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Talking to the Almost Dead

Defeated. Angry. Undervalued.

That’s how I felt during a warm July morning in Texas. I was deployed on a disaster medical team and supposed to be a part of a code team within the facility we were assigned. The expectation didn’t match reality.

I had just spent the last three days as a sitter. I had been demoted from a paramedic to a sitter. Sitting in a hallway in full PPE for 12 hours a day. The facility requested our team to fly in throughout the US because they were so overwhelmed and needed help. Yet the best use of me as a resource was as a sitter, a really expensive sitter.

My heart ached for our patients. The area was underserved on a good day. Then COVID came and 40 people a day started dying in that area. It was a time travel back decades in medicine. One EMS crew brought in a code with two ET tubes sticking out of their mouth and thought that was really odd. As I got closer I realized it was a combi-tube.

That morning I spoke to my team leader about my concerns. We shared similar feelings, but ultimately it's their turf and we’ve got to play by their rules. And better yet, I was a little frustrated with God because I prayed that he send me to serve - and this is how he can best utilize me? I came to realize that he had me exactly where I was supposed to serve.

Talking to the Living

I was in the ER that particular morning. The first patient that rolled through the door was brought in by EMS. He was a 25 year old, COVID positive Code. We called it after his arrival. His family was devastated. His sister provided bystander CPR and did everything they were suppose to. I was standing outside his room while the family was in there, just listening to sadness and shattering of their lives wishing I could alleviate some of their hurt.

My team leader, the Doc, came up to me and shared that he was talking to Tom’s family on the phone. Tom (not his real name) was over 400 lbs at 33 years old. He had diabetes AND hypertension AND, AND, AND... His odds of surviving were really low. Tom was there for a few days waiting for an ICU bed to open.

Waiting for an ICU bed to open almost became a euphemism. The ET tube was the kiss of death. The ET tube in a COVID patient is like a dagger to the heart, every day is just another twist and another toe in the grave. It was normal to come in for shift change in the ICU and ED to find out that 3 or 4 people died over night. Only one out of the 50 or so patients that were on a vent came off during our time there. Waiting for an ICU bed really just meant waiting for someone to die from COVID.

He came in because he wasn’t feeling well. He was talking and joking with the team. Two hours later he was intubated because of declining sats and mental status. He was on the vent, propofol, fentanyl, and vecoronium drips.

Doc shared that he was on the phone with Tom’s wife - so his wife could talk to him. They were wrapping up the phone call and Tom’s wife prayed for him. Doc asked Tom if he knew it was his wife praying from him? Tom’s response was a head nod. Surprised Doc asked Tom to follow other commands without any response.

Doc and I bawled our eyes out in the ER. Everything just came crashing down and just felt the weight of the situation and what we were there to do. What we did mattered regardless of whether we were utilized to our full capacity. The small things create an innumerable difference. That phone call mattered.

Talking to the Dead

After lunch I noticed that Tom was diaphoretic. I grabbed the thermometer to verify his temp. He was running another fever. As I was about to doff, I noticed the IV pump that was running Propofol was giving an occlusion alarm. Traced the line, looks good to me, hit restart. Beep Beep, another occlusion alarm. I double checked the line, looks good to me. Grab a flush, and I can draw a little bit of blood but the IV won’t flush. I grabbed the nurse and we started trouble shooting. We were hoping this would work because he only had one functioning line. When I go to flush again I notice his hand has a twitch. Surprised I asked Tom if he could hear us. He shook his head.

My jaw dropped and was utterly astonished. Tom is for intents and purposes almost dead and now he’s awake and aware. The second emotion was fearful. We now have a 400 lbs patient on a ventilator without any sedation or paralytics who is hyperthermic; best case scenario is we try to restrain him when he goes for the tube. And there are NO IV sites to stick and an IO is probably the worst idea. We start packing him with ice and grab the IM docs who are overseeing his care.

“Tom, this is Adam. I’m a paramedic that’s helping take care of you. Your IV isn’t working and we’re not able to give you any sedation. The paralytic is also starting to wear off so I know you’re going to be aware of a lot of things and may start being able to move. It’s going to feel like sleep paralysis where you’re awake, but can’t move. You’ve got a breathing tube down your throat and hooked up to a breathing machine. It’s going to be really tough right now to stay relaxed. Let the machine do the breathing for you and try your best to breath with it. Don’t try to fight it. It is really important that you don’t reach for the breathing tube in your mouth. You’ve also got a catheter in your penis and I can promise you, you don’t want to pull that out. The docs are going to come in here to put a central line in your neck. They’ll numb the area up and won’t feel pain, but you will feel some pressure. I know you’re feeling really hot, is the ice helping?” Tom shakes his head yes. “Is it too cold?” He shakes his head no.

I ask him if he can open up his eyes. Tom’s eyes open and we make eye contact. “Hi Tom, I’m Adam. This is Latisha, she’s your nurse. And this is Frank, he’s another nurse that is helping us out.” He shakes his head yes and give a little smile. “You can close your eyes if you want. I’m going to help the rest of the team out, but I’m going to be with you for a little bit.” Tom shakes his head and closes his eyes.

The docs come in and a bit later they’re able to place a right IJ line. Meanwhile I get to talk to Tom throughout the procedure and hold his hand. “Tom they’re finished. We’re hooking the meds back up so you’re going to go back to sleep.” He shakes his head yes and squeezes my hand again. Not once during the procedure did the vent give a high-pressure alarm or he get agitated.

I come back in after getting the central line dressing. I ask Tom if he can squeeze my hand again, but no response. His temp is back down and he’s completely sedated and paralyzed again.

I doff my PPE and boy do I need a drink of water. I look at the clock and it’s almost been 2 hours since I first went in there. Doc gives me a fist bump and states “Good job, you kept him calm throughout that entire time.” I went from really negative feelings to really proud of myself. Overwhelmingly proud.

The Outcome

Tom was transferred to the ICU later that day. We came in next day to learn he died overnight.

We shed a tear for Tom. Then had to return to our service, trying to make whatever positive impact we could on our patients and staff.

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