Lately this blog has been my cathartic dumping ground while I reconstruct my career, and this post will be no different.  The events that I am about to describe have haunted me for years.  I am almost 40 years old, and it is hard to change gears and start in a new direction.  This may be why I keep looking back to the past to try and categorize my feelings and thoughts.  When you are twenty-something years old the thought of doing something as self-absorbed as writing your memoirs seems conceded and absurd.  But, at my age, that’s not the case.  I don’t think what I have to say is best seller material, but this blog affords me the opportunity engage in my little mental ’show and tell’.  I have seen a lot of death and destruction over the years, and it seems silly to simply take these experiences with me to my own grave.  Why not let someone else get freaked-out and haunted as well?

Overdoses at assisted living facilities are more common than you would expect.  One reason is that elderly people who may be disoriented are still allowed to keep track of their own medications.  There is more assistance with living at these places than there is assistance with healthcare.  However, this case was not going to be the average overdose run.  It was originally dispatched as an unconscious/unresponsive patient.

We arrived to one of the upscale assisted living centers in our district.  The apartments in this place were nicer than what I was living in at the time.  Okay, nicer than what I live in now.  The extended family was already on scene, which can never be a good thing.  Four or five family members were pacing around the living room looking worried or quietly crying.  I pushed the cot past them into the bedroom.

The patient was lying on the bed, fully clothed.  The room was spotless and neat, as was the rest of the apartment.  All of the patient’s medicines were neatly placed on the nightstand next to a glass of water.  A stack of photo albums was nearby along with a couple of shoeboxes filled with more photos.  It didn’t take a rocket scientist to figure out that this overdose was intentional.  She had planned it very carefully.  And from the look of the drugs on the nightstand, she was going to be successful in her attempt to leave this earth.

We had arrived with a fire crew, and they had started bagging the patient to maintain the airway.  I stayed in the room long enough to find that the patient was bradycardic and hypotensive.  Nothing unexpected.  She was almost 90 years old, and I thought she might be a DNR, so I decided to go out and talk to the family a bit before I got aggressive with care.  Maintaining tact while talking to a family very quickly is difficult in situations like this, but I gave it my best shot.

I scanned the room and decided to approach the person who looked like the eldest son. “Sir, who called 911 originally?”

“It was me.  Is she going to be alright?”

“They are doing everything they can, but I need your help.  What were her wishes in the event that this happened?  Did she want to be placed on a ventilator?”

“She had filled out something like that before.  I am not sure about it though.  We want everything done that can be done.” The vacant look of denial was plain on his face.  “We want here to live.”

This was going to take some tact.  I knew he wasn’t that thick.  He must have known what she had done.  I decided to lay out one more hint, and then let it drop.  “I understand sir, but it is her life, and I am sure that you would want to respect her wishes.  If she had filled out any papers outlining her wishes, it would be helpful see them so we can do what she wanted.”

“I don’t know the location of any of those papers.  We want everything done.”  He wasn’t forceful or angry, just blunt.  And vacant.  He didn’t get it.

I went back to her room and pulled the bed out from the wall.  The firefighters were confused.  “What are you doing?” they asked me.

“I was told to do everything.  I’m gonna save her, I guess.”

“Dude…that’s wrong.  She’s like 90.  It’s obvious she wanted this.  They have to understand that, don’t they?  If my grandmother did this, I wouldn’t have even called 911 until I was sure she was finished.”

“I asked, and got shot down.  We’re fixing this.  Come on out and let me get back there.”

I got my airway kit and went to the head of the bed.  They had already placed her on the monitor and she was well into the 40’s with an occasional dip into the 30’s.  She was still breathing agonally, and our protocols called for nasal intubation.  I lubed up a 7.0 and gently inserted the tip into her right nostril.  A few twists and a push took me to that place a few inches in where you can feel the turbinates.  I gently twisted past them and advanced without resistance.  Then I waited for the next breath.  When it came I advanced farther and the deed was done.  It felt just like any other nasal tube I had ever dropped.  I confirmed breath sounds with my stethoscope and got obvious air movement on both sides.

With the airway secure I started to think about how to get her heart rate up.  A quick look at the monitor told me that more oxygen wasn’t going to do it.  I started to look at the meds on the nightstand, theorizing which ones were working against me.  I asked the crew to bring the cot along side the bed.

“Buck,” the voice sounded a little more frantic than usual, “something didn’t go right.  You better have a look!”

I turned my attention from the medicines back to the patient and was horrified to see one side of her neck bulging out like a balloon.

“Crap!  Stop everything!  Let me look…okay bag her once…again.  Damit, it sounds like it is in, but it can’t be!”

With each bag full of air, the balloon got bigger.  Her neck was swelling and it was starting move into her chest.  I pulled the tube and instructed my partner to bag her with a mask while I thought about my next move.

There was no resistance whatsoever.  I dropped it without trouble.  This was going badly.

“Oh my God, what happened?”  The son had come into the room.

At this point I wanted to just bail out the window and move to a different country.  The hair on the back of my neck was standing straight up.  My palms were drenched with sweat.  My face felt hot.  But it wasn’t about me.  It was about her.  So I sucked it up and looked him in the eye.

“Sir, there was an unexpected complication to a procedure I performed to manage her airway.  We are going to try another procedure and get her to the hospital shortly.”  It sounded good, but she still looked like a bullfrog and rice crispies were starting to form under the skin.  Yes.  Something had gone horribly wrong.

