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.
