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Excerpt from my novel, "Esbenshade"
My partner, Sam, gave a sort of surprised gasp as she was shoved into my chest, pinning me against the side of the ambulance. She was a small woman, barely five feet tall, and weighing no more than about a hundred pounds, but the force exerted by our suddenly combative patient was more than enough to send my six-foot frame reeling. I managed to get hold of Sam's shoulders as she was shoved backwards and move my head to the side so that I took the impact of her head in my shoulder and not in my face, but we were momentarily winded, both from the physical pounding and the surprise. The ambulanced bounced over a pothole and then was rocked by a blast of wind from the turbulent night outside as we both dove for the stretcher simultaneously, trying to gain a purchase on our patient. The patient was writhing around on the stretcher, twisting his body first one way and then the other while uttering a string of obscenities, most of them mainly unintelligible. Sam, who had returned to her original position, was having a difficult time trying to hold his head, and she suddenly gave up trying to use her hands. She stood, putting a knee against each ear, and held his head locked between her legs while she pushed down on the patient's chest with all her weight. It worked well enough for me to get the nylon straps back across the patient's legs. I had never seen a patient free his legs from beneath the straps before, and I marveled at how quickly he had accomplished his task.
"You little bitsh! Leggo my fuckin' head!"
"Relax, Frank. If you plant your ass on that stretcher, I'll let you go," she said commandingly, if somewhat breathlessly.
"Remind me never to pick a fight with you," I said, as I set about reattaching the leads to the electrodes on his chest, so that we could keep an eye on his ECG waveform.
"I may be little, but I can get mean if I have to, she said, flashing me a brief, impish smile. I didn't see her smile for long, for she was suddenly pitched head first before my eyes. I realized, as I scrambled to catch her, that although my partner was small, she had had a definite leverage advantage, and it had taken tremendous strength to pitch her forward.
I managed to get a hand on the small of Sam's back as she did a forward somersault toward the foot of the stretcher, breaking her fall somewhat before she slammed into the stretcher frame at the patient's feet. I then made a full flying tackle into the chest of our belligerent guest. The wind went out of him like air escaping from a bellows, and I felt Sam land across his legs beside me as the ambulance was rocked by another blast of wind.
"You okay?" I asked her somewhat breathless myself.
"I think so," she rasped in return.
"Can you get the straps across his abdomen?"
"You betcha!" she said, her strength rapidly returning. She was having a tough time with the straps because the ambulance had hit a rough patch of road and began bucking back and forth and bouncing up and down.
"Our Pennsylvania highway tax dollars at work," I said dryly.
"Get da fuck off me!" Our patient was beginning to stir again.
"I'd like to do that, Frank, but I need to know that you're going to calm down," I told him, trying to keep my voice calm, with measured success. To my left I felt Sam tightening the straps across his abdomen.
"I said get da fuck off me!" I was suddenly lifted and flung to the side.
"Jesus!" I heard Sam mutter under her breath, as I hit the side of the ambulance once again, whacking my head against a cabinet door. I was lucky my head didn't hit the glass. I looked up to see our patient desperately fumbling with the straps across his abdomen, as he continued to mumble to no one in particular.
"Ya aint gonna do no sperimentin' wi' me. I ain't goin' unner no knife. Goddamned bastards!"
Sam was on him again before I could get my feet back under me to help her. She was trying to subdue his arms. She had taken hold of his left arm, pulling it down with everything that she had. I was clinging to the handrails attached to the ceiling, trying to work around to his right side to grab that arm when I saw his hand close on the handle of the portable defibrillator/monitor that we had him hooked up to.
"Sam! Look..." was as far as I got. The monitor came whipping off the sideboard where it had been sitting and caught Sam squarely in the side of her head. She went out like alight, slumping down beside the stretcher, and I immediately found myself full of rage, the intensity of which I didn't ever remember feeling toward a patient before.
