The stink of death.
There is a smell on people who are recently dead (or dying). Perhaps it's all in my head but I smell it. I ran a code today (did a lot of stuff on someone who's heart had stopped to reverse that) and I got the "stink" on me.
I'm riding as a student with one of my preceptors who I'll call "Lucky McGee." I'm calling him that because, 12 years ago, he fell 50 feet to his death while fighting a fire and was resuscitated. He's a GREAT preceptor.
We're wrapping up from another heroin overdose when a call comes out as "not breathing." Lucky McGee knows I need experience with endotracheal intubation (putting a tube in someone's windpipe to be sure they can breathe) so he "squirrels" the call. It's right down the street. I hear him say:
"Dispatch, we'll take that call."
The patient is 89 years old and is at a nursing home and an EMS supervisor had arrived before us and taken over care. What I didn't know was that Lucky McGee called the supervisor and told her not to intubate the patient. He told her that he had a student who needed a tube and if she thought the patient could wait, hold off until I got there.
As it turned out, the patient had been down (not breathing and/or pulseless) for a while before we were even called. That didn't matter to me or any of the other 8 rescue workers in the room when I arrived. We all worked her as if she was our own mother.
McGee and I slide into the room.
"Maddog, Set up for the tube." He tells me and I do so.
I'm set up and I "go in" with the laryngoscope. This is a device that is, basically, a "spade" to move the tongue out of the way and show me where the vocal cords are. It scoops the mouth open and has a light on the end of it that lets me see where to put the tube.
I see the vocal cords perfectly. I pass the tube perfectly. Apparently, when I was removing the stylet (an insert that makes the tube stiff and easy to push), I dislodged the tube from her trachea and it slid into her esophagus. When checked, it showed as being in her stomach.
I pulled the tube and ordered the patient to be ventilated. There was some fumbling but we got some air into her in short order. We did a really good job of putting air into her lungs without an endotracheal tube. This, combined with the regular, rhythmic shocks to her heart, caused my patient's heart to start beating and for her to try to breathe on her own.
I was undeterred. Despite the positive change in my patient, I knew she needed an airway.
"Stop bagging, I'm going in." I tell the firefighter who's helping.
This time, my patient's been knocked around a bit by all the other people there. Her head has shifted and I can't see her vocal cords or any necessary part of her airway. I'm digging around with my 'scope but I can't find her vocal cords in time.
"How do you know how long to look, Maddog?" You might ask.
Well, this is one of those cases where what you are trained to do actually works in the field. When taking the time to pass an endotracheal tube into the trachea (windpipe) of someone who's NOT breathing, one necessarily deprives the patient of oxygen and breathing. Understandably, one must limit the amount of time that one deprives the patient of oxygen. In hospitals, there is a cornucopia of devices such as Pulse Oximetry, Blood Gas Analyses and other deep and dark magic to determine when someone has been long enough without oxygen. In the field (such as in the crappy room of a patient in a nursing home) we may not have such tools.
So, you ask yourself, how do I know if someone is short on oxygen?
"Physiological empathy!" Says, I!
I hold my breath from the moment we stop ventilations on my patient. When I need to take a breath, so does my patient. It seems cosmically fair to me. I'm going to jam this tube down your throat. The least I can do is starve for oxygen with you. More importantly, I know when my patient needs to get more air.
After digging around for a bit, I need to take a breath.
"Bag her!" I command and give the 'I need your help' eye to my preceptor.
Lucky McGee slips into my spot. He takes a second to re-position the patient's head. He tilts her head back a bit more and then performs a perfect intubation. His true coolness is displayed when he asks me to confirm the tube (listen, with my stethoscope, to her stomach and lungs to make sure we don't have air in one and we do have air in the others). The man is dead on. I'm learning from a master, no doubt.
Once we have an airway, we move the patient to our Medic unit. On the way, she loses her lovely heart rhythm an her pulses. CPR starts and I say, "Pacing?" to Lucky McGee.
He nods and I set the cardiac monitor/pacer/defribrillator to 80 beats per minute. I start the pacing (this is where a regular, rhythmic shock is given to the chest of someone in order to make the heart contract and pump blood the way it's supposed to) low and work my way up. At 45 milliamps, I begin to see electrical waves that tell me her heart is responding to the shocks.
"I've got electrical capture," says I, "check for pulse."
"She's got a pulse!" Says Lucky McGee. Awesome! I'm making her heart beat!
Unfortunately, that quickly goes away. We 'work' her. This means we pump her heart for her, breathe for her, shock her heart and give her drugs that will (hopefully) make her heart go to work on it's own. We don't have the legal authority (nor do we want it) to declare this patient as dead. I've done marathon sessions of CPR before. I get to work and we 'pump and blow' all the way to the hospital.
In the ER, the doctor declares her dead. Nurses take over the necessary parts of the process. As I clean our cot, our monitor and gear, I watch the team perform the legally necessary steps of declaring someone truly dead. They use a sonogram to check for any heart activity, record the EKG of a flat line (asystole) and such.
Okeydoke! Get the medic unit ready and we go back in service for the next call. Like nothing unusual had happened.
But there's the smell.
The smell of death.
I'm sure I'm the only one who notices it. Every dead person I've 'worked' has a smell on them. It's a combination of a lot of elements. There's urine, bad breath, some unidentifiable sour smell, and a bunch more I can't articulate into words. The thing is, it's a sticky smell. An hour later, it's on me. It gets into my clothes. I smell it later. It somehow works its way into my pores. It gets in me.
Is it a condemnation of my inability to 'save' this one? Is it a reminder that sometimes we paramedics are the shepherd of death as well as the giver of life? I don't know. These questions are too philosophical for me. All I know is that I stink.
I turn down the offer of a pint after work from Lucky McGee. Instead, I go home and change into some running clothes. I go out for what should be an easy 4 mile run but turns into a 3 mile march of misery. I'm trying too hard to outrun something. As I sweat, I can smell it. I can smell the death. It's in my pores. It's in me. I try to go faster. My knees hurt. I try to go faster.
Now, I'm sore, cranky, sweaty and I smell bad. Somehow, I feel I've sweated it out. I go home and get the dog.
The winter sun is setting but I have about 20 minutes of light left. The pooch and I go out and I don't even bother with the leash. She's 13 years old, incontinent and mostly blind but she's still my puppy.
In the open field, she runs for the joy of running. Go, puppy, Go! I run with her. Somewhere in that field, the Stink leaves my pores. A shower at home is all it takes. I'm ready again.
There is no doubt. I'm ready to be a 'medic. I'm ready to be the best medic I can be.
"Try not. Do, or do not! There is no try."
Posted by --maddog at 06:18