My wife once told me, “It was like everyone was your friend.” And she may be right. I connect well with others and take an honest interest in them. In practice, I always ask where they are from. I find that a great opener, and even Alzheimer’s patients and the elderly can often answer that one. I have done that since my paramedic days.
Don’t get me wrong, though, as I can surely be sarcastic and cynical at the desk, especially when I have a 7:55 patient and an 8:00 closing time, and a two-hour drive home. But when the clinic door shuts behind me, I am in my element, and I quickly calm myself and treat people with respect.
Usually. I’ve had my moments, but this was not one of them.
On this weekend day, I found myself in very rural Texas, staffing a three-bed critical access emergency room while my supervising doc was usually off riding his bike on the rural roads or taking some well-deserved rest, for he covered everything at that hospital. Yet he was always very good to me. I still appreciate him twenty years on.
But this day was a rough one. The ambulance called and said they were bringing a code into us. A 55-year-old lady had collapsed and had CPR in progress. When they arrived, I recognized her immediately. She was a large, tall African American woman who was a local preacher by trade—or by calling, if you could ask her—but you can’t. She came in often as she would drive and accompany someone from her flock to the ER. And she was as friendly as I was, so we would sit and talk and laugh and generally just shoot you-know-what in my little ER.
I really enjoyed her company.
Today we didn’t get to talk. We almost did, as I almost had her back and awake, but the actions of others changed that. Now, I know I can’t ever say what her outcome would have been, as she was circling the proverbial drain, but I can say I tried my best.
It was one of those times I relied on my instinct, and I’d like to think my instinct was right. I have tried to refine that intangible skill called instinct over a twenty-year full-time EMS career, and it often served the patient well. And by this point, I also had ten years on as a PA. My specialty, if we have one as PAs, was in the ER. I was again in my element. By this point in both careers, I may have intubated way into the hundreds—on rooftops, in pouring rain and blinding heat on black concrete, even inside overturned semis, and many times driving and bouncing and sliding down the highway while sitting in a box that was put on a large diesel truck chassis and called an ambulance. I have run thousands of codes of various causes. I taught ACLS and PALS for many years, and I took the ATLS course—and passed—as soon as it opened to mid-level providers.
I would like to think I knew what I was doing.
On this afternoon, she arrived as CPR was being done. As soon as we got her moved into our bed, though, I could immediately detect a pulse. This made us halfway there at that moment, as she still wasn’t breathing, so I intubated as the industry standard suggests. Like I said, intubating was not new to me. I know when I am in. I have strong, sinewy forearms; it’s not hard for me, and I always watch it pass the vocal cords, and this was no exception.
Except, I had noticed as soon as I went to intubate—she was not under any anesthesia unless the angels gave it to her—that her pulse slowly dropped, and we lost it.
My instinct—or someone, somewhere, for some reason—told me to extubate. Not because we weren’t in. We were.
I did, and her pulse came right back. Strong, with normal blood pressure. She was slowly in a sinus rhythm on the monitor. But she was still not breathing. I made another attempt to intubate, and I watched as everything dropped and disappeared—her heart rate, her blood pressure, and her pulse. My tube was just fine. This is no doubt, as I confirmed it with auscultation and capnography. The RT also confirmed it.
But something kept bothering me—and bothering her too. She did not like the tube, and I again extubated her. I explained to my team why I did so, which was to save her life, despite our perception and assumption that she had to be intubated to “secure an airway.”
Keep in mind: We don’t have to “secure an airway” that is secure. And hers was secure.
Instinct.
Her heart rate came back. Her blood pressure came back. Her O2 sats normalized. She started some restless moving, though she was not awake yet. She then started breathing, like an old car motor firing up. Her airway was secure. She didn’t have to have a tube to secure it. And now she was breathing almost normally with some assistance from the Ambu-bag.
We had to restrain her arms; she was now moving so much. She still had not opened her eyes, but her O2 sats, her pressure, her pulse, and her ECG were all in the normal range and steady.
She was trying with all she had. I bent down many times to talk to her and let her know to keep fighting and that I was trying too. Again, she was a friend. She was only in her fifties and still had a flock and kids that needed her. Her airway, despite common perception, was secure—have I said that before? I did not need a tube to secure it, though this is the standard. But our standard was killing her this time. So, we bagged when she needed it or watched her sats stay normal as she breathed on her own.
I could not awaken her, but she was now having some purposeful movements. I called LifeFlight so we could send her to Lubbock for better care and admission to their ICU. And when they arrived, it was two men, younger than me, but as a fellow paramedic (still licensed at the time), I had hope that they would understand. But I knew the ego in this business, especially among EMS professionals. I am one—ego, that is.
I pulled the two of them into a side room and explained the situation to them. I asked them, begged them, pleaded with them not to intubate her. I rehearsed and rehearsed what had gone on. They fake nodded in agreement and went off to load her onto their gurney as I signed some more transfer papers.
And then they passed by me. She was intubated. And of course, sadly, she wasn’t breathing. She was in asystole already after just being in a sinus rhythm. And they were doing CPR. Those two fill-in-the-blank, as far as I was concerned, didn’t even wait to get out of the ER before they intubated. She wasn’t their patient, not yet. She was mine.
And she was a friend.
She never recovered. And of course, she died. Because they intubated—not despite it. I admit I was irate; I still am after many years. I called them in Lubbock and gave them a piece of my mind in not-so-pleasant terms. And their reasoning why they had to kill her?
It’s cramped in a helicopter, and they can’t easily intubate in the bird.
Really?
She died for convenience.
Convenience, friends, if I may call you friends.
Dale J. Bingham is a physician assistant.
