As Easter rolls around again I am reminded of a call that nearly cost me my job. Years ago just days after Easter my crew was called to a difficulty breathing call. Yeah that was all the information we got as was the situation many times. Not that dispatch didn’t want us to have more information; sometimes a little info was all they could gather.
We arrived emergent at a nice suburban home and were greeted by a near hysterical mother and a somewhat calm dad. They quickly explained that their teenage son wasn’t breathing. As we entered the living room I saw the boy on the floor. He was tiny for his age and obviously had some sort of physical condition.
He had sever kyphosis a curvature of the spine, something like you see in the elderly where they have a huge hump below the base of their head. He was on the floor on his back and ghostly white.
The first question any paramedic asks themselves about a patient is simple; we ask is the person sick or not sick. Because of experience a good medic or EMT can tell in seconds if the person is sick and this kid was very sick.
As I approached him I could see that he had a pulse because of his slender neck his carotid artery was visible and pulsing. So I knew we didn’t have a cardiac arrest, yet. His body was very small and malformed he was less than fifty pounds but due to his outward appearance I could tell he was well past puberty.
His mother began telling us what had happened as I instructed my crew to begin protecting his airway. Mom said her son had a muscle disorder like MS or MD but didn’t really narrow it down. She explained she had picked her son up from school in his wheelchair and on the way home he had fallen asleep so she let him nap in the car.
Dad came home and when he went to check on his son he found him unconscious and not breathing so he had carried him in the house and called us. The first thing to do is check vitals and secure a patients airway. His vitals were all down and his oxygen levels as measured by a pulse oximetry was in the low 60’s, that isn’t good.
The first thing my guys tried was an oral airway device, this caused the boy to begin to gag, next option is a nasal tube, both are designed to help us push oxygen into the lungs with a bag valve mask, it too caused him to gag. So we were out of options at this point to use basic techniques to help him breath.
It is paramount that we gain control of a patient’s airway, in this condition if the boy were to vomit he would aspirate stomach contents into his lungs and even if that happens even to a fit person it can spell huge problems later.
As I considered my options I remember looking at the Easter decorations around the home and thinking of God. I was prone to praying for all my patients but really praying for the ones that I probably couldn’t help.
My next option was a procedure known as a cricothyrotomy, many people believe can we do a tracheotomy in the field but we can’t. A cric as we call it is like a tracheotomy only different, we have to use a scalpel to make a small hole in the neck right at the Adam’s Apple and then push a small plastic tube in to the airway.
I had done this on a conscious person before and it was horrible, the boy wasn’t conscious but because of his condition this wasn’t an option either, I couldn’t even tell where his Adam’s Apple was. About that time the ambulance crew arrived and much to my relief the paramedic on the ambulance was one of the few that had been on the streets longer than me.
I filled him in quickly as to what was happening and told him I felt the only thing we could do was what is known as an RSI, a rapid sequence intubation. An RSI is kind of scary on your average patient but on this kid it was not only going to be difficult, it was going to break the law.
You see an RSI requires that the paramedics completely paralyze the person with a series of drugs administered in a precise order. There are some rules or standing orders associated with an RSI; first you must have complete confidence that you will be able to get a tube in to the airway of the patient.
We knew we didn’t have that, mom had already said good luck with that as it normally takes numerous tries in the hospital to get him intubated. Second one of the drugs we needed to use was absolutely contraindicated for use in people with muscular disorders, this is known as a Black Box Warning by the FDA.
So what were to do? Let the kid die or break some rules? We chose to break some rules. About that time mom passed out in the kitchen and slammed her jaw on the back of a chair. I redirected my crew to care for her and myself and the other medic (I would use his name but I don’t have his permission, but he is one of the very best and still on the streets of my home town, thanks CS) rushed the boy to the ambulance.
We knew what we had to do and went to it. It went horribly wrong for us in many ways as we tried every known technique to intubate this kid without success. The good news was that once paralyzed it became very easy to bag oxygen into the boy’s lungs. His color went from gray to pink and his oxygen leaves increased to the mid 90%. We called ahead to the hospital and asked to have an anesthesiologist in the emergency room when we got there.
We finally used another device known as an LMA to secure his airway and it worked beautifully, thank God.
Myself and the other medic were subjected to an intense review for our actions and only avoided firing and criminal prosecution because of one thing.
The kid lived. So every Easter I think of that day and that boy and my friend (CS) and know that God is great.