Algorithms

His shoulders are slouched and his eyes are heavy with sleep….and something more. The moment I catch sight of him, I realize something is terribly amiss. There’s only one reason that my normally bright-eyed co-worker is in plain clothes in the ER at midnight on Christmas. I catch his eye and his determined march down the hallway slows and eventually stops.

“You know her?” I ask gesturing to my left with my head, indicating the patient I just brought in lying no more than 10 feet away in the hospital bed, an array of medical professionals hurriedly working to stabilize her. He nods in response, more of a quick jerk downward with his head verses a full nod but he seems unable to form words as he looks past me to the lifeless woman nearby. He’s avoiding eye contact. My heart is sinking and the knot in my throat is growing exponentially.

“What happened?” he finally asks, barely above a whisper.

“She told her husband she wasn’t feeling good. Then she collapsed.” I spare him the details for the moment but I know there will be more questions and explanations to come. “I’m sorry,” I mumble. The room is suddenly suffocatingly hot.

“The family is here,” he says, still avoiding eye contact.

“I already let the doctor know,” I reply. “He said he’d be out as soon as he can.”

“I need to go see them,” he tells me, and wanders off in the direction of the waiting room.

In his absence, I realize that I haven’t taken a full breath since I first saw him and I attempt to fill my lungs but the air gags me and I can’t shake the sharp pain that sears through my chest as I watch him amble away.

It’s not supposed to be like this. There’s supposed to be happy endings. I went to paramedic school to save lives…right? I think back on the nearly 12 years since I got my certificate and I can’t think of a single time I’ve actually SAVED someone’s life. I’ve had moments on the precipice of glory when I think that everything will work out. That I’ll get the call a few weeks down the road that the family and/or patient wants to meet me and thank me for giving them a renewed opportunity at life. But it never happens. The only call I get is that one several hours or the next day that says they died. So, I’m left with the singular hope that I’ve at least made a difference. That even in the tragedy I dealt with it with dignity & that when the grieving family and friends look back on those horrible moments when my life intersected theirs, that they will remember me for doing the best I could and that I made them feel like they were important too.

My mind rewinds to the moment when we first received the call less than an hour ago. The temperatures outside were subzero & I was nestled under my fuzzy blanket back at quarters where I had snuggled in well over an hour before, hoping for a quiet night on the cusp of Christmas. My partner and I hashed out the call arrangement a few hours before when I had first come on shift and I knew that no matter what the first call was, it was mine to lead and ultimately write the report for.

Childbirth? A drunk? Car wreck? Seizure? No. Unconscious female. Or so that’s what the pager said when it first screamed to life on the nightstand a few inches from my head. Not having had time to quite hit the REM stage of slumber, I scrambled to my feet almost immediately before my mind could object while simultaneously flipping on the bedside lamp. The next 30 seconds are a blur. As is the case with most nighttime calls, they played out in robot mode…my body moving long before my cobweb brain could interpret what was going on. Pants? Check. Don’t forget to do up your zipper. Pager clipped to belt? Check. Glasses on. I struggle with getting the hair tie off my wrist and pulling back my hair into what will probably be an epically sloppy ponytail. Where in God’s name is my phone? Put that in my pocket. Boots. They’re near the door. Half-running, I step into them and zip the sides. My hat? I need that. It’s freaking cold out. And my sweatshirt. For whatever reason, I can’t get it pulled all the way down. I hear my partner open the door of the station and soon after the garage door open. Forget it. I race outside with my sweatshirt still in my armpits. The cold air hits my lungs the moment I step over the threshold and somehow, I stagger to the ambulance without falling, still struggling to right my stubborn sweatshirt.

I clamber into the passenger seat as the words come across the radio “Agonal breaths.” Every paramedic and EMT knows the significance of those words…especially me. I teach all the time about their meaning and I’ve been on far too many calls that come in as “unconscious” individuals but ultimately turn out to be patients who have gone into full cardiac arrest. “Agonal breaths,” also known as “guppy breathing”, those resembling a fish out of water, represent the brain’s last efforts to keep someone alive…just after their heart has stopped.

My partner offers me a sideways glance as well pull away from the station. “I don’t recognize this address,” I tell him as he swings right onto the main street.

