DWPA (Dead With Paramedic Assistance)
In this exclusive book excerpt from ,"A Paramedic's Story: Life, Death, and Everything in Between," Kelly Grayson looks back at one particular call
His name was Frankie Maryland, and he was 25 years old when we first met. He still comes around to visit me occasionally, usually when I'm feeling pretty cocky. He reminds me that I'm fallible, that I make mistakes.
Frankie was black, well over six feet tall and 250 pounds, and a pretty good linebacker during his high school days. His friends would tell you he was a funny guy, the kind who was quick to loan money to a friend, and then forget about the debt.
His friends weren't the most reputable people around, but Frankie was extremely protective of his younger brother and sister. He didn't bring his friends around the house, and he was pretty strict about who his brother and sister ran around with.
Frankie and his siblings lived with their aunt, a single woman with no kids of her own. Carlotta raised Frankie and his little brother and sister since Frankie was eight years old, when their mother abandoned them and ran off to Detroit with her dealer.
I first met Frankie on his 25th birthday. He wasn't having much fun, the festivities interrupted by gunfire from persons unknown. Frankie took a round in the belly.
I was called to Fort Sperry at 3:30 am that morning to transfer Frankie to West Oneida Regional Medical Center for exploratory surgery. I was tired, groggy, and in a foul mood. They called me from Mason Ferry to make this transfer while the Fort Sperry crews slept comfortably, less than a mile from the hospital.
I only half listen as the nurse gives me report.
Blah, blah, blah...BP 100/52...blah, blah...two IVs, good for you...blah, blah, blah...oxygen at two liters, yeah you people think oxygen is a poisonous gas...blah, blah...combative, huh? Well, can't blame him. I wouldn't be happy about being in this Band-Aid station either...blah, blah, blah...restrained on a long board...blah, blah...yeah, you too. Thank you for calling the big white taxi.
Fifteen minutes into the trip, I was taking vital signs and I couldn't get a blood pressure.
No big deal. It's hard to hear in the rig. I'll just palpate one.
While I was trying unsuccessfully to palpate a blood pressure, Frankie moaned and said, "I'm gonna puke."
"Just hold on," I told him, scrambling for an emesis basin. "Take deep breaths."
He did just that, as I found an emesis basin and set it beside me on the seat.
We were evaluating a new vital signs monitor, so I figured then was as good a time as any to try it out, and I wrapped the cuff around his arm. As the cuff inflated, Frankie moaned again and vomited before I could get the emesis basin under his chin. It was pure, bright red blood, and there was a lot of it. Frankie heaved again, and more blood fountained out.
Holy shit! Where was all this blood coming from?
I scrambled to loosen the straps and tilt him on his side with one hand, while reaching for the suction with the other. He was too big to tilt with one hand, so I yanked at the suction tubing to untangle it, then dropped the suction tip on the seat.
I grabbed him with both hands and rolled him onto his side, and the blood drained out of his mouth and puddled on the floor. His eyes were rolled back, and he was making horrible gurgling sounds.
God, he's aspirating this stuff right here in front of me!
I jammed the rigid suction tip into his mouth and flipped the switch, but nothing happened. In my haste, I had pulled the tubing loose from the suction canister. I hurriedly reattached it as Frankie vomited again. I was having trouble tilting him and working the suction unit at the same time.
I applied suction, and watched the blood creep up into the suction canister at an agonizingly slow rate. Frustrated, I yanked the catheter tip off and stuck the hose in his mouth and breathed a sigh of relief as the blood cleared. He still had a nasty rattle when he breathed.
I looked up at the vital signs monitor, and the blood pressure was only 72/40. The cardiac monitor showed a sinus tachycardia at 130. I pulled my knee from under the board where I had been attempting to prop him on his side, and put a non-rebreather mask over his face.
I opened up both the IVs wide open, but they seemed to be running pretty slow. I looked carefully at the lines and at both sites. Both of them were 22-gauge catheters - in the antecubital veins, no less.
"Goddamnit!" I blurted in frustration.
Who was the idiot nurse who put 22-gauge catheters in a trauma patient?
"Everything all right back there?" asked my partner, Terry Mitchell.
Aunt Carlotta was riding in the front passenger seat, and she had turned around in her seat, watching through the small window between the box and the cab.
"No, everything is not all right!" I shouted back at him in frustration. "Step it up! And call West Oneida and tell 'em he's crashing!"
"That all you want me to say?" he asked as he hit the lights and siren.
"No, but I'm too busy to talk right now. Just drive!"
I managed to see a little stretch of vein above the IV site in his left arm. I delicately inserted a 14-gauge and switched the IV line over, and it flowed quickly with no swelling. So far, so good. I was taping down my second line when Frankie vomited again. It was more blood, and it kept on coming.
Oh no, not that again! Please, please stop this. Where in the was all this blood coming from?
I stuck the suction tubing back into his mouth and reached with one hand for the airway kit. I grabbed a tube and stylet and assembled my laryngoscope, and without warning the suction unit stopped working. It was still making noise, but it wasn't clearing his airway anymore. I looked disbelievingly at the full canister. "Goddamnit!" I shouted. "Don't do this to me!"
