Wednesday, October 10, 2007

start to finish

‘Help me!’
As we push our way into the cluttered bedroom the elderly woman slumped on the edge by the head end throws us a look pressed with fear. She is such a ghastly white colour, and the sheen of sweat on her face and body is so immediately apparent, that without saying anything to each other Rae and I cut the usual preambles and set to work more quickly. The woman has cans of oxygen – trendy looking things advertising pastel peach and jasmine flavours – scattered around her across the rumpled duvet. I ask the intensely worried man who gestures for us to go ahead of him into the room what his wife’s name is.
‘And how long has Elsie been like this?’
‘Fifteen years.’ Then he realises what he has said. ‘But not as bad as this, of course.’
‘Help me, please!’, she gasps.
Simply getting round to her is difficult; getting her into the chair will be a struggle. And from the way her abdomen balloons out underneath her soaked nightie, the two flights of stairs and the dark jaunt across the lawn will be a serious challenge.
I pull out our oxygen cylinder from the resus bag and fit a mask together as quickly as I can. Rae establishes that Elsie does not have chest pain at the moment, does suffer with angina, has been breathless all day but acutely short of breath for about half an hour. I step over the piles of clothes, books and boxes to put the mask on her, but she wrests it away, saying that she can’t have her face covered.
‘I’m scared,’ she whispers. ‘Please!’
Rae holds the mask back up and insists she wear it. Meanwhile I put the carry chair together and get in as close to her as I can; Elsie looks at the chair, gathers up a clutch of bedclothes around her and refuses to move. Rae talks to her severely, parent to child.
‘Listen to me, Elsie. Listen, now. You must do as we tell you. If you want help, you have to get into the chair and let us take you down to the vehicle. The sooner you move, the sooner we can get you the help you need.’
Despite her whimpering, and with anxious entreaties from her husband the other side of the bed, we haul her up and into the chair. She has pulled the mask off again. The oxygen hisses vainly into the air. Rae wrestles it back onto her face as I blanket her as best I can from behind. We know that Elsie is combative because her brain is being starved of oxygen. It’s a struggle to move this situation along, and we are aware of the clock ticking.
‘Can you take the bags down for us?’ I ask the husband. His big, crescent moustache, yellow with nicotine, emphasises the mournful expression in his eyes.
‘No. They look heavy. I’m not well myself, you know.’
‘Okay. Don’t worry,’ I tell him, measuring out this effort of control word by word.
Rae grabs the bags, takes them to the head of the stairs, throws them down to the first landing, then comes back to help move the chair. Elsie is at the limit of our lifting ability, but the adrenalin of the situation gives us the extra power we need. Down onto the first landing, I steady the chair whilst Rae throws the bags down into the lobby. A neighbour has come out to see what all the noise is about.
‘Can you collect our bags and carry them out to the vehicle for us?’ I shout down to him.
‘Sure. I’ll just get my shoes on.’
Every little detail is in sharp focus. How each factor may help or hinder us.
We have Elsie outside now. When her breath allows she gives fearful moans. I drag the chair backwards across the lawn. It’s good to be outside; my shirt is already sticking to me. At the back of the vehicle I move the chair into position, climb into the back, and we dead lift Elsie inside. Alongside the trolley, Elsie refuses to move out of the chair.
‘Look at me, Elsie. We can’t go anywhere until you get onto the trolley. You have to do this. We’ll help.’
We count one, two, three, I tilt the chair forwards, and we manhandle Elsie’s bulk onto the trolley. I pull the chair off to the side and then with shaking hands find a nebulising mask and a couple of vials of salbutamol and atrovent to help ease her breathing.
Rae says: ‘She’s gonna go on us.’
I fumble, trying to work even more quickly, but then:
‘She’s gone.’
At the same time Rae has dropped the trolley into a flat position and thumped Elsie in the middle of the chest. The back of the vehicle opens and the husband peers inside.
‘Can you shut the door please?’ Rae shouts over her shoulder. He retreats.
I throw the mask and drugs to the side and pull an airway out of a side drawer whilst Rae rips Elsie’s nightie apart and slaps some defib pads on her. I try to get the airway into Elsie’s mouth, but her jaw is locked tight – probably a hypoxic fit. I toss that aside in favour of an airway that goes down through the nose, as Rae looks at the ECG – some waveforms, but there is no pulse, a condition called PEA, or pulseless electrical activity, which is, in effect, no activity at all. I pull the BVM out of the resus bag and start trying to force air into Elsie, but her airway is blocked. Rae interrupts the chest compressions she has been doing to flick the aspirator on so that we can suck out the vomit that’s clogging up her airway. As we do all this we discuss our options – Rae needs to cannulate so she can start up with the necessary drug therapy; she also needs to intubate, which we know will be difficult as Elsie has such a short, fat neck. We also need to call for back up. I take over compressions and ventilations whilst Rae gets her equipment out. She cannulates quickly, blood spilling onto the floor. These are hurried, pressurised moves. We are aware of Elsie’s husband waiting outside the vehicle, but awareness is all that we have at the moment. There is no time for sympathy. I interrupt CPR just briefly to help Rae try to visualise the vocal chords, but two attempts both fail – the tube goes down into Elsie’s stomach, and trial ventilations only serve to drive up more vomit – more to suck out. Rae takes on the CPR whilst I jump out of the side door and climb into the cab to radio for assistance. I punch the priority button, and when Control answers I simply say:
Resus in progress on the back of the vehicle. Back up to this address, please.
I hear them say that support is on its way from quite a distance. It will be a judgement call whether to run as we are or stay and wait for help.

