I know why it happens. The number one cause of death is birth. As a paramedic, though, I don’t like it. No one does. It is simply a fact of life. As EMS professionals, we try to fool ourselves into thinking that we save lives. We don’t. We can only give God the opportunity to change His mind, because we all know that sooner or later it happens to everyone. And, one sunny, warm, beautiful summer day it happened to Bobby.
Bobby was four years old. He was an average kid, nothing exceptional about him. His brother and sister hated him; that’s what they told him anyway. Kids always hate their brothers and sisters. They don’t know how to use words to accurately describe their feelings, so they say, “hate.” Bobby hated his brother and sister too. They were constantly taking his toys and calling him stupid, so he returned the favors. He constantly frustrated his Mom and Dad; he didn’t pick up his toys, he couldn’t be quiet when they were trying to watch TV or use the computer. He was just like every other normal four year old in America. He liked Nintendo and the Power Rangers, and he hated lima beans – more than he hated his brother and sister.
And included in all of his failings and failures, his weaknesses and fears, his frustrations and desires was the seed for a wonderful and amazing life. A life that promised to be full of triumph and joy and happiness and, of course, sorrow and sadness; no one escapes those experiences either. But life is to be experienced in all of its facets. Bobby’s life was ahead of him and that is why the sorrow in our hearts is so great when we lose a child.
As fate would have it, or as God deemed it to be, Bobby’s life was meant for something other than all of the accomplishments and glory that people seem to dwell on after a death. There was value in his life, as short as it was, and in his death, also. He touched the people nearest to him. And, though I never knew him in life, he touched me profoundly with his death. He opened my eyes to the possibility that, maybe, there is a meaning behind death. Perhaps it isn’t all senseless and random. What a caterpillar calls death, a butterfly calls life.
We were on our way to a man who had fallen, a basic run, nothing really serious or life threatening, when dispatch notified our second rig about a four-year-old choking on a hot dog. The address was only two or three blocks from our location. Common sense dictated that we take the choking call and divert the other unit to the fall patient.
I was confident. Most choking calls are over before we even arrive. The patient has either cleared his airway on his own, or the family has overreacted to a minor situation. Even if this was truly a choking we were so close to the call that it would be simple, reach in with the Magill forceps, and voila, a miracle, live child. Yep, no problem. It’s great to be a paramedic, saving lives, curing disease, and performing miracles on a daily basis. I believe, in hindsight, that this attitude may be why I took his death so hard.
We arrived to total chaos, a normal situation. Mom was running frantically around the yard with her phone in her hand. She ran to the ambulance babbling about the location of the child. A firefighter who had responded in another squad ran from the home, the first sign that there was a real problem here. We unloaded the airway bag from the truck, and I quickly reviewed, mentally, the algorithm for choking.
Stepping through the front door I found Bobby surrounded by three firefighters attempting to ventilate him with an Ambu-bag. His airway was occluded by a hot dog, according to the mother, and they couldn’t get any air movement. Bobby was purple. He obviously hadn’t just become unresponsive. He had been down a while. I went to work quickly and efficiently setting up the laryngoscope and took a look inside his throat. “Oh my God, what happened?” I thought.
In front of me I saw blood, mucus, little bits of hot dog, but no vocal cords to put an endotracheal tube into and no single piece of anything that would block his airway. I asked for the portable suction unit. It was still in the truck. Someone ran to get it. I cleared what I could of the bits and pieces with the Magill forceps.
“Bag him!”
My partner attempted to ventilate Bobby and breathe for him, without success.
“Let’s get the monitor on him,” I ordered, as calmly as I could.
I continued to clear fluid and crud from his airway as the electrodes for the EKG were placed on his tiny chest. Flat line, damn! I used a 4X4 to soak up mucus and blood. His throat looked like someone had sliced it up with a knife. He had blood oozing from scratches and scrapes all over his upper airway. I had a mini trauma scene in front of me, right where I didn’t need it.