In the back of my mind I knew that the patient was not in control of himself, that he didn't really know what he was doing, but all I could see was my partner being struck down while she was trying to do her job and it made me mad. I struck the man hard across the face with my open hand. It shocked him enough to remove the look of madness that had been on his face a moment before, but instantly the look returned, so I hit him again with the other hand. I was about to hit him a third time, when I felt Sam's hands against my raised arm.
"Jay!" What are you doing?" The alarm in the shouted question suddenly brought me back to reality. Sam didn't waste any more time with questions as she quickly grabbed the patient's left arm again, trying desperately to hang on. He had worked the abdominal straps loose and was beginning to sit up on the stretcher, and Sam was rising with him. He was trying to shake her off with the left arm while he pushed at her with the right.
I quickly moved around, positioning myself to the right of the patient just behind him and grabbed for his right arm. For the moment it looked like we were finally getting things under control. He was still sitting up, but Sam had his left arm and I had his right and he didn't seem to be able to break loose. Then his eyes rolled up until all we saw were the whites, and he collapsed onto the stretcher. Sam grabbed for the blood pressure cuff that had been flung across the ambulance as I searched for a pulse, and I scrambled to put the monitor back in place and reattach the electrodes.
"Pressure's ninety over fifty," Sam informed me. I got the monitor going again.
"He's bradycardic," I said to her unnecessarily, which meant that his heartbeat was less than sixty, in this case about fifty beats per minute.
"We need to secure the airway," Sam said as she reached for our equipment bag and handed me the intubation kit, since I was nearest the patient's head. I unzipped the cloth bag and removed the handle of the laryngoscope and selected the flat, Miller laryngoscope blade and a 7.5 mm tube. I positioned myself with a knee against each forward stretcher wheel, and I placed my left hand on the patient's forehead, pulling back to open the mouth as I positioned the blade in the patient's pharynx. I pulled up on the handle and luckily managed to find the trachea on the first shot, pushing the end of the tube down to where it would assure a patent airway. By the time I had the tube secured, Sam had medical command on the cellular phone, and she handed me the receiver while she set about starting an IV.
The doctor on duty at Esbenshade hospital, where we both worked, was Emily Evans. Emily directed me as I worked to keep our patient alive long enough to get him to her. I quickly gave her a report on what we had so far.
"How long til you get here, Jay?" Emily wanted to know.
"Just a second, Emily," I said as I realized that I'd lost track of where I was in all of the activity. I turned and moved up to the glass in the little door that separated the cab from the back of the ambulance and slid it aside.
"Ritchie, how long?"
"Five minutes," our driver informed me. "Are you two okay back there?" It sounded like a rumble."
"Yeah, we're fine. Just step on it, will you?"
"I'm goin' as fast as I can," he assured me. I slid the glass back and picked up the phone.
About five minutes, Emily."
"Let's hold on the atropine for right now, Jay"
"Eighty over fifty," I informed her.
"This is going to be along ride," I said to Sam.
"You mean it hasn't been already?"
It was about 10:30 PM; our shift was due to end at 11:00. The interior lights were on, but the darkness outside still caused the reflection from the revolving emergency lights to flash on most of the interior surfaces. We had been on the Route 11 bypass, but as we came down the exit ramp toward town we heard the familiar 'woop, woop, woop' of the siren, followed by the bleat of the air horn. The ambulance shuddered and rocked lightly as we hit a pothole coming off of the ramp.
The call had been for an emotional disorder on the East Side of town, out of the farmland that seemed to look more desolate and distressed each time we went there. The whole area seemed to be slowly dying; it seemed to have a gray pallor even when the sun was out.
The patient's mother had come home from work to find Frank sitting on the back porch with a shotgun, staring out into the woods and crying profusely. In a panic she had called the police, who after some very careful maneuvering, had taken the gun from him. The man had continued crying, however, sobbing about one seemingly unrelated subject after another. Not knowing what else to do, they had called us to take him to Esbenshade Community Hospital for observation and to await transport to the state mental institution.
