DON’T DO THIS!

by Julie Martinez, R.N.

as published in The Lutheran Witness, Aug. 2002

                 Until that night I had thought that the only thing worse than working a medical code, or cardiac arrest, was working a trauma code.  In many years as a paramedic and flight nurse, I have had to respond to many of both types, and the outcomes are almost always bad (read: the patient does not survive).    The difference between them is that, by following Advanced Cardiac Life Support guidelines, there is at least a small chance of survival in a medical code.  Trauma codes, by their very nature are caused by multiple injuries and are not cardiac-related, hold very little to no chance of survival. 

                 In either case, you are responding to somebody who has essentially died.  There is no pulse, there is no breathing.  That condition will rapidly become permanent unless there are immediate interventions, such as CPR, defibrillation, and cardiac medications.  The procedures that are followed by field medical personnel are brutal and messy, the kinds of things that don’t get discussed in basic CPR classes.  Ribs often get broken, vomit and other body fluids are ever-present, and rescuer stress levels soar as time goes on and there is no return of circulation.  It hurts to work so hard for so long, and then finally, when there is nothing left to try, to stop the effort.  For those of us who work in the field, it is an up-close reminder of how nasty death really is. 

                 Last week, I found out that there is something worse than working a trauma code, and that is working a code on a friend.  

                 It was just after 2:00 AM.   I was working in the local nursing home, and over a third of the residents were sick with fevers and respiratory symptoms.  It had been a busy night.   My three nursing assistants (CNA’s) and I were taking a break after baths, dressing changes and nebulizer treatments.  Just as we started to relax with our lunches, Barb, one of the CNA’s, said, “My head feels funny”.  Then she collapsed into her chair and started to fall off.  By instinct I grabbed her and lowered her to the floor, and checked for a pulse, which wasn’t present.  The other two CNA’s were just sitting there with horrified expressions on their faces.

                 “Call 911!”, I barked to Sonja, while I asked Deb to help me.  Verified, no pulse.  Chest clear, precordial thump, still no pulse.  “Start CPR!”  Deb just looks at me.  “I don’t know how to do that.”    A quick demonstration.  Where is the ambulance crew?  The station is just across the street, what is taking so long?   CPR, no pulse, CPR.  “Come on, Barb, don’t do this”.

                 Finally, the ambulance arrives.  People I know.  “Terry, take the defibrillator, Jill, start an IV.  Give me your airway kit.”  Laryngoscope, pull up, look, suction.  Where are the vocal cords?  There, the pearly gates are open, ET tube slipped in.  Airway secure.  VFib on the screen.  Terry charges it up.  First shock.  No change.  Two more shocks.   No change.  Jill has the IV going.  Cardiac drugs going into the line.   More shocks.  Still VFib.  More CPR.   No pulse, nothing.  Twenty minutes pass like 10 seconds.  Finally a change, but not a welcome one.  The cardiac monitor shows asysole, flat line.  “No way, Barb, don’t do this!”

                 Can’t shock asystole, it won’t help.  CPR, different drugs, still no change.  Helicopter paramedic calls on the radio for patient condition.  A familiar voice, an old flight partner.  The EMT gives me the radio.  I key the mike, report what I see, and look at the flat line on the monitor as Jill pushes a milligram of Atropine into the IV live.  Still a flat line.  I hear futility in the flight medic’s voice.  I’ve been there; I know what they are thinking. They will land, verify her condition, and then fly off without her.  There would be no point... 

                “....asystole, CPR is continuing, pupils are dilated.”  One more look at the monitor.  Was that a spike?  “Stop CPR!”  Everybody stops.   It’s very quiet.  One sinus beat drifts across the screen.   A long pause.   Then another one.  Then more, coming faster and faster until the rate is over one a second, a good rate.  “Check for a pulse!”  Strong radial pulses.   Her color, once sickeningly white, is getting pink again.  “Hurry up!”, I stupidly tell the helicopter crew.  Cheers from the EMT’s! 

                Soon, the EMT’s are out the door, taking her to meet the helicopter.  This doesn’t feel right.  Nobody comes back like that after 20 minutes, especially once they’ve gone into asystole. 

                Two hours later, I call the Emergency Room and talk with the flight nurse.  Barb is still alive, they are moving her up to ICU soon.  “Good work!”, she says.   Somehow, it still doesn’t seem very good.  If she lives, will there be brain damage?  Other physical deficits?

                 Barb’s daughter now tells of an early morning phone call from the cardiologist, who told her that he thought that Barb would live no more than two hours.  But live she did, and after two surgeries, she is now recovering in a nursing home in another town, with the expectation for a full recovery, both physically and mentally. 

                 The two CNA’s, friends of Barb, tell their version of the story.  They say it was a miracle, and that if I hadn’t been there, she would have died.  I really can’t say.  I tell them that I only did what I was trained to do.  Having done exactly the same thing so many times previously, it just kicked me into autopilot mode.  And it's always a team effort, and everyone on the team counts.   In all the codes I’ve worked, this is only the third one where there was a positive outcome.  But I’ve never seen anyone come back after being down for so long, or after deteriorating to the point of asystole.  I tell them that God’s hand was in this, and if Barb’s life today is a miracle, it is more about her, and about God’s plan for her, than it is about any of the rest us who were there.  He put the people with the right training in the right place at the right time, and then He did the rest.

                 There are no two ways around it.  Death is monstrously ugly.  It truly is the wages of sin, and each of us will one day know it personally.  But we really don’t like to think about it.  When a friend is talking with you one moment and lying dead on the floor seconds later, there is no choice.  We can’t fail to see it, to confront it.  For those without faith, (as I had been for most of my life until only a few months ago), it is especially heinous.  Friends and loved ones are gone forever, and there is no comfort to be found.  

                Barb and I had talked, only a few weeks ago, about my recent conversion and baptism and the changes that my new faith in Jesus Christ has brought into my life, and I remember her tears at the time.   Prior to my baptism, I had tried to find God through the law, thinking that if I could only be better, then somehow I would find the closeness to God for which I longed.  However, the more I learned, the more I saw God as awesome and fearful, commanding us to do things that were impossible, and punishing us accordingly.  Although I really wanted to love Him, I found that I feared Him greatly.  Thanks to a very patient and loving pastor, I learned how much God loves us, and me in particular.  He loves us so much that He became man for us, to take our sin and the punishment we deserve, and to give us His righteousness in return.   Hearing and believing that gospel message has opened up a new love in my own heart for Him, knowing that, although there was nothing I could do on my own to earn His love, He still loves me as his own child, and has given me the promise of salvation through Jesus Christ.  The gratitude and love I feel for Him are almost beyond my ability to express.  Death remains ugly.  But now it has lost its terror, for it is not the end, but only the beginning of life with God.