“I don’t either. I’ve got it up on the GPS,” he says as I flip on the emergency lights and the siren screams to life. “I knew we’d get a code tonight.” Although he’s focused on the road and I can only make out the profile of his face in the darkness, I can hear a sprinkle of excitement in his voice. These are the calls that we train hardest for, and, somewhat sadistically are my favorite.

“It’s code season,” I reply, mentally preparing myself for what lies ahead.

Code season. That unavoidable time of year, generally from November through February, in which it seems that people unsuspectingly drop like flies. It’s a medical phenomenon but it plays out in jurisdictions nationwide as the holiday season picks up full swing. I rack my brain for a brief moment on WHY that’s the case but when the answer doesn’t come to me right away, my mind shifts back to the situation at hand as my partner makes a sharp left onto a narrow snow-laden street in the older section of town.

“It’s over here?” I ask, obviously puzzled. How can it be so close to our station yet I’ve never been there? I can see the fire engine rambling towards us. We’re converging on the same narrow thoroughfare and my foggy brain still hasn’t processed exactly what’s going on. As our apparatus inch closer together in what looks like an emergency vehicle game of chicken, our flashing lights catch the street sign. We’re there. As we carefully turn onto an even narrower street with larger piles of snow, a yellow sign rears its ugly head, “NO OUTLET”. I came to dread long ago such signs. “NO OUTLET”. Turn this way, and you’re trapped. And if that stupid GPS steered you wrong, you’re going to look like a fool driving out the same way you came in. As we turn down the narrow street which appeared more like a driveway than an actual public street, the street lights gave way to darkness. In the distance, under snow-covered trees a few lights from various houses nestled in this seemingly foreign neighborhood twinkled through the night. There were no obvious indicators of anyone needing emergency help. No porch lights to beckon us. No frantic bystanders. As our ambulance crawled through the deep snow we peered out, looking for anything that would guide us to our patient in distress. Nothing. A slew of curse words from both myself and partner pierced the mounting, tense silence in our ambulance. The GPS sat uselessly on the dashboard. Finally, we chanced a driveway on our left…and struck out. Another wave of curse words burst through the ambulance as we struggled to turn our truck around. Hitting buttons on our GPS, we fought with it for answers on where our patient could be. The fire truck which had finally navigated onto the narrow street and law enforcement vehicles, were closing in on us. More curse words. Someone was dying (was technically already dead) and none of us could discern the poorly marked addresses in this section of town. The frustration was tangible. As we inched our way further down the street with no outlet, our lights bounced off another house. It was the last one on this road, there were no other options. It had to be the one. No house numbers were visible but I launched from the truck as my partner put it in park.

“Go! I’ll get the equipment!” he shouted at me. I was already on the front steps by that time. How had I traversed 30 feet of icy sidewalk and stairs in the span of time it took for him to spat out those words? The fire captain emerged from the darkness and joined me. I knocked then almost immediately tried the knob. It was locked. Curse words. And then, from the depths of the house, an elderly man, running toward us like a rabbit scared from its den. I marveled for a brief second at his agility as he quickly unlocked the door.

“She’s in there,” he gestured wildly with his right arm as the captain and I pushed past.

“What’s her name?” I asked as I rounded the corner into the dining room and saw an elderly female lying limply on the floor wearing a bathrobe.

“Larry,” he said, obviously mistaking my question. I didn’t have time to ask again before one of the many law enforcement officers burst through the door and ushered him toward a back hallway.

As the fire captain felt our patient’s neck for a pulse, I single-handedly pushed the dining room table up against one wall and out of our way. It would soon become part of our work space too and I still can’t figure out how I moved it all by myself as the captain drug the patient into the now-vacant space in the center of the room.

Two more firefighters and my partner burst through the door with equipment of various kinds and the room was instantly transformed into controlled chaos. Medications. Airway management items. A CPR device. A cardiac monitor. A firefighter started chest compressions. More law enforcement came through the door but veered left down the hallway where the patient’s husband had been taken.

