Drowning

The ambulance's siren wails ahead of us as my partner navigates through suburban traffic. I adjust the elastic strap that holds my safety glasses tight against my head. I only use the strap when I think I'll really need to keep them on. An "unconscious party" is one of those times. I'm prepared for the absolute worst--a "core," or someone in cardiac arrest. The thought is, if you're prepared to pull out the big guns for the worst case scenario, then there is less of a chance of being surprised on scene. In my mind, I run through drug dosages and ACLS algorithms.

I grab the airway bag, leaving the rest of the gear for my crew to grab as I navigate through the ranch home that stinks of cigarettes.

I can hear my patient before I can see her. It's the oddest sound. Her breathing--it sounds like someone blowing bubbles underwater. An obese, elderly woman lies semi-upright against a mountain of pillows in a dirty bed. She makes no acknowledgement of my presence, her entire existence focused on her next breath. An oxygen cannula hangs crookedly from her nose, her son awkwardly fiddling with it as he explains no one knows how long she has been like this. The family, as is often the unfortunate case, is of little help. Either from an ignorance of her condition or the stress of the situation, they offer little in the way of a medical history, and barely a name. I take a quick listen to her lungs, redundant in retrospect as it merely confirms the gurgling that I can hear across the room.

For all purposes, she is unconscious. On demand, she opens her eyes to me. But there is no fear, or panic. Just defeat. Her congestive heart failure has filled her lungs with fluid, and she is drowning.

This is a patient to move quickly with. My crewmates struggle and place the patient in a chair they've found in the next room--more expedient than returning outside to grab the ambulance's specialized chair. A circus of oxygen tubing, bags and people, we make our way down the hallway to the stretcher. An oxygen mask is placed on the patient and as the stretcher makes its way to the ambulance I formulate my plan of care.

Through my direction, a bag of saline is spiked for an IV, the patient is loaded, a second paramedic is assigned to the back with me for the ride in and vitals are taken. But not taken. My FI reminds me we can do this on the way to the hospital, and in the interest of time I belay the last. No matter though, as a minute ticks by as my lieutenant shows up with the proverbial wrench in the monkey works: the patient is in hospice care with a DNR. This means that the patient is in end of life care, and in the event of cardiac arrest does not wish to be resuscitated. This, for the moment, does not change my care. The patient still deserves and wishes care and comfort for her condition. But it puts in a brief question in mind of how to proceed: is this a priority patient to rush to the hospital? Though there was some debate, the answer in my mind was clear: yes. This patient deserved to be made as comfortable as quickly as possible, and if nothing else this young paramedic did not want her dying in the back of HIS ambulance.

The doors slam shut and our new guy takes off lights and sirens to drive us to the hospital. As is always the admonishment, we caution him to take it "nice and easy" and to "mind the bumps." Either way, an emergent return to the hospital is usually like trying to do patient care inside a paint mixer.

While my partner obtains vital signs and looks for an IV, my first order of business is her airway. I pull out CPAP, a positive pressure airway mask. It is a slightly medieval looking device that straps to a patient's head, but the oxygen forced into their lungs can push enough fluid out of the way to drastically improve breathing. My patient submits to the mask easily, and the audible sound of gurgling goes away.

Cardiac monitor on. Vitals taken. IV attempted, unsuccessful. Again, this time successful. Nitro given, lasix pushed, all to try and relieve some of the fluid on her lungs. All the while, I look from the patient to the airway kit I have laid out beside me. Mentally, I figure that I'll try a 7.5 tube to intubate the patient if she becomes unconscious.

Through this the ambulance siren wails, cars whiz by, and every bump is amplified.

After what seems like an eternity, we arrive at the hospital. In we go, a tangle of wires and tubes. A quick report to the ED doc and my job is done. It is, technically, a success for us: our patient was still breathing on her own when we arrived.

While we clean up and I write my report, my self-critique of the call begins. We could have moved faster. Got her on CPAP faster. I think that I probably should have tried to nasally intubate this patient. I think she was borderline in our protocols for CPAP. But intubation wouldn't have pushed that fluid out of the way. Perhaps CPAP was the right choice. My FI says I did fine. But I still question. As I write my report I calm down. My FI joins me in the EMS break room and says he saw our patient go into V-fib in the room, briefly. What? I'm nervous again, thinking that I somehow missed the patient doing that on our monitor. A careful review of the strips, and my worries are assuaged. Report done, pram clean. Our unit clears, ready for the next call, but my mind lingers on the what if.