This lifesaver pin was presented to me to celebrate my first CPR “Save” – when, early in my EMS career, I worked as part of a team of EMS professionals to apply CPR (Cardiopulmonary Resuscitation) to a Sudden Cardiac Arrest victim, and this resulted in the patient having their pulse restored long enough to be transported via ambulance to an ER for definitive care for their blocked coronary artery. The patient lived, was able to walk out of the hospital, and to the best of my knowledge, lived a long and happy life for a good number of years after that. I wear this pin with pride, celebrating this moment in my career when I worked as part of a team of professionals to truly save a life, to help literally bring somebody back from the dead, to give them a second chance at life. To make the biggest, greatest, possible difference in a human being’s world one could ever possibly hope to make.
That was a long time ago.
I’ve also been party to a number of what we in the industry could potentially call “saves” – bringing people to the ER with a pulse when we found them without one, but really we are just giving the family time to say goodbye. We aren’t providing a meaningful, neurologically intact recovery for that patient. The very grim, sad truth of the matter is that, even before Covid-19, most Out of Hospital Cardiac Arrests only have an average true save rate (i.e. those patients who live to walk out of the hospital, with no or very few neurological deficits) between 3% and 10%. These numbers are in the most progressive and well-equipped EMS systems, in the busiest, most affluent, and most densely-packed cities, with easiest and fastest access to AEDs and a fast first-response system. If you live outside the city, or in an area without AEDs, or if your EMS department has a less-than-stellar save rate, you’re looking at even worse percentages. True saves that I’ve been party to? I think I can probably count those on one hand. And since Covid-19 hit? None.
I feel like all I do is show up on scene at cardiac arrests, and go through the motions of allowing family members to believe that they did the right thing by calling 9-1-1 when their loved one stopped breathing and fell to the ground. I compress their loved one’s chest, violently, for 30 minutes or more, with a mechanical device designed to forcefully and rapidly press down on one’s chest cavity stronger and more rhythmically than any human EMT or paramedic could ever hope to, hoping that by artificially squeezing the heart and forcing blood to circulate throughout the body, and therefore the brain, we can sustain some brain function until the heart begins to beat on its own again. I place a breathing tube in their airway, hoping that maybe a lack of oxygen being delivered to their lungs is the problem. I place an IV in their vein, or more likely, drill a needle into their bone, to deliver fluids like saline and medications like Epinephrine or Amiodarone to stimulate the heart or correct the heart’s abnormal electrical beats. If, by chance, the heart is in a “shockable” irregular rhythm on the cardiac monitor, I can deliver electricity to the patient’s body through big sticky electrode pads, hoping that by sending a shock of biphasic current across the heart, I can cause it to restart in a normal, regular rhythm. But since Covid-19, most of the time, we show up on scene and the virus has already done it’s deadly job. The patient has stopped breathing, and the heart has already given up. The tell-tale “flatline” or asystolic rhythm is all that remains on the monitor when we hook up the EKG leads. In most cases, there’s very little time to come back from this, and unless the patient is discovered right away, and EMS is only moments away, there’s not a lot of heart and brain left to save. We do our due diligence, and try everything we have in our protocol. but the note on the mobile data terminal in my ambulance prior to arrival at the residence is like a big, red, waving flag in my face every time “***COVID POSITIVE PATIENT***” and my gut gets a knot in it, knowing that this could be yet another family member taken away by this virus that took our country by surprise, and continues to shake us to our core.
We arrive on-scene and work together as a team, Paramedics, EMTs, firefighters, a supervisor most of the time, maybe a Police officer or Sheriff’s deputy. Sometimes the family member is able to be coaxed into providing “pre-arrival” CPR by the dispatcher on the phone, too, and they become part of our team for a brief moment. The first few moments are hectic. Getting things organized. Assigning roles. Identifying potential underlying causes. Figuring out the timeline of events. Establishing vascular access. Applying the compression device. Getting an airway placed. Timestamping everything as we go so that I can document it thoroughly in my written patient care report when I finally sit down an hour or two later. But after the first 10 minutes have passed, and we all have established our roles, and the automatic CPR machine is running, and the drugs are on a timed schedule, or on an IV pump, and we’ve identified anything we could immediately correct to help the patient, (was their blood sugar low? was the arrest caused by an opiate overdose? are they a dialysis patient with an electrolyte imbalance?) – it becomes a waiting game. The room falls mostly silent, save for the rhythmic thumping of the automatic CPR machine, and the occasional whoosh of the BVM forcing oxygen through the endotracheal intubation tube that’s been placed in the patient’s airway. All of us waiting, watching the monitor, or checking for a pulse, dutifully carrying out our individual roles to ensure not one possible correctable cause is missed, and not one proverbial stone is left unturned, to give every patient their best possible fighting chance. But the end result, statistically, and anecdotally, winds up being the same. We quietly, so as not to upset the family, discuss amongst each other whether we have truly exhausted all of our options. Is there anything else we can try? Have we missed anything? Have we double-checked all of our interventions? Everything is in place? Everything is secure? Haven’t missed a dose or a time-check? No underlying medical issues we didn’t fail to consider? And then somehow…. it’s already been 35 minutes that we’ve been hovering over this soul in their living room, or dining room, or workplace breakroom, or on the side of the road, or in a bathroom. And I call our online medical direction, and I talk with a physician for further guidance, filling them in on what interventions we have performed. What lengths we have gone to ensure that we didn’t miss anything, what I have seen, what I learned about this patient in the short time I have spent with them and their family. Then the physician and I come to an agreement; it’s time to stop.
I make a note of the time on my glove. We turn off the machines. Disconnect tubes and wires. All of the effort, all of the cognitive processing, all of the emotion and work and determination – was for nothing. Again. I find a small amount of comfort in offering condolences to the family. Sometimes it was an expected death and they are prepared. More often than not, they are unprepared, and do not know what comes next. I have explained many times to surprised and scared family members the process of a medical examiner coming to take a couple of pictures, ask a few questions, and then the funeral home transport arriving after that to ferry their loved one’s body away. Many times I have been moved to pray with a distraught spouse, child, or parent who seemed to be alone and without a shoulder to cry on. I don’t usually share with them that I’m Jewish, we all basically share the same prayers – hope that their loved one is now comfortable, at peace, no longer in pain, wanting them to watch over us down here on Earth until their loved ones can meet them again, however they might believe that will happen in the future.
Then I walk away. Feeling as if I have accomplished nothing. Death won again. Covid won again. Misery won again. Heartbreak won again. Instead of being the hero, the the lifesaver that they expected, that they wanted, that they needed when they picked up the phone and dialed 9-1-1, I showed up and performed some medical procedures that they didn’t understand and didn’t ever dream that they would bear witness to, and then I was the bearer of the worst possible news they would hear; their loved one is dead, unable to be saved. No miracle today. No lifesaver award. No CPR save. Just the quiet walk back to the ambulance to wipe everything down with gallons of disinfectant spray, restock the equipment, tubes, wires, needles, and drugs we used, and then back to the station to sit down, and spend about another half hour rehashing the entire call again in my mind as I write out in excruciating detail every moment of the call on my patient care report, from dispatch to returning to service, leaving nothing to the imagination, and wondering if maybe the next one I’ll be able to document a “save” or not.