I was able to orally intubate her fairly quickly.  She gagged for a quick second but I was in and out before she could clamp down.  Now I had a perfect airway, but my confidence was shot.  This was before capnography was available and the way things were going, I wasn’t trusting my eyes or ears.  I listened.  I knew I was in.  The chest rose up and down.  Air went in and out.  The pulse ox shot up.  But the subcutaneous emphysema kept growing.

We raced to the truck and transported immediately.  I was able to get a line but atropine didn’t work.  The heart rate was slowing.  I applied the pacer pads to her chest.  The fire fighter who was with us was unfamiliar with pacing and thought I was going to shock her.

“No,” I explained, “I am going to use this to take over her heart beat and speed it up.”

The pacing worked and I was able to raise her pressure.  The air under her skin was getting worse though and now her face was hideously deformed.  Her eyes had swollen completely shut and it was hard to even discern a chin.

All too soon my partner shouted from the front that we had arrived.  We rolled in and the first thing that came out of the doctor’s mouth was, “What the hell is this?”  He rolled his eyes and just waved us down the hall.  The next few minutes were some of the most humiliating and frustrating moments of my entire career.  They grilled me about everything.  They questioned my tube.  Inexplicably, they turned off my pacer.  I protested, but they ignored me while her heart rate plummeted.

Finally I got aggressive and said, “Look, you all have already decided I am an idiot and that is fine.  But you just turned off the pacer that was keeping her alive.  Put away your attitude and look at that heart rate of 30.  Think about what you’re doing.”

The doctor ordered the nurses to pace the patient on the ER’s machine, but it took forever.  I left the room, disgusted and found another nurse outside to sign the chart.  I did my paperwork in silence on the other side of the unit.  I took one last look before leaving.  It is a picture I will never forget.  The pacer was sending rhythmic shocks to her limp body, making her arms twitch.  Her bloated and contorted face looked like dough.  Her features were unrecognizable.  This was in stark contrast to the image in my mind of her lying peacefully in bed surrounded by photos of her family.

On my next 24-hour shift I was scared to go to work.  I dreaded having to make another run.  The fear of not paying my bills won out though and I showed up on time.  Early that morning I caught our medical director walking through the bay and asked to speak with him privately.  We went to the captain’s office and I told him the story.

“How old was she?” he asked.

“Almost ninety.”

“Well, there is your problem right there.  Her sinuses are tissue-thin.  When you are getting an airway on someone that old, things sometimes happen.  I’m sure you tore right through something and started blowing BVM’s full of air right into her subcue space.  That is an unfortunate complication of the procedure.  As long as you say you weren’t pushing past some obstruction, you have nothing to fear.  It happens to the best of us.”

But I had trouble sleeping.  I couldn’t leave it alone.  Thoughts about this call became invasive.  I talked about it with a couple of co-workers, but they always said the same thing, “She wanted to die, man.  So what?  Sounds like she got her wish.”

But they didn’t understand what I was upset about.  They didn’t understand why I couldn’t sleep.  My wife started to notice that I was depressed and she finally confronted me with it.  I had been avoiding the subject and she had finally grown thin with my evasions.  “What the hell is bothering you?” she asked.

“Alright,” I said, “I’ll tell you.  I screwed somebody up the other day.”  I then proceeded to tell her the story.  Like most people I had talked to, she told me that it wasn’t my fault.  She saw that I was getting angry while she spoke and tried to be supportive.  “It wasn’t the fact that she died!  I don’t care about that!  She wanted to die.  I get it.  It was the way that she died.  She had lived to be over eighty.  She lived all those years and saw her husband die.  She saw all her friends die.  She got lonely and one day decided that was enough.  She sat down, looked through all her pictures, took some pills and tried to check out.”

“Yes, and her family put a stop to that.”

“True.  They did.  But I am the one that made it horrible.”

“What do you mean?”

“I took it away from her.  She just wanted to lie down and go to sleep.  She wanted to remember her kids and her grand kids and go to sleep.  And I shoved tubes into her, made her swell up into a hideous shape, shocked her body with the pacer, and made sure she died a long, slow, painful, humiliating death!”

Now that I had finally put words to it, I thought I was going to pass out.  I couldn’t breathe.  I couldn’t see.  I started to cry and stumbled into the bathroom thinking I was going to throw up.

In the end, that was it.  She deserved to die a dignified death, and I had taken that  from her.  I once took an oath to do no harm.  After I was done with her I am not even sure she was going to be able to have an open casket funeral.

My wife was finally able to calm me down.  But I had been holding that in for too long and the emotional hemorrhage had drained me.  All I could do was go to bed.  I woke up the next day feeling a little better.  Finally verbalizing it must have let some of the poison out of my body.  But there is still plenty left.

Looking back on this, there is nothing I could have done.  No moral to be learned,  I nasally intubated many people after that without trouble.  I don’t think I should have pushed the family further.  I don’t think I did anything stupid.  I was just in the wrong place at the wrong time.  There is no lesson to be learned here.  Just a recurring nightmare that wakes me up from time to time.  But most nightmares have that built in relief that comes when you wake and remember that it wasn’t real.  Not so with this one.  When this one wakes me up at night and the fog clears from my head, I remember that it really did happen.  And I roll over, close my eyes, and try to think about something else.