The Line

You’re a paramedic. You’re on your knees. A naked obese patient lies in front of you, their flaccid head in your hands as you try to position their mouth open. Watery vomit flows from between their lips. The monitor shows flat line. Every time your partner does compressions, more warm vomit spews onto your hands. The room is crowded with first responders looking to you to be in charge. You go in with your laryngoscope, but you can’t make sense out of anything you see. The tongue is massive. There is no neck. The airway is filled with brown watery secretions, and you don’t see the chords anywhere. You suction. You try not to puke yourself, and you think how just five, six minutes ago, you were sitting peacefully in your ambulance, reading a magazine, talking to your partner, eating a hamburger and fries and listening to Lynyrd Skynyrd on the radio, thinking how great is this job.

We’ve all been there.

Yesterday I was sitting in my area, sipping my Diet Coke and reading an interesting book about an EMT in London when I heard another ambulance sent for a “person on the floor.” Sometime later they call our number and say for us to head to the same address to back up that car on a code.

I like being in charge, but I will confess I am much more relaxed going to a code when I am backing up another car then when I am the first one in. When I am first in, I think, I hope it’s an easy tube, I hope there isn’t a lot of vomit and puke and shit to deal with, I hope it all goes smoothly. When I am backing up another medic, it’s like, hey, how can I help you. If there is shit, you’re kneeling in it not me. If the tube is hard, well, you have to deal with it first. I’m just there for support.

The address is clear on the far side of town, so it takes us awhile to get there. There is a fire engine outside. I have my partner check just to make certain it is another medic on scene and not a basic car. I didn’t want to go in without any equipment and have them look at me like where’s your stuff, you’re the medic. Dispatcher replies it is a medic unit.

It is an apartment building. I can hear the commotion behind the door, which is unlocked. And there it is obese no necked man on the floor. Vomit, shit, and the medic right where I have been, kneeling at the head, trying to get the tube, and calling for more suction. The patient is asystole.

“How can I help you?” I say.

He asks for some crick pressure.

I kneel by the head, carefully avoiding the secretions and try to apply some pressure on the neck to help bring the chords down into view. It doesn’t help. I take the tube from him and have him use his own hand to manipulate the neck to see if he can find the chords, and then I’ll put my hand there. But the mouth is filling with fluid, and he has to reach for the suction. I suggest he try a bougie, and while he gets that, I bag the patient with the aid of a firefighter. The medic tries to bougie, but it goes all the way down. He tries again to tube, but is clearly frustrated. I admit thinking glad you were here first, and not me.

There is a point of frustration. You can’t get the tube, you can’t get the mouth suctioned, poor IV access, and you just know the person is slipping across that line from which they cannot come back. You feel so helpless and frustrated. I think it is particularly hard for him because he is a new medic – one of our most promising ones – it’s not a situation any medic wants to be in.

I say, “Let me try.” And he gives me the laryngoscope while he goes to look for an IV.

I go in, and it’s like, I can’t see anything. “I need suction.” The mouth is full of blood and brown water. I suction away and look around and can’t see anything that looks like anything. I try the bougie, but it slides all the way down. I slip the tube over it, but it’s no good. I yank it, and then there I am, at the airway of the obese, no necked, vomiting person and I can’t get the tube, and its like I am back to square one – all my prowess out the window – all my I’m a veteran medic I always get the tube pride slipping away — and I’m thinking I wish I was back reading my book and sipping my Diet Coke.

Then I look at the laryngoscope and realize it is a Mac 4, not the shorter Mac 3 I always use, and I remember how when I was new, I often went too deep with the Mac 4, and that was why I switched to the 3. The person with no neck often has chords very anterior, and a Mac 4 isn’t always the best choice. So I switch blades, and I ask for a pillow, which I put under the patient’s head, and get him in the sniffing position, and I go in again, and I look for my landmarks and I see the epiglottis, and I lift up and out, and then amid the red and brown I see the bottom of the chords. I pass the tube, blow up the balloon, and yank the stylet. Nothing in the belly, equal breath sounds on both sides. I put on the capnography, but the machine says line blocked. I get a fresh capnography filter, but then the old one is stuck on the top of the ET, the top connection of which pulls out. So I just open up a fresh tube, pull off the tip and stick it on top of the tube in the man’s throat, and then attack the new capnography filter. With the first bag is a beautiful wave form.