Fifteen minutes later and the second crew is with us around the patient. The back of the vehicle looks just as if it the ambulance had rolled down an embankment and landed back on its wheels. There are empty syringes, dressings, tubes and blankets scattered around us. Elsie is spread massively across the trolley, arms and legs over the sides. In any other context you would think that this was simply a restless sleeper, but here, in this cramped and clinical chaos, the posture is the undignified sprawl of death.
The second paramedic agrees that the cardiac rhythms we are seeing on the ECG are the random firings of a heart artificially goaded by the chemicals we have shot into her. There is nothing viable here, but we all decide to run to hospital anyway. The other technician says she will take the husband in her ambulance. I jump out into the cab for the second time, pass a brief summary of the situation through to Control, and then drive on blue lights to hospital.

‘My God! This couldn’t be any more difficult!’
The medical registrar at the hospital has climbed on board to assess Elsie. He picks his way through the detritus of the incident with the fastidiousness of someone simply used to more room.
‘I can’t imagine having to intubate in these circumstances. And I have to agree with you – this patient is a definite Category Four.’ This means that even in an operating theatre, using fibre-optics, they would intubate with difficulty. Elsie is declared dead, and the form signed.

When the second ambulance arrives a few minutes behind us, the charge nurse takes the husband to the relatives’ room, gives him a cup of tea, and prepares him for the worst. The nurse tells us afterwards that he had said: ‘I know. I saw them jumping up and down on her chest. I knew it wasn’t good.’
Rae and I realise that the husband will want to see Elsie before we take her off to the Mortuary, so we tidy her up as best we can, and make the vehicle presentable. When we are ready, we send word to the nurse, and he leads him out. We help him onto the vehicle, and he collapses in tears across her. We leave them alone for ten minutes or so, then we help him into a chair to talk about what happened and what we tried to do. We tell him what to expect now, and leave him in the care of the charge nurse.

It’s just after midnight. I ring the on-call Mortuary Attendant. He tells me that we are to admit the patient ourselves. We drive back to base and collect the keys, then head out to the Mortuary, which is located at the end of a discrete driveway inside a large municipal graveyard.