Jesus Christ, that's what, more than a liter of blood in just a couple of minutes? And his heart rate was only - Oh God - forty-four beats a minute! What was I supposed to do now?
I'm not sure if I was screaming at Frankie or fate, but I kept shouting as I hurriedly tried to intubate. "Frankie! Frankie! Can you hear me? Stay with me, man. Hang in there!"
I couldn't see the airway through all the blood. I tried to scoop out as much as I could with my fingers, but it only welled back up as soon as I scooped it out. I tried to empty the suction unit, and dumped the entire canister into the biohazard bag, but when I reassembled the unit, it didn't work.
Apparently I had put it back together incorrectly in my haste, and I snarled, "**** me!" as I gave up on using the suction unit. Frankie still had a pulse, but it was a faint one. He wasn't breathing any more.
"Frankie, stay with me!" I shouted at him, my voice rising. Even I could hear the fear and desperation in my voice. Aunt Carlotta was sitting in the front seat, watching, but I couldn't shut up. "Goddamnit, don't you give up! Hang on! Damn you, you sonofabitch, you will not die on me!"
I tried again to intubate, and still could see nothing.
**** it! I was blindly inserting the tube. If it went into his trachea, I'd have an airway. If it went into his esophagus, at least the blood would come out the tube and onto the floor.
Sure enough, the tube wound up in his esophagus. The blood wasn't coming as quickly as it was before, just slowly oozing up out of the tube, but then I didn't imagine there was too much blood left.
I felt for a pulse as I reached for another tube. He had one, I thought. The cardiac monitor showed a rate of 36 in an ugly idioventricular rhythm.
I was just getting ready to try another intubation attempt when the back doors flew open. We had already backed into the ambulance bay, and I hadn't even noticed. Terry looked scared. I couldn't even imagine what I looked like right then. Carlotta was standing off to one side, sobbing uncontrollably. I tossed the tube, BVM and laryngoscope onto Frankie's chest, as Terry got the IV bags. They were both nearly empty.
The doctor met us right inside the door. I didn't recognize him, but he didn't look pleased with me. Right then, I couldn't have cared less. The doctor looked at me, at Frankie and at the tube and started yelling. "What the hell is going on here? What happened?" He hooked up the BVM and squeezed it once, auscultating Frankie's stomach as he did. "This tube is in the stomach!" he said angrily.
"Wait, don't pull the-" I started to say as he snatched the tube out, but I was too late. "Well, that's just great! Now try to get an airway! Idiot!" I screamed at him, spittle flying as Terry wrestled me away.
The doctor and several nurses wheeled Frankie hurriedly into a room. I calmed down enough to see that everyone had stopped what they were doing, staring at me uneasily. I looked down at myself to see that I had great smears of blood all over my uniform shirt and pants. There was blood all over my forearms. Aunt Carlotta acted like she hadn't heard a thing, standing behind us sobbing quietly.
"Come on, Kelly. I'll buy you a Coke," Terry said quietly as he steered me into the nurse's lounge. He said nothing to me as I cleaned up at the bathroom sink. A nurse walked in a bit later. She handed me a scrub top.
"Here. It's about the only thing we have in your size." I nodded gratefully and ducked into the bathroom to change. My eyes were red, as if I had been crying. I couldn't remember. When I came back out, the nurse was still there. "You okay?" she asked me, concerned.
"Yeah, I guess so," I sighed shakily. "Is he gonna file a complaint?"
"Nah, I doubt it. He's not really a bad guy. You just took him by surprise. I think he thought you were gonna flip out and whip his ass. We all tried to convince him you weren't really unstable." She grinned at me and winked. It worked - I felt a little better.
"Thanks. How's my patient?" I asked her, dreading the answer.
"We called it about five minutes ago," she said softly. "Never did get an airway," she added, as if this would make me feel better.
"Yeah, I figured that. Well, thanks for the scrubs. I appreciate it," I told her as I turned to leave. She shrugged as if to say, "Don't mention it."
Outside, Carlotta was leaning against the wall, smoking. She had stopped crying, but I couldn't face the look I'd see in her eyes. I tried to slip by her as if I hadn't seen her, but I felt her hand on my arm as I walked past, and she gently turned me to face her. I just stood there, afraid to say anything.
She reached up and pulled my head down to her shoulder, and put her hand on the back of my head. "It's okay," she whispered in my ear. "You did all you could. I know you did your best." She held me there for a few seconds longer and then grasped both of my arms, forcing me to meet her gaze. "Really," she said seriously. "Thank you." I nodded dumbly and walked away.
Terry and I didn't talk on the ride back to Mason Ferry. The sun was coming up as we pulled into the station. I walked alone into my bathroom and turned on the shower. I sat down under the spray, arms wrapped around my knees, rocking and crying uncontrollably. I rocked and shook and wept for I don't know how long, then quietly dried off and climbed into bed.
Frankie Maryland died on his 25th birthday, seventeen years ago. It was my fourth call as a paramedic.
- Airway Management