I look at the number. It is 52!

Someone who has been asystole this long – we’re talking at least twenty minutes – considering his neighbor found him not breathing – you would expect to see the number around 4 or 5. 18 to 15 would be excellent. 52 is so high I don’t know what it means.

The patient is still asystole. The medic now has an IV in the patient’s left arm and is starting the epi and atropine. I have the firefighters take over CPR and counsel them in the new CPR, push hard, push fast, push deep. I have the monitor set up so they can see the wave form they are making with their compressions. I have them switch every two minutes. And they are pounding the compressions. Excellent CPR. Likewise, I have one of them be certain and bag only eight times a minute, and just a quick small tidal volume. We use the monitor to guide them. One of the EMT’s is getting the patient ready for transport, but I suggest that since he has been asystole this long, we just do 20 minutes and out. We all agree. Lives alone, lengthy medical history, unknown down time, if twenty minutes of ACLS doesn’t bring him back, transport is futile.

He is still asystole after the first two epis and atropines. Still I am puzzled by the high ETCO2 number. The research says the higher the initial ETCO2, the better chance to resuscitation, but he is so high he is past the good high level, into the bad high level. I can’t understand it.

A firefighter asked if it looks like we will need the police, who take care of the dead bodies. I say, yeah, go ahead and start them. It doesn’t look like he is going to come around. And then I see the CO2 go even higher. Its 70, then 80. We stop CPR. There looks like the beginning of a rhythm there. There is a rhythm.

“Check for pulses.”

“I’ve got a pulse.”

The rhythm is clear now. We do a blood pressure 190/ 110. I’ll take it.

Back from the dead.

Every time I gets pulses back, I think, you know, it really is sort of amazing. Everyone has that look of wonder about them. The fire fighters are smi
ng and nodding to each other. I think of all the parts of the code, the people who have the deepest connection with the patient are not the medics who get the tube and give the drugs; it’s the compressors, because they are the ones whose hands come closest to the patient’s hearts. Their bodies lean into the patient, they drive their strength down into the chest and then as they lift up, the patient’s heart recoils as blood rushes into it. The compressor pushes down again as their sweat falls down onto the patient’s skin. Yeah, they are the ones who are closest to the line between the living and the parted. I rarely do CPR, but I remember how in a recent code I took over CPR briefly to demonstrate how to really pound, and I drove myself into the patient, and I pounded hard, and then all of a sudden we had the patient back, and I felt like I had accomplished magic — a feat of both wizardry and will. I think the firefighters were feeling that. You go to work, you grind through the tediousness of the day, and then briefly, you have a moment where your hands have helped return life to the dead. And you think, wow, what I have I just done? It’s a feeling that verges on holiness.

So we package him up, get him out to the ambulance. As we go through the lobby, the cops are coming in. They look confused. They were sent for a body. “We got him back,” we say. They nod — good news for them too. I drive – in the back is the original crew and one firefighter. I go easy, no lights or siren. At the hospital, he is satting at 100%. Pressure of 150/70. Pulse 72. Normal sinus on the monitor. ETCO2 -45. The doctor tells us good work.

Whether he makes it out of the hospital and makes it out without neurological damage remains to be seen. He was down quite awhile, but you never know. I talk to the doctor later, and he says the patient has a history of hypercapnia – too much carbon dioxide in the blood, which explains his high ETCO2 readings. He probably stopped breathing due to a hypercapnic breathing event as opposed to a heart problem. That may be why once we got his heart beating, it was able to sustain him.

I have been doing this a long time now, and while there are still calls that rattle me, the truth is, you do learn over the years, you get better at your job, you’re calmer, you have the experience to stop and say, okay, why am I not getting this tube? what can I do differently? Your past patients give your future patients the gift of your experience with them. I still have some patients who I want to pay back, who I want to be a better paramedic to in their future reincarnations – a premature baby, a woman in asthmatic arrest, a child struck by a car. I know every medic has the calls they need to do over, to do better to show what they have learned, to pay the past back.

