Saturday, 12 November 2011

Time of death

"89 year old male, cardiac arrest"

There is no other job like. In essence this is what we are there for. This is what people associate with ambulances, the blue lights and sirens. It is life or death. Make no bones about it. If we don't get there quick enough, if we don't work as a team and if we don't do everything correctly the slim chance of survival is gone. Personally there is no adrenaline rush like it. Nor is there a greater sense of achievement following a positive outcome. Similarly there is no greater feeling of disappointment when your best efforts are not good enough. Guidelines are constantly changing to reflect a constant change in opinion on what is the best way to achieve a positive outcome.

In recent years the compression to breathe rate has changed from 15:2 to 30:2, drugs have come and gone and most notably the idea to 'stay and play' rather than 'scoop and run' has become more popular. It is thought, in certain rhythms, staying on scene and running a full Advanced Life Support (ALS) protocol until the patient is in a 'transportable' rhythm is the best way forward. A few years back it was decided that a patient in Ventricular Fibrillation (VF) was to be treated for as long as necessary on scene. Although it lead to better outcomes it resulted in some pretty lengthy and often futile resus attempts.

This particular day, it was our 'off job'. The last one of the day. We were due to finish our shift in 10 minutes but that wasn't to be. And none of us cared. It's life or death. It's our job and finishing on time is not the priority. We raced to the address. The FRU was already there. We grabbed extra kit and headed to the second floor of this mansion. We entered the tiny loft bathroom to find the FRU delivering CPR. Auto pilot was engaged. We knew our jobs, we knew what had to be done and got to it. Within minutes the patient was intubated, intra-venous access gained, shock pads applied and drugs were being administered. The patient was in VF, a cardiac rhythm that we shock. It's basically a spasm of the heart, and needs stopping in the hope it returns to a regular beat. We administer shock after shock but the patient remained in VF. After 40 minutes and 18 shocks we called the clinical support team for advise. We were told to change the pad placement and up the voltage of the shocks. We did. We also had to request a 3rd crew as we had used 2 drug packs worth of drugs and urgently needed more. After 32 shocks the patient was still in VF. At this point we were told to transport the patient to the nearest A & E.

We put the patient on a carry sheet and began the task of getting him down the huge winding stair cases, which had stair lifts running up the middle, whilst still doing CPR, shocks every 2 minutes and delivering oxygen and drugs as necessary. Eventually, once on the ambulance we headed to hospital. By the time we arrived we had delivered 39 shocks. We had been doing CPR for close to 2 hours and it showed. We burst through the doors into resus and whilst transferring to their bed I gave a handover. The Dr then addressed the resus team:

"Right, due to the history, the age, the amount of shocks and the length of time he's been down, we are going to call it. Any objections?..........No? OK.....time of death......."

"Wait!! " shouted one of the nurses.

"I have a pulse.....and respiratory effort......he's breathing......we've got him back"

We've?!?!?! The guy survived for an hour, long enough for his family to arrive and say their goodbyes. And that counts for a lot. The frustration for us, isn't being 3 hours late off, or him not surviving to discharge, it's that for too often hospitals don't appreciate the sheer effort we have put it. There were 7 of us stood open mouthed, sweating and exhausted in the resus room, as the Dr called time of death without trying anything. Maybe I'm selfish but at least do something. Even if it is wait until we have left the room! What was the point in us trying and transporting if they won't? For those who have administered CPR you'll appreciate how we were feeling after 2 hours and to have that simply ignored was horrible. I like to think that that is why the patient started breathing again. He died on his terms, with a little help from us, and with his loved ones at his bedside. That is job satisfaction. That is why we go to work and that is why I love my job.


  1. Reminds me of a similar job I had