Saturday, May 28, 2011

Starting the Journey

I was driving cross-country to internship when I led my first emergency as a doctor.

During my two-day drive I dropped by a tiny clinic in a mountain village.  I’d worked a clerkship there and wanted to say hello/goodbye.

“Perfect timing,” said Marie, the nurse practitioner who ran the clinic. “911 call – near drowning on the river.  We could use your help.”

I hopped in the ambulance driven by a forest-service volunteer.  Having graduated from med school the week prior, I was the ranking member of our three-person team.  We stopped briefly at a warehouse to pick up lifejackets then sped downriver to the mile marker from dispatch.

The setting:  a cliff-side river bend in desert forest.  Pickups and SUV’s filled the narrow highway shoulder and an audience of a hundred spread over the steep rock slide bordering the river.  The scene of my first consultation looked like bleacher seats for a grizzly bear brawl.

Defibrillator slung over my shoulder, I scrambled down boulders through the crowd.  In the center churned a class III rapids – spring melt-off overflowing banks, soaking tree trunks.  A rubber raft, bobbing and twisting, was tethered to a douglas fir.  Rafting guides in the boat, soaking hip-deep, gave mouth-to-mouth and chest compressions. 

“Make room for Dr Porter,” said my forest-service companion, as I waded into the ice water.  Eyes of the first-responders and boatmen met mine with great expectations.

The ambu bag didn’t seem to work.  Chest wouldn’t fill with air.  I was soaking from chest down, pondering the path of the electrons, when I got the defibrillator pads in position.  No wave whatsoever on the screen.  Back to airway – why couldn’t they get air in him?  I tried.  Each squeeze honked incompetence, escaping between the man’s face and the mask.  He was deep blue, but then, so were the river guides helping me.  My hands were white and trembling, like my mind.

“Want to try this?” asked Marie.  She handed me a fourteen-gauge needle.  “Laryngospasm, maybe?”  Thank heavens for wise Marie, the only care provider for a rugged winter village and the only ER service for thousands of summer hikers.

My stiff fingers found thyroid eminence and slid down to cricothyroid.  I knew the importance of airway and of airs of confidence, and I knew I was at the membrane.  I pushed the needle in a quick, sure motion, threaded the catheter, and withdrew the needle.  I took the mask off the bag and laid the nozzle on the man’s throat over the cath hub.  Pumping the bag again, I heard all the air escape his mouth and nose in a horrific snore.  I asked someone to cover his mouth and nose and squeezed again.  Useless.  Tried bag over mouth and nose again.  Watched the EKG tracing.  Nothing.  The man was cold as the river.  I moved from task to useless task over several minutes, racking my brain, trying mask again, re-starting defibrillator, re-checking the man’s pulse, as more traffic stopped and joined the crowd.  I silently pleaded for an EMT or ER doctor to happen by.

“Do you think we should call it, Dr Porter,” asked Marie.  The swollen river crackled,  rushed, and slapped the tympanitic tubes of the raft.  Further away the low thunder rumble of bigger rapids was just audible.  The sound was beautiful – it had put me to sleep under starlit skies all summer in my river-guiding youth.  I heard Marie, but still needed stall time.

“What, Marie?”

“Do you want to call off the resuscitation?”

It would be the first doctor’s order I ever gave.  I felt again for a pulse.  Stood there a full minute pressing fingers in the man’s neck. 

“Hold the bagging a sec,” I said. 

What am I missing, what else can we do?  Could he possibly be alive, and I’m missing it?  I switched hands on the neck, and put a palm over the man’s sternum.  On the riverbank I spotted a woman sobbing.  She was crumpled between boulders, almost choking, waving away would-be comforters.

“How long were you doing CPR when we got here?” I asked the river guides.

“Forty minutes.  Forty-five, maybe.  And it took us a while to bring him out of the water.  Five minutes, probably.”  He pointed upstream.  His voice quaked.  “He went out in the rapids two bends back.  Swear he was only under water a few seconds.” 

This was the guide who’d lost his passenger, I just realized; I knew what he felt.  His plaintive eyes blazed red.  Under his lifejacket he was shirtless - sinew and sweat despite the cold.  He wanted instructions, and I had none.  He was coiled for action like when he’d entered the rapids.  He would carry the raft and patient on his back anywhere I said, but there was no place to go.  We were failing our patient.  I fumbled with the defibrillator pads and checked the tracing again.  Nothing.

The quiet was unbearable.  Time and a hundred anguished faces were at a standstill when I realized who I could help, if not this poor wet man in brand-new river sandals.

“Marie, I’m calling it,” I yelled to shore.

“Yes,” she nodded, relieving me a small measure.  I’d lost the first patient I touched as a doctor.

I unplugged the defibrillator and waded ashore, not looking back at the river guide.  The patient’s wife still filled my view.  I walked a wide arc around her, through the crowd now coming slowly unfrozen. With the sound of the river again filling my head, I climbed the steep rock road and resumed my trip east to internship.

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