“Bag him!” I bellowed.
Nothing. His airway was still blocked.
“You want to get him in the truck and get moving?” asked one of the firefighters.
“NO!” I shouted, with a little too much gusto. “He needs an airway and he’s going to get it now!”
The suction arrived and I cleared gobs of junk and crud and blood from Bobby’s oropharynx. “There! A glimpse of the vocal cords. Torn up hot dog still wedged in there.” I got a hold on the edge of a piece of hot dog and pulled slowly, fearing that it might tear. It dislodged, and the airway was clear. “Yes!” An endotracheal tube larger than what should have went between his vocal cords and into his lungs. It shouldn’t have, but I took a chance and it worked. Bobby needed air. I did not inflate the cuff to prevent adding more trauma to his airway, but ventilated. There was good air movement. The lung sounds were good. No adventitious sounds over the stomach, which would have indicated that I had intubated the wrong place. We continued ventilating, watching the monitor with our breath held. “Please, God, give me something to work with.”
“Start CPR!”
Compressions and still nothing. “Damn!”
“Let’s move!”
We scooped Bobby’s lifeless body off the floor and moved to the ambulance, bagging him and doing CPR the whole way, fumbling over each other as we went. Bobby was laid on the cot and we rolled to the ER.
“Please, God, if you ever let me get an IV line let it be now,” I said.
The truck lurched forward as the adrenaline overrode my partners’ normally very calm and cool driving habits, throwing me backwards as I began to set up an IV line. The tourniquet went on Bobby’s arm and there was nothing to be found. No veins would fill up to insert an IV into. ‘It’s intraosseous time,’ I thought. I waded between the firefighters who were riding in with us, jostling about, trying to make my way towards the cabinet the intraosseous needle was in that would allow me to put IV medications directly into one of Bobby’s larger bones like his tibia, while trying not to fall over from the movement of the truck.
“Two minutes out!” my partner yelled back to me. I had forgotten how close to the emergency room we were. Better advise them.
“Give me the HEAR (hospital encoding and receiving) frequency,” I hollered.
“You’re on channel two,” my partner relayed back to me.
I gave the ER a short and sweet call-in, just to let them get ready, and went back to Bobby. CPR was still in progress, and I cussed at myself for not being able to get more done. “At least he has an airway,” I thought, “sometimes you don’t get past the first step in the primary survey,” I consoled myself.
We wheeled him into the ER. The staff was ready. They worked him another forty-five minutes, without success or the slightest indication that Bobby would return to life.
All of the emotion that I had been holding back suddenly began to come forth. I felt tears welling up in my eyes and struggled to keep them in. “It’s not professional to fall apart like this,” I told myself. The staff continued working Bobby. No one wants to give up on a child, but we all knew that he was not coming home. My emotions were more visible than I had hoped; because people began to steal glances at me as I watched them work on Bobby. The doctor called the code. I left the room and went outside to collect my thoughts.
The sun had set, and the stars were glowing brilliantly overhead. It was a perfect evening. But, my failure blinded me to it. I tried to believe I had done my best. I tried to tell myself there was nothing more I could have done. I tried to trust that God had a reason to take Bobby, but I couldn’t. Not then. The tears came, and I sobbed like a baby, hoping that no one would come out of the ER and see my weakness.
Fifteen minutes later I had collected myself enough to write my report. I toyed with the thought of going home for the rest of the shift. “No! If I start that habit I’ll never be able to finish a shift again. It’s part of the job. Get over it!” I chastised myself, “This is how PTSD starts.”
As I came back into the emergency room, the meanest, nastiest nurse of the shift, the one who had never complimented me, the one who always thought I should have done more, or should have done something different, the one I can never please, and in whose eyes I am always an idiot, who never has a kind word, and never supports me in any way, walked over to me.