I knew the drill. I taught this stuff all the time. I had not only performed this scenario on literally hundreds of occasions but I had coached countless numbers of students through similar ones, possibly thousands of times, in a classroom. To say this was second nature, was an understatement. In spite of my familiarity with what needed to be done, I suddenly recognized the sound of my heart pounding in my ears & my face felt hot. Keep it together, for the love of God. What in the world is wrong with you? Breathe. I conscientiously slowed my breathing & the sound of my heart disappeared.

Part of me felt guilty that this was such a perfunctory call. So perfunctory in fact, that they are referred to by algorithms. A woman was dead in front of me. Someone’s grandma, mother, wife, aunt, sister, friend. But to me, she was an algorithm. I pushed those thoughts away as I charged my monitor and delivered the first shock in an attempt to jolt her heart back into controlled, life-giving beats. More chest compressions. IVs. Medications. Two minutes. Pause to check my cardiac monitor again. Asystole. The ominous flat line…death. Complete and utter nothingness. More chest compressions and medications. Clinging to desperate yet quickly-fading hope. Rarely anyone comes back from the flat line. In the movies, that’s what they always show when all hope is lost. And even though this wasn’t the movies, we knew the reality of what that line represented. But there was still work to be done, we aren’t allowed to just stop there. Twenty minutes. That’s how long we minimally have to run the algorithm. Twenty minutes…an eternity when CPR is being done.

The algorithm of compressions and medications continued. Another brief check of my cardiac monitor. The line remained. I cursed silently. Not on Christmas. Why do I have to tell her family the news on Christmas. “Sorry. We’ve done everything we can but we can’t restart her heart. I’m sorry for your loss. Can I do anything for you?” I’d rehearsed these things a million times in my brain. They even give you training on how to tell family and friends that their loved one has died. But it’s never any easier no matter how many times you rehearse, train, or actually do it. In those harsh moments, the algorithm has ended. All that is left is the reality that that algorithm was indeed a huge part of another human being’s world.

She’s 71. My mine calculated the odds of what lie in front of us. “Stop thinking about it,” my brain shouted at me. “Remember the algorithm. You still have 14 minutes left.” I bit my lower lip to keep the rush of curse words contained. It was as if they were a flurry of fists pounding at my vocal chords. I swallowed hard to force them away. “Do your job. Just do your job,” my brain silently coached.

Another quick pause after 2 minutes to glance at my cardiac monitor. Wave forms. Rapid, succinct wave forms. A simultaneous but silent rush of astonishment fell over the room.

“Does she have a pulse?” I asked the fireman closest to her head. He reached up and felt along her jugular.

“No pulse,” he said, instinctively resuming the chest compressions.

I’m sure my mouth twisted in some contorted display of frustration. “Please, God. Don’t make me have to tell her family,” I silently prayed.

Two more minutes of the algorithm ticked by.  I quietly reviewed my notes that were scrawled across the small notebook I kept in my pocket specifically for these calls. Any other calls, the latex glove across the back of my hand was sufficient for notetaking but the algorithm required more writing space than what the back of my hand could offer. Hence, the notebook. There was really no need to look at it. I knew what I’d done and what still needed done lay clearly out in front of me. With 10 minutes to go in the algorithm, I chanced another glance at my cardiac monitor. The succinct wave forms continued their hurried march across the screen.

“Does she have a pulse?” I again asked the firefighter.

As his fingers made their way along her jugular, the look of desperation in his eyes shifted. “I feel a pulse.”

A long pause as we tried to wrap our minds around what was unfolding in front of us. None of us thought this would be the outcome.

“Do you want us to get the backboard so we can move her out of here?” the fire captain asks me. Somehow, he has ended up by my side.

“Yeah. Let’s do that,” I reply, pushing away my surprise. A flurry of activity ensues. “Keep your finger on her pulse and make sure it doesn’t go away,” I direct the young firefighter crouched at her head. His eyes connect with mine in a sort of silent reply as he obediently does as I have requested.

While we quickly begin arranging our equipment and dragging in a backboard, his words cut through the chaos, “It’s slowing down, Amber.”

A quick glance at the cardiac monitor confirms our fears. I grab a syringe of atropine from my medication bag & quickly administer it through her IV. Before I can finish, his words again find their way through the activity unfolding around us, “It’s gone.” Once again, we resort to relentlessly compressing her chest, back in the algorithm.

