Epic

Saturday morning. The whole call is like a movie.

*BEEP* *BEEP* *BEEP* "Engine 401, Squad 402, 4809, Engine 95, Medic 105, an echo response, cardiac arrest, across from Fargone Park, 49600 Wayout Road. Map page 6295-D, working Tac 2, time out eight thirty two."

We're a block from the fire station, going on a non-emergent walk-in sick person. My partner grabs the radio microphone. "Medic 105, we're diverting to the echo response at Fargone Park."

I hit the red EMERG MASTER switch, twist the siren knob to WAIL, and off we go. It takes us about eight or nine minutes to get there, hauling butt, and we beat all the fire responders (volunteers and paid from two rural departments).

About halfway there we get the expected update that CPR is in progress.

It's an area I don't know well at all, but my partner directs me; left turn, right turn. I drive hard -- either the gas or brake is all the way to the floor, the whole time.

We scream across a bridge, and we can see three or four people gathered around a man lying half in a mud puddle, doing CPR.

My partner bails out almost before the car is stopped, shouting to the bystanders, "Don't stop!" He grabs the monitor. I grab the hard plastic medkit and skid it across the pavement towards the patient, then sling the airway bag over my shoulder and run over. My partner drags the patient out of the mud puddle and the bystanders start compressions again.

They're doing good CPR, damn good in fact. They've taken a class recently and know the new standards.

Great. Keep going.

I pop an OPA in and start bagging. My partner gets the patches on -- "Check a pulse! None? Okay, we're in PEA. Continue CPR!" and starts getting stuff ready for a line.

I hear a growler siren and glance over to see the first of the calvary -- the squad and the duty officer -- pulling across the bridge. Brilliant.

A moment later we've got four or five firefighters eager to help. They take over compressions and bagging. My partner has an IV in, and starts pushing drugs. I rip open the airway roll and get my stuff set for a tube.

When I'm ready, I nudge the fireman aside, twisting my baseball cap backwards so the bill is out of the way. Drop to my knees in the mud, wipe rain off my face. Everything tunnels down to the narrow world of laryngoscope and mouth.

Suction.

Slip the blade in.

Look. See the cords. Lose them when I go to pass the tube.

Esophageal. Crap. Out.

Fireman bags. Adjust the tube.

Suction again.

Look again. A hint, a glimpse.

Lift his head all the way off the ground with my other hand. There. Bullseye.

Get a fireman to support the head. Cric pressure from my partner.

Perfect. Pass the tube, pull the stylette, inflate the cuff. Attach the BVM.

I bag as my partner listens. Good tube. My first in the field, after a frustrating series of misses and failures.

And the code goes on. I drop a second line and we start a fluid challenge. The PEA goes to v-fib and we start shocking him. We push the drugs: amiodarone, lidocaine. The v-fib continues. At some point the two engines, from different departments, show up. We keep rotating compressors for good CPR. At some point I run to the car for more epi.

The v-fib keeps going, and we've got to transport. Load him on a board, to the gurney, to the car. I get an escort by the duty officer's SUV out to roads I know. Manage not to throw my partner and the firefighters around too much.

By the time we're at the hospital he's in asystole, and been down over an hour. I code-surf the gurney in to the ED, doing good hard compressions. About eight minutes after we arrive the doc calls it.

My partner, running out immense code summaries, tells me they pushed twelve rounds of epi. We have to go out of service to quarters to get more drugs.

As we're leaving, I note that one of the bystanders seemed very emotional, on scene. "Yeah," my partner says, "it was his brother." They were enjoying some Saturday morning fishing.

I don't know if I could do CPR on my sibling.

And it was good CPR, too.

The Apartment Fire

It was about 9am, on a quiet morning just before the winter holidays. I was driving. My co-trainee rode shotgun. Our field training officer (FTO) sat in the jump seat in back. We were headed for a station in the southeast part of the city. Then the radio crackled to life.

"This is fire dispatch calling box 8513, report of an apartment fire..."

East of us, in a large suburb. We heard the assignment go out and clicked our second radio over to the operations channel. The first-in engine arrived and sized up what sounded like a decent fire. More apparatus arrived, and then --

"Dispatch from Command, start us a code 3 ambulance."

My co-trainee and I looked at each other. "Are we closest?" I asked.

"I don't know," he said. "Maybe? Levels are low..."

A few more seconds went by. "Huh," I said. "We must not be--"

Five things happened at once. Both of our radios alerted, an unmistakable BEEP BEEP BEEP BEEP. The computer bleeped a priority tone, doo-doo-doo-DEEP. Three pagers started vibrating. A screenful of information came up on the computer with the highlighted text ASSIGNED in the middle. And the dispatcher told us we were going out to the fire.