Give us our chance to save them. Let our hands do in the future what they could not always in the past. Touch us when we reach toward their stilled hearts.



  • D Bunny says:

    It’s been over 7 years since I’ve ran a code. I’d call the first strip asystole (with some artifact from a moving ambulance), but did you treat it as fine v-fib? And the second strip appears to be my favorite rhythm, 3rd degree heart block. Please tell me I’m right, or I’ll feel inferior for all I’ve forgotten over the years! 😉

  • PC says:

    You need to see longer sections of the strips to be able to see what we did cand have a better quality strip to view than what I have been able to post. The first was asystole with some wires shaking making some bumps. The second was a slightly irregular sinus. To be third degree you need the QRSs to march out evenly and have no relation to the p waves. The QRSs are slightly irregular here. A better strip in another lead would show the p waves. I also wish after the call that I had collected better sample strips. For instance at one point a firefighter was doing amazing compressions producing a rythm that looked like V-tach or a wide complex SVT. he’d stop and it would be back to asystole, but it was a great lesson in how good compressions can really pump the heart.

  • E says:

    “I know every medic has the calls they need to do over, to do better to show what they have learned, to pay the past back.Give us our chance to save them. Let our hands do in the future what they could not always in the past. Touch us when we reach toward their stilled hearts.”Very well said.

  • Anonymous says:

    You write some amazing stuff and I hope you continue writing as often as possible.

  • Katherine Howell says:

    Beautiful post, Peter.

  • Snoop says:

    Fine writing. Many thanks.

  • Anonymous says:

    The day after I read this, I had almost the same exact cardiac arrest.36 y/o male unwitnessed arrest. Cold and dry skin on arrival. Very obese, no neck. Watery brown vomitus in the airway. Except my suction kept getting clogged with food and he kept filling up and I could never see the cords so I couldn’t tube. Tried every trick I could to position him. Padding under head, padding under neck…He must have had weird neck anatomy too, since the combitube refused to insert.They pronounced him within 15 minutes in the ED. Took the respiratory therapist 3 times to intubate him, 2 of those times went in to the belly and brought up more food, so I didn’t feel bad about the tube.

  • denvermedic says:

    nice save.i agree – it’s definitely sinus and definitely not third degree. the morphology of the t waves is a little strange, but i’m guessing it is just the reading from the pads – they almost look biphasic.i’ve been away from your blog for a while and somehow started reading about the large pregnant woman with eclampsia. here i was thinking you were recounting a call and i was going to say i was impressed…but then you throw this asystolic pt. who i would have doubted had much chance of being resuscitated (and you’re right, neurologic compromise is a very real possibility) and you got him back. nice job.

  • Anonymous says:

    Great save. This further demonstrates the need for capnography. If you aren’t using it you can miss the boat!

  • Francesca says:

    Facinating glimpse into your world. You write so well! Thanks for sharing this with us!

  • Tom Reynolds says:

    Every time I gets pulses back, I think, you know, it really is sort of amazing….while I think “bugger – what do I do now?” and “exactly *how many* stairs do we have to carry him down?”…(I love the new resus guidelines – they’ve got our success rate up to 15%)I came over here because of a comment left on my blog – on the basis of this post alone you’ve gone into my RSS feed – superb post, and well done on the tube/resus.(And thanks for letting us know why the Etco2 was so strange – it would have annoyed me all day trying to work it out myself).

  • uphilldowndale says:

    Brilliant Post, my heart rate went up just reading it

  • Anonymous says:

    I lost a patient 5 days ago. I happened to be @ home and a neighbor was found down. Last seen 15 min. before. I keep running the the call in my mind. I think some of the links were broken in our first responder chain.This guy had a chance. The help that arrived was, I just do not have the words for the lack of education on that bus.We can’t change the world but we should be able to do our jobs. Live and learn.