Her eyes, in which I had never seen any kindness, were soft and accepting, and she said; “There wasn’t anything else you could have done. You did the best you could, with what you had.” And then she hugged me. The tears began to come back, and I choked them away. Other people said the same words to me that night, but the only person from whom they meant anything was the one person who did not say those things to anyone. Her words are probably the biggest reason I am still a paramedic. It would have been much too easy to tell myself I wasn’t cut out for this work, that I wasn’t any good at it, and that there was no point to it, because people die regardless of what we do.
The rest of the story began to filter in. Apparently Bobby had gone down several minutes before Mom had even known. He was eating lunch with his brother and sister when he began to choke, and fell under the table. His brother and sister thought he was playing around. When they finally realized he was really having a problem, they ran to get Mom, who was outside. She immediately tried to clear his airway. She was fond of long fingernails, and in her panic she managed to slice the hot dog and Bobby’s throat to pieces. At this point, 911 was notified and 30 seconds later we were dispatched, two minutes after that we arrived on scene. Bobby was beyond hope from the moment we arrived. It took possibly another two minutes to get him intubated, the longest two minutes of my life. And by then he had been without air for too long. He was dead.
I was the man who was to walk in and save the day. I was the one whose job it was to bring back the little soul that had departed and return him to his family. I was the one that everyone looked to in despair and whose eyes they searched, for some sign of hope, some sign that I knew it would be OK, that Bobby was coming back to this world. I failed.
I can chastise myself for not doing one thing or another sooner. I can second-guess all of my decisions that day. Perhaps I should have done a surgical cricothyrotomy. Maybe we could have gotten more information from the family about how long poor Bobby had been without an airway. The epinephrine could have gone down the ET on scene. We could have worked him longer on scene, rather than rushing to the ER. I could have done an intraosseous IV on scene. Who knows? We did what we did. Still, all of these doubts and concerns bring me right back to the same realization; we did the best we could with the circumstances we had.
Death is the price of life. It is an inescapable truth, and I must believe that there is some purpose behind it, otherwise I would go mad pondering the feelings of complete powerlessness I felt that day. Every paramedic has had those calls, the ones where nothing goes right. The calls where we fumble with the equipment; what we need is not where we need it; batteries keep dying; tonsil tips are missing; the ET tube we need can’t be found; the laryngoscope bulb is burned out; the list goes on forever. It’s fate that seems to determine for whom and when these difficulties arise. I’ve had numerous calls where I was sure it wouldn’t go well, and everything came together. I was in “the Zone.”
“The Zone” doesn’t seem to come from within me, and it isn’t only me that seems to be in it when it happens. It extends outward to the whole EMS team. It comes from outside of us. It is a connection with something greater and more intelligent than us. When “the Zone” blesses us with its presence, suddenly we can do no wrong. Magically, the ET tubes are there; the suction works; the equipment simply appears in our hands at the right time; the batteries are charged; and the laryngoscope bulb burns brightly. We can pretend we control these things; but no, there are too many times I can remember when the equipment was fine when checked and then, suddenly, it wasn’t.
Can there be any sense to be made of the events that summer day? Why did Bobby have to die? Are there even answers to these questions? I don’t know.
I do know that I am a better paramedic because of Bobby. I know my limitations. I know that I can’t save lives. I can only help save lives. I know that God’s hand is the only thing that can instill life, or bring back a soul. And, I believe that our role as EMTs and paramedics is to allow His hands to work through ours, and to trust that His will is served. I have learned acceptance, and in return I can keep my sanity, because I know that I am not in charge. This realization has lifted a great deal of guilt and frustration from my work.
I still work hard. I still strive to learn and grow in my skills. I still tend to be overly critical of myself. But, when a patient dies, in spite of the best efforts of the medical team, I can accept it and know I did my best, and the EMS team did its best, and the ER staff did their best, and our best is all that can be asked because sometimes people die.
But what do I know. I’m just a dumigod.