Inside the Mortuary there is bank of fridge cabinets four high and five deep, with a separate section for longer term residents. Each occupied compartment has a label in the door; we identify an empty compartment, then I fetch over the mortuary forklift – something like a pallet truck, with a large white tray suspended in front of it. I raise it up level with our trolley, and with some effort we roll Elsie on to it. Rae goes over to a Victorian-looking ledger, and I shout out the items of jewellery that Elsie is wearing for her to write down. Gold watch, gold chain, wedding ring, ear rings. Her bag of medication, slippers and other things we put in a bag and place this on the tray between her legs. I tie a label to Elsie’s left big toe: her name, date of birth etc. Another label goes in the door. Then I manipulate the forklift into position, and open the door. There is a hard, metallic smell to the fridge, something like a cold, well-cleaned butcher’s stock room. We count to three and then slide her in, feet first. Her arm lolls out to her right, so I reach in to replace it by her side. It lolls back out again. It won’t catch in anything, and I can’t think how to secure it, so I leave it there. The other people in the fridge are all wrapped in white plastic, with only their heads showing, but we haven’t the time or the expertise to do this with Elsie. She will have to wait the few hours till morning. I move the forklift back, and we shut the door. It swings to with a clunk.

Thursday, October 04, 2007

manhattan by night

We’ve just cleared up from our first job of the evening, way out in Oldport. A man had been dancing along the pavement outside his house, playing his tin whistle, when he fell down an uncovered manhole and scraped his shin. I was surprised that he escaped with such minor injuries. He lay contentedly sprawled on some tie-dye cushions like some down-at-heel sultan whilst his girlfriend talked – with worrying intensity – about infection, fractures, compartment syndrome. I had cleaned the graze and offered some reassurance whilst the man stroked his wispy black beard and stared down at me lovingly.

Back in the cab, finishing off the paperwork, I put the cab light on. The grey evening sky is plump with rain; thick spots begin to rattle down on the cab. And then a red call comes through on the terrafix: along with the address, the description of the problem reads Man with bag on head. We laugh, just as Control calls up on the radio asking us to advise and assess as this patient is possibly deceased. I ask for the police to attend as well; Control tells me that they are already en route.

‘Are they all like this in Oldport?’ I ask Richard as he puts the blue lights on and we bully our way out into the traffic.
‘Absolutely every last one,’ he laughs. ‘But the houses are affordable.’

We pull up outside the address, one of a long row of light coloured semi-detached houses, each one only differentiated from the other by the colour of the door and the condition of the little white wooden balcony over the living room window. Through the downpour I can see two men standing hunched over mugs in the doorway. I jump out, haul out the resus bag, and then walk over to them.
‘Hello,’ I say briskly, ‘What’s the problem?’
Whilst one of the men stares at me, glassily white as his mug, the other takes a bracing sip and then turns to lead me up the stairs.
‘We’ve been away for the weekend’, he says. ‘We came back and found him like this.’
‘Is he a relative of yours?’
‘A friend.’ And opening the little bedroom door, he stands aside to let me through.

There is a naked man lying on his back on the bed over by the window. He is obviously dead. Even through this sixty watt gloom I can see the post mortem staining – the blotchy tide mark on the underside of his body where the blood has pooled. But then, without this marker, there would still stretch out a profound distance between us, the living ones at the door, and the dead one posed and frozen over there on that bed. The difference resonates on the chill air as the rain rails down outside.
As I walk into the room I check the details: a clutter of little plastic popper bottles and something that looks like a small thermos flask around his feet; his penis lolling darkly up onto his abdomen from its tightened scrotal sack; his arms fixed upright, crooked ninety degrees at the elbow, his hands and fingers delicately curled. I am reminded of Millais’ portrait of Ophelia, drifting off to her doom on a dark river. But whilst that Ophelia wore an expression of sensuous detachment, this one is racked by a monstrous Elvis sneer, and for a second I wonder why - until I understand that he has something stretched tightly over his head, nose and mouth.

Richard stands beside me. ‘Whoa!’ he says.

‘Isn’t that – a condom?’ I say.
The nipple shaped crest, designed to catch his ejaculate but filled here instead with a quantity of stale air and some nitrous oxide, pokes up like the button on a joke policeman’s helmet. Through the translucent rubber bubble the man’s eyes stare out at us, his eyelids half-closed.

Richard nudges me, and gives an infinitesimal shake of the head to let me know that he doesn’t think I should mention the condom again.

‘Could you go to the vehicle and ask for an ETA, please?’ he says, pleasantly. And then leads the friend back out of the room to ask him further questions.

I pick up the resus bag and turn to follow them out. My last impression of the scene is of the picture that hangs above the man’s bed, a cheap, gold-framed print: Manhattan by night.