the empty bottle of vodka they pulled out of his pocket. It’s the classic “drunk on the bus” and I’ll have to take him to the ED because he can’t even walk by himself. It takes four of us to pick him up and plop him on the gurney and the firefighters take off without even taking vitals or offering to help out.

As I strap the seat belts on my new patient I notice a little bit of plastic between his lips. I reach up and pull out a baggie that’s been chewed down so all that’s left is just a few white grains of powder – obviously an attempt to hide a drug possession from the officers. I hand the baggie to the officer and feel for a pulse; strong in the sixties – good for now. “Kevin, I’m good to go as soon as we load up, this could go downhill fast…”

My new patient isn’t answering questions or even acknowledging that I’m here so my only assessment is what I see on him and the monitor. The most obvious options for the white powder are crack cocaine, crystal meth, or heroin. Crack and meth speed you up; heroin slows you down – I really hope it’s the heroin because that’s the only one I can turn off.

We’re a half mile from the hospital when the vomit and head spinning scene from the Exorcist starts up right there in the back of my ambulance. First thing I notice is the heart rate climbing from 66 beats a minute to an incredible 236 in the course of twenty seconds. As I tell Kevin to upgrade to Code-3 the vomiting starts. Now I’ve got bio-hazard all over the back of the rig (not to mention the stench), and all of my focus is on keeping his airway open to prevent him from aspirating vomit into his lungs. I’d love to throw a line in and hit him with a sedative but I can’t do it at the expense of his airway. Well, I guess it wasn’t heroin.

Two minutes later we have him in the ED. Two minutes after that they are throwing the drug box at him to slow down his heart and attempting a gastric lavage to clean out his stomach. Fifteen minutes after that they are doing CPR – his heart had stopped beating when it gave out from fatigue. Twenty minutes after that the maintenance crew is mopping up the vomit from the floor and trying not to disturb the dead body on the table with the sheet pulled over its head.


Dissolution

dis·so·lu·tion

1: annulment or termination of a formal or legal bond, tie, or contract

2: decomposition into fragments or parts; disintegration

3: formal dismissal of an assembly or legislature

4: extinction of life; death

It’s a Code-2 response – no lights and no siren – and I’m in a morose mood as I make my way to the middle of the county. I’m responding solo and driving myself for once. The passenger seat next to me is empty. Scottie is responding from the other side of the county and I’ll meet him there. As I start to get closer I see others on their way to the same place. Uniforms in cars and ambulances, driving slowly in the same direction. I pass a fire engine with its cab full of new hires who are in the academy. I ponder the lesson that the brass is teaching them by having them take the day off from the hard work of the academy and attending a funeral: death is real.

As I make the turn into the cemetery I see the ambulance parked across the street. The cemetery happens to be at a normal posting location. Ambulances are sent to this intersection as it has easy access to a few different cities, as well as the necessities of a mobile crew: a bathroom, some shade, and nearby food options. Many of the cars parked along the wide streets running past the headstones bear county EMS stickers in their back windows.

Walking up to the small chapel I pass ten ambulances, four fire engines, and even a ladder truck. Our brothers and sisters from the fire service have made a good showing – every city in our county is represented, and we all appreciate their presence.

Walking over the small grassy hill to the chapel I see the sea of uniforms – I’ve never seen so many of us in one place before, and it’s overwhelming. Paramedics, EMTs, dispatchers, firefighters, police officers, and of course the honor guard with class-A uniforms complete with swords. There’s even a mounted EMT from the equestrian unit – I never even knew we had an equestrian unit.

All are here to pay their last respects.

At any given time at least a third of us are working the streets and responding to calls in the county. But the 24×7 nature of our work and the size of our county makes it difficult to get so many of us together at one time and in one place. Today is the exception – they put out the call to neighboring counties for mutual aid. Other counties’ EMTs and medics came into our county, checked out our rigs, and opened up the map books to respond to our calls, allowing us to gather for this final goodbye.

There have to be over 300 uniforms standing around the chapel, yet Scottie is able to pick me out of the crowd and he makes his way through it to stand next to me. We have a comfortable silence between us. We’ve only been partners for about a month but spending twelve hours together on a daily basis can bring people together fast. I notice that many other partners have found each other and taken comfort from being together during this emotional time. There is one person who is unable to stand with their partner and that stands out that much more for his solitude.

I find myself in a line which is slowly making its way into the chapel; the honor guard stands at attention as we enter the doors. As I enter the chapel I realize that all the seats are taken and this is actually a line to view the casket – it’s an open casket funeral. I wasn’t quite prepared for this and that’s a strange thing to say. Unlike most people in the world, we get up in the morning and put on a uniform knowing that we have the possibility of seeing a dead body or even watching someone die. Somehow I forgot about that this morning and I wasn’t prepared to see a friend in a casket. I place the rose petals on his chest and file out the back of the chapel before I lose it.

Eulogies are given and a life that ended too soon is remembered. I look over at the crew that worked him in his last minutes and feel an unbelievable sadness. They were camping and hiking that day and too far away from any urban areas when they saw the skin signs. We all know the skin signs – pale, cool, diaphoretic – and the cardiac etiology that they speak to. They did CPR on a friend without their paramedic equipment and waited the 45 minutes for the ambulance to respond.

I can imagine the time feeling like hours as everyone does the sad math in their head. Only about 15% of cardiac arrest patients actually survive. Once in cardiac arrest the chance of survival diminishes by 10% for every minute of down time. I can imagine the absolute anguish of seeing the ambulance finally arrive only to find out it’s an EMT ambulance with no advanced life support equipment on board. The county where they were hiking isn’t as well funded as our county. The three medics and two EMTs that were with him could only use the most basic of skills in an attempt to save his life. The EMS gods were in a very bad mood that day.

The color guard snaps to attention and the bugler begins the sad song of Taps. The flag is ceremoniously removed from the casket and meticulously folded to be handed to the family. The casket is slowly taken from the small chapel to its final resting place. The procession slowly walks past a double flank of hundreds of uniforms standing at attention with salute in place. One of our own has been taken.

The color guard does a sharp left face and marches off. A final salute is given and the assembled uniforms are dismissed.

One week later Scottie is driving us to the post across the street from the cemetery. He angles the rig so we don’t have to look at the rows of headstones with flowers laid beside them.

“I don’t like this post any more.”

“Yeah, neither do I…”