As 2 minutes give way, a brief pause to look at our monitor again shows rapidly firing cardiac waves and a faint pulse is felt. As my partner and the firefighters quickly resume loading her onto our backboard, then onto our cot and into the ambulance, I dial the ER to give them a heads up that we will be there shortly so they can have a team waiting to intervene the moment we come into the hospital. As the ambulance picks its way down the narrow street, the faint pulse once again disappears. Compressions, medications, silent curses. As our ambulance pulls into the garage at the hospital, I ask the same fireman who somehow has still managed to remain at the patient’s head through it all, to again check her pulse. To our exhilaration, it has returned. This time, the firefighter says that it is strong. We rapidly unload her from the truck as the first of many ER personnel meet us. We wheel her into the brightly lit ER room.

“Everyone be quiet as we get her moved over,” the ER doctor loudly directs the team. He then turns his exclusive attention to me as I relate the events that have led us to this point…the algorithm.

A flurry of activity again unfolds in this new place but our patient maintains her pulse. I shrink into the corner, out of the way, as I typically do in these types of situations. I wait a substantial enough time for the doctor to ask questions and collect our equipment, then, as I make my way from the room, I catch sign of my off-duty colleague.

The algorithm again reared it’s very personal, human head. And this time, I could not shake it. I caught sight of my partner and wandered toward him, unsure of what I hoped to gain in talking to him. “He knows her,” I mouth to him as we both watch our crestfallen co-worker wander out of sight.

“I know,” my partner says much more aloof than I currently am. “I have the ambulance almost all put back in order, I’ll have to do some restocking back at the station.” Then he wanders off while I finish up my paperwork.

Before I can make my way from the ER, my off-duty colleague is back with his fiancé. I can’t dodge them so I tackle things head on. He is still struggling to take in being on the receiving end of what would normally be a common situation for him. I hug him and again offer my condolences but they do nothing to soothe any of the ache we are all feeling. We know that the patient is still in a precarious condition and that, until she wakes up, we cannot know if she will fully regain the capacity she had before her heart so cruelly shut down on her. Under his request, I offer a brief recap of the details of the call, finding it odd that I don’t have to weed out my medical jargon. He takes it all in, as stoically as possible. “She’s trying to breathe on her own right now,” I offer in hopes that it will help lift his spirits. But we both still recognize the reality and it does little to stifle the concern we both still have.

“I need to get back in service,” I finally say when the silence becomes uncomfortable. I again hug him and his fiancé and make my way from the ER without looking back.

Back at the station, the ambulance restocked and the paperwork complete, I crawl into bed and fight for sleep. As I toss and turn, my phone lights up in the dark, piercing the comforting quiet. It is the ER tech, a friend of mine, texting me. The message read, “They took her to cath lab. She didn’t make it.”

More curse words, this time out loud in my silent bunk room. I turn over as my heart breaks anew. There isn’t going to be much sleep tonight at all. I think of my co-worker, the patient’s family and friends. All of them having been hoping for a Christmas miracle that never came. A miracle of which I was to be a large facilitator. My brain snaps back to 4 hours ago when my pager first screamed to life in this very room. I recap all of the details that unfolded since then and pick apart minute details, questioning everything and wondering if there was anything I’d done wrong. Eventually, pure exhaustion extinguishes my whirling brain and I fall asleep.

A few short hours later, just before shift change, my alarm wakens me. I slowly crawl from bed, knowing I’m going home to my family and sourly thinking about all the people who wished my patient was going home too. As I drive home on this snowy Christmas morning, open my front door and catch sight of the bright-eyed children playing just inside, my spirit lifts a little. I hug all of them, then wander into the kitchen to make a cup of coffee.

Long ago, a wise preceptor once told me that caring was good because it meant that what I did mattered to me. And if my work didn’t matter, there wasn’t any point in staying in it because I wouldn’t do the best job possible. But he also reminded me that it was important not to let it dominate everything I did and make sure I tried to get back to normalcy as soon as possible. So, I pour my coffee and make my way back to the other room where I watch those joyful young kids play, far away from the heartache of the world beyond.
I know there will be more calls like this one. And each of them will have their own heartaches and challenges. But nothing replaces the opportunity to try to make a difference...no matter the phone call I get when everything is said and done.