I looked at the address, asked over my shoulder to my FTO, "Straight out this street, right?"

"Yup," he said. A second later he added, "Only about a hundred and ten blocks away." The gas pedal was flat to the floor before I even hit the switch.

Forty blocks later, fire command updated us: "You have one patient, he'll be in front of the truck company on the east side of the complex."

Oh good, we thought. One patient. Three of us, we should be able to handle it, even if he's badly burned and needs tubed, or whatever. We got it.

"Additional for the medic unit, your patient has lacerations to his arms from glass."

Oh, jeez, we think. No problem at all. We're golden. We got it.

In thinking this we forgot the cardinal rule of emergency medical services, and indeed any 911 response: The radio always, always lies.

* * *

It wasn't hard to find the complex. Usually we respond to medical calls with a single piece of fire apparatus, and if they've arrived first the last directions from the crew member with the mapbook go something like, "Turn right on 42nd and look for the marker truck." A thirty-thousand-pound red truck covered with flashing lights is an excellent indicator of where the call might be.

In this case, there were six or seven such vehicles (five engine companies, two truck companies), plus a few command SUVs. We found the specified truck company and parked behind it. It was beginning to rain a bit. As we're climbing out, a firefighter comes hustling up. In all his turnouts. With his airpack on.

"Hey," he said, sounding a bit worked up, "we need your airway kit over here!"

Airway kit? I thought. For lacerations? Maybe he got some smoke too... I asked my co-trainee to grab the kit and I followed the firefighter. He led me right past the truck, and across the parking lot to a small SUV with the back hatch open.

Standing next to it, wrapped in a blanket, in pajamas, was a woman in her twenties, with soot on her face, darker under her nostrils and around her mouth. Tear streaks cut across the black.

Inside the back hatch, also wrapped up in blankets, were three kids -- a two year old, a four year old, and a six year old -- all with soot-darkened faces. One had a cut on his forehead, and dried blood streaked his face.

I'd like to say that in the five seconds before my partners caught up with me I thought something like, okay, four patients, we'll need at least one and maybe three more ambulances, and we'll need them all on high-flow O2 for CO poisoning, and we need to first off evaluate them for airway burns because we may need to tube them early, and we should probably declare a Multiple Patient Scene and get fire medics to help...

But the truth is, in the first few seconds, I could only stare at them and think, very loudly inside my head: Oh, sh*t.

* * *

My training officer took one look and came to all the conclusions I didn't. "Give me your radio," he said to me, "and get them to the car." He turned away, looking for the command officer for the fire, and said over his shoulder, "High flow o's, and check their airways!"

I looked over my shoulder. It's just me and my partner trainee. I ask the kids, "Are you okay?" and get solemn nods in return. "Okay," I say. "We're going to go over to the car now." I picked up the smallest one and handed him to mom. We got the other two, and all of us walked in the light rain to the ambulance.

We got everyone settled inside, and then it really got fun. A firemedic hopped in (fortunately she'd ditched most of her gear) and so there were now 3 paramedics and 4 patients in the back of the ambulance. Thank god we have the Type III boxes, but even so it was cramped. Everyone's airway got evaluated. Things looked pretty good for the kids, but mom had some soot in her throat. Everyone got on oxygen (just imagine the hoses snaking from two wall-mount ports and two portable tanks).

At some point my training officer stuck his head in the door and told us, "I declared a Multiple Patient Scene [sort of a low-grade Mass Casualty Incident] and we have a second ambulance coming. Do we need more?" My trainee partner and I looked at each other, looked at the kids, and shook our heads.

The denouement of the story is sadly -- or rather, happily -- quite boring. The other ambulance (coincidentally our sister car, working the same hours as us) took the two older kids, and we took mom and the youngest. I drove, with my partner trainee and FTO in the back. They thought about tubing mom -- apparently in the right sniffing position you could see soot all the way to her epiglottis -- but decided to hold off.

Everyone did fine at the hospital. Mom never did get tubed, and everyone's carbon monoxide levels came back low enough that they didn't need hyperbaric oxygen or even to be admitted. They left the hospital before we were off shift.

And our original patient that we never actually saw, with the lacerations? The heroic neighbor kid who discovered the fire, and punched out a plate-glass window to alert the family when he couldn't get in the door. He went by personal car to the hospital, and got all the media attention.

Well, almost all -- there was a lovely shot of our FTO's butt on the 6pm news. You'd better believe he heard about that.