Last Moments

This last shift, I responded to a reported seizure at a local care facility. I obtained a report from the staff and interviewed the patient. She looked pale, was slow to respond, and was weak. Nothing too unusual for this particular care home, most of the residents were here because they were truly sick. I put her on the monitor after feeling a very slow radial pulse and sure enough, she was in 3rd degree heart block. Very soon, I had a feeling my patient's heart was going to stop.





I had had a feeling to dispatch rescue when we were first assigned to the call and at this point, the engine crew walked in. I gave them the quick report and we went about starting an IV, getting the patient on oxygen, repeating vitals, and moving her to my cot. I held off on the Atropine because of the block, and considered pacing. She was stable, tolerating the rate well, with a good pressure, and so for the moment, I held off on the pacing (later, the ER doctor reassured me it was the right thing to do).

The nursing home is four blocks away from the ER, so I told my partner an easy code 1 return would be fine. I radioed my report, receiving a very emphatic and clipped NO! when I asked if there were any questions. We turned over the patient to the ER staff and bid the patient a good afternoon. My patient, 85 years old, had just spent some of her last moments with my partner and I.

A few shifts back, my partner and I had a candid discussion about how our patients often spend the last few waking moments of their lives. My company uses a Rapid Sequence Intubation (RSI) protocol to manage the airway in traumatic and medical cases when the patient is unable to maintain their it themselves. The procedure uses medications that cause sedation, retrograde amnesia, and paralysis to facilitate intubation. Sometimes, because of their condition, the patient dies and their last waking memory is some sweaty, adrenaline fueled paramedic looming over them saying "I'm going to put you to sleep now so I can take care of you."

This occurs frequently outside the realm of the RSI patient. We take a critical cardiac patient into our ambulance to be transported and they arrest during transit--again the Paramedic is the last person they see. We are cutting someone out of a mangled car, and they decline shortly after--the Paramedic and the firemen are the last people they see. A patient actively stroking, trying to tell their family I love you through a mouth that doesn't work, then finally hemorrhages in the ambulance--the Paramedic and his partner are the last people they see.

I've tried to take this to heart, realizing that often as the Paramedic, I am one of the few people to see a critical patient in their last minutes or hours of life. They can arrest on scene, in my ambulance, or at the ER after being turned over to the nurses and doctors. The patient may even have the prophetic impending sense of doom and know that their death is coming. As a Paramedic, my training is to prevent that, but I know that's it is often as much about factors outside my control as it is my skill level. So how would I want to be treated by a Paramedic in my last few minutes and hours?

I take this with me and use it to shape my attitude and relations towards my patients. I treat every patient with dignity and respect. I do my best to make sure they are comfortable on the cot and warm enough. And I try to reassure them that they'll be taken care of, whether it is their last moments or not.

My 85 year old arrested shortly after arrival in the ER. I had a feeling she would, so did the ER doctor and the nurses. Her heart would only tolerate a dysfunction like that for so long. My hope, for both her and her family, is that her last moments were as comfortable as they could be.