Gone Too Long

I was working the ALS transfer car I usually work, on a Saturday. Just working as an EMT, with a very experienced paramedic alongside me.

We got tossed into the 911 system abruptly, given a code 3 call a long ways away out of the blue. No problem. Fire is there in a few minutes, so our long response doesn't compromise care. We get onscene eventually to a relatively simple chest pain. I drive, my medic does the regular ALS stuff on the way to the hospital. Prehospital 12-lead by the fire dept didn't show anything. We found out later it was cardiac.

Clear from the hospital. Cleared to quarters. Out of the system. We stop for fuel, and while we're doing so we're yanked back into the 911 system. The county's at low levels. We head back down the freeway, to a low-level post, basically on an overpass. As we're pulling up the onramp, the county alert tones go off, three monotone beeps on the fire radio, and--

"Dispatch with an echo response, 4321 Pringle street."

As the fire tones start to go off and I look for a place to turn around, I swallow nervously, and hope I misheard. As soon as I hear tones for a second station, I realize I was right.

Under the Medical Priority Dispatch System responses are coded (in order of increasing severity) Alpha, Bravo, Charlie, Delta, and Echo by calltakers, based on carefully determined criteria.

Alpha response is no lights and sirens, a nothing call. Bravo might be something. Charlie and Delta calls are serious. There are only a few things that can get an Echo response; generally they're for a patient not breathing or a full-on code (cardiac arrest). You rarely hear one.

Sure enough.

"For Engine 314, Rescue 332, Medic 34, echo response on a child not breathing, 4321 Pringle street. Repeating, Engine 314, Rescue 332, Medic 34, echo response, child not breathing, 4321 Pringle street. Fire map page 671 C-Charlie, working Tac 2, time out fifteen thirty."

Crap. I put the pedal to the floor as my partner starts talking to the dispatchers and mapping me in. We scream down the interstate, hop the divider at a traffic-clogged offramp, and go wailing up city streets.

On the way dispatch confirms that it's a pediatric patient. CPR in progress. Crap. But then a second update comes in: breathing now. Okay. Maybe this was new mom syndrome? Or something else less serious than it sounds?

As soon as we arrive I know it's exactly as serious as it sounds. The kid is primary-school-age, with a form of muscular dystrophy, lying on the ground next to a motorized wheelchair. Where he isn't pale as a sheet he's blue, and he's working hard to breathe.

We're on-scene for about nine minutes, just long enough for the medics to figure out they can't get a line easily and that he's not ready for a tube without the rapid sequence drugs. No IV, they can't sedate, paralyze, and tube this kid, and without that the only option is mask ventilation with high-flow oxygen. They can't get an O2 sat either.

We load and go, lights and sirens, my medic plus a firefighter paramedic in back. The children's hospital knows him, surely, and no doubt they can take care of him better than we can.

But a couple miles up the road he codes, for real, and I have to pull over, ask for the fire units to meet us (for more help), and jump in back to help do CPR and suction while the medics try and get him tubed. I glance at the monitor at one point, and I'm not sure if I'm seeing v-fib, or artifact from my compressions. Not my job. I remember the new CPR class I took recently, and push hard and fast with the heel of my right hand. With the other hand I reach over and poke the Yankauer into the corner of his mouth and suction vomit. It's all over everywhere, and the kid is gray.

They get their tube, finally, on the second attempt. I'm sure it would have taken me more than two tries. Tough airway. But now he's getting ventilated, effectively. Look at the monitor -- asystole. Flatline. The first dose of epi goes down the tube.

The engine and rescue show up again. I happily clear out of the back of the ambulance, making way for a few more medics. After looking briefly for an IV, they put an intraosseous line into his leg. At some point I realize I parked almost in the middle of the road, and somewhat blocking an intersection. Whoops. Someone from one of the fire units cones off the area.

Finally they've got what they need done so we can go again. We divert for the closest hospital. I don't even know how many fire department paramedics we have in back -- three, plus my medic, I find out later.

We arrive with the kid still in asystole. The back of my ambulance is destroyed. Supply wrappers are everywhere. Two or three laryngoscope blades lay on the flood by the airway seat. Suction tubing, oxygen tubing, IV tubing, monitor cables -- it's a spaghetti hell. My paramedic looks at me and says, "Just decon everything." As I'm getting started, one of the fire medics comes out of the ER.

"You guys aren't going to believe this, but he's got a rhythm. Narrow-complex. Sinus tach. I don't believe it."

We're all happy for a minute, then someone points out the downtime. Fifteen, twenty minutes. Too long? Hard to tell.

* * * *

Three months later, my name and the name of the medic I worked with that day are in the pat-on-the-back section of the newsletter at work. An excerpt from a letter about the call, presumably from the kid's parents, thanks us warmly. Nothing to suggest what the call was to anyone else. But to me the connection is clear, and when I go back and check the dates match. No outright statement of outcome, but the way it's phrased makes me think he died. They thank us for doing everything we could.

And a few days after that, I catch up with the medic I worked with that day. Yeah, he says, the kid died. Of course. Sick to start with, twenty minutes of downtime. No chance. But, he tells me, he got a nice letter from the parents, through our agency. Didn't I get a copy? No? He'll make me one.

They included a picture, the medic tells me, and I suddenly, desperately, want to see it, so that I can have a memory of the kid's face that isn't gray, limp, and streaked with puke.

* * * *

(Please note that like everything I write here, while this is based on a real call, circumstances, locations, and details have been obfuscated or changed. Any identifying information has been removed.)