My partner was good at talking to people in mental distress, and she seemed to be getting through to the guy. We hadn't strapped him tightly to the stretcher because we were afraid that it would further upset him. He seemed quite docile and controllable, and indeed he had been right up until Sam had begun questioning him about his family. They had been sitting there chatting quietly, making small talk, discussing life and it's little problems. She had simply asked if anyone else in his family had had any type of mental problems, and the next thing we knew, all hell had broken loose.
"Pulse is erratic, Jay." I could tell from the look in my partner's eyes that she was really concerned, but she was always very concerned about her patients, sometimes concerned to the point that it drove her crazy. I took a look at the monitor and could tell that it was having a difficult time discerning the pulse rate, which was indeed indicative of an erratic pulse. The rate that it was indicating was fifty.
"We should be there in a minute," I assured her.
"Call Emily back," she said, shaking her head. I'd been partnered with Sam long enough to know to listen to her instincts. I picked up the phone again and dialed, and Emily picked up on the first ring. She must have been waiting for the callback.
"Pressure's dropping; pulse is erratic and dropping," I informed her.
"Push a half a milligram of atropine," she instructed.
Sam already had the atropine out and was attaching it to its special syringe. I took the syringe from her and squirted the medication directly into a port on the patient's endotracheal tube. Sam and I were both watching the monitor, and we saw the patient go almost immediately into tachycardia or rapid pulse. His heart rhythm had gone too far in the opposite direction.
"Oh, shit!" Sam said, voicing both our sentiments.
We felt the bump and light sway of the ambulance as we pulled into the hospital drive that led to the emergency entrance. As we pulled up outside of the big automatic double doors to the ER, someone opened first one ambulance door and then the other, and a blast of arctic air invaded the ambulance. ER personnel were already standing by to help with the stretcher, and they unhooked it from its stays and lifted it to the ground, while Sam carried the IV bag and I carried the monitor. Emily Evans was beside the patient before we got to the doors, asking me for a report as we wheeled the patient into the trauma room.
"We need a crash cart over here," Emily ordered. She didn't raise her voice at all, but her confident tone left no doubt as to who was in charge, and the crash cart, with its defibrillator on top, was quickly wheeled into place as she cut the guy's shirt open.
She took the paddles from their holders on the sides of the defibrillator and positioned them on the chest to get a 'quick look', whereby you get an ECG waveform through the paddles themselves without taking the time to hook up electrodes. We could see that his heart was in V-tach, or ventricular tachycardia, which meant that his heart was not pumping effectively.
"No pulse," Sam informed her after palpating the carotid artery.
"Let's shock him," Emily said. "Two hundred joules." I reached over and adjusted the dial on the defibrillator that controlled the amount of electricity released. "Clear!" Everyone took a step back as I hit the charge button and the machine whined up to power. Emily then hit the discharge buttons on each paddle simultaneously, and we watched the patient's back arch and his hands jump as the electricity was released into his body. We could see that there was no change on the monitor.
"Three hundred." I readjusted the machine and the process was repeated. Still there was no change. "Three sixty." Still no change. The patient was turning an ever-deepening shade of grayish-blue before out eyes, and his skin had a pasty look to it. Nobody commented, but I thought to myself that it didn't look good.
Emily palpated the carotid artery, and then opened his pants and palpated the femoral artery just above the hip. "No pulse. Begin CPR," Emily directed. Sam attached a bag-valve-mask to the end of the patient's tube and began squeezing it, and we watched his chest rise as the air was pushed in. I began doing chest compressions as Sam ventilated him.
We kept this up for several minutes, and then Emily administered epinephrine and shocked him again. Still there was no change. She administered lidocaine as we continued with the CPR. Still there was no change.
Another paramedic named Ella Robertson, who was just coming on duty to relieve me, took over the chest compressions as I got tired. We weren't going to lose a young man without putting up a hell of a fight, but the monitor was now showing no ECG activity at all. After a while, I took over compressions again, but after ten minutes, we still saw no improvement.
Finally, Emily stepped back, her face reflecting a mixture of both controlled frustration and resignation, and said quietly, "That's it. He's dead."