Wednesday, September 2, 2009

It's not your day to die

I was a rookie EMT when I encountered my first abdominal aortic aneurysm. It was a dark, frigid day in late January with a storm front moving in. That's why Lifeflight couldn't fly, and that's why I was called, consequently, to take the ALS ground transfer. We still staffed 2 EMTs on ALS transports - to help the nurses, of course.
The patient was already loaded on the ambulance cot in the ER when I arrived. He was a bear of a man; he looked alert, so I approached and introduced myself. His eyes focused on my face, and my heart dropped.
You are going to die on us, you poor bastard. I don't even know what's wrong with you, but I know what death looks like, and he is looking over your shoulder and laughing at me because he knows what I do know that you don't: the nearest trauma center is a hundred and ten miles away, there is a blizzard blowing and there is absolutely no other way out of here for you.
He was watching me so intently, I had to mentally shift gears, afraid he could read my thoughts. I busied myself helping C, our nurse, finish getting him ready to roll. He had two large bore IVs infusing and C asked me to carry several more bags of fluid from the warmer. There was such a sense of urgency, as we scrambled to get everything we needed in the rig, that it all seemed futile at the same time. My mind was racing - there was no sign of trauma. No blood. Internal injuries? I saw the last BP reading as I ripped the auto-cuff off his arm - 80/45.
The ER doc opened the back door of the ambulance as we were getting our patient hooked up. A blast of arctic wind and snow hit me in the face. "Fly like the wind! It's his aorta!"
The door had barely slammed shut and we were into the storm, lights and sirens dimly penetrating the blizzard.
I looked at our patient. He was so white. Damn!
I busied myself with what I needed to do, but I could feel his eyes on me. "It's my heart, isn't it?" He asked. Without waiting for a reply, he sighed and looked at the ceiling. "I knew it. All day long, when I was layin' on that trail, I told my buddy, I'm having a heart attack."
I froze. What the hell was I going to say? No, dude, the good news is it's not a heart attack - it's just that any moment your LARGEST BLOOD VESSEL is going to burst and you will bleed out and you will be dead AND there is NOTHING I can do for you... ?
Thank God for experienced nurses. C distracted him before I was able to pry my dried out tongue from the roof of my mouth, saving me from a horrible gaffe. When I finally found my voice, I asked him to tell me about his day. Boy, I wished I hadn't.
He had been snowmobiling with a friend when he started to experience "horrible back pain, but it was in my chest, too" that got so bad he was forced to get off his sled somewhere mid-trail and lie down on the snow-packed ground. He said he laid there for hours, he thought, in too much pain to go on. His friend wanted to go for help, "but I wouldnt let him," he told me. "I knew, I just knew, that if he left me alone, I would die out there."
Eventually he was able to climb back on his sled and they made to the nearest road, where they flagged down a car and got a ride to a nearby resort where an ambulance was called. He was transported to us, the only hospital in the county, and now we were transfering him to the nearest trauma center, over 2 hours away. He had a CT scan done in the ED, but the doc had arranged for transfer without waiting for results because of his condition. The results had come over the wire minutes before we left.
That ride through the storm is one I will never forget. At some point, I remember our patient telling us the pain was moving lower in his back, and we imagined the worst - blood was starting to pool there. We kept the spare fluids for his IVs warm under our shirts. He laughed at us - he had no idea how close to death he was. I watched his blood pressure drop steadily, and my heart sunk along with it. I was trying to steel myself for the inevitable, I thought. I still didnt think he was going to make it. The road was rough, and every bump, sway and lurch brought the fear into my throat.
We arrived at the trauma center amidst a screaming blizzard, and I have never been more thankful to see the harsh lights of the ED in all my life. Our patient was ashen, and no longer able to hold his head up, but he was alive and still talking to us. We were met at the doors by a trauma team of roughly 12-15 people, and as we prepared to transfer him from our cot to theirs, the surgeon's shrill voice cut through the others - "Watch it! Be very, VERY careful moving him!"
Like we didnt know that.
Our patient smiled weakly up at him. "It's okay, doc, if you only knew how many hours of rough road I've been over today, you'd think this is a piece of cake."
"I know exactly where you came from," the surgeon retorted crisply, "And I'm saying you've used up all your good luck today."
The surgeon looked at me. I shook my head. His eyes widened in disbelief. His tone was much softer when he spoke. "You have an abdominal aortic aneurysm, sir. That means you could have bled out hours ago."
My patient, now on the ED cot and surrounded by nurses pulling him away from me, reached out and took my hand. I walked alongside the cot for him. If it was possible, his face had gone whiter at the doc's words. "You knew?" He asked.
I nodded.
"You thought I was going to die." It wasn't a question.
"But you didn't," I said, feeling a little choked up.
A slow smile spread across his face. I had to let go as they took him away from me. "It wasn't my day to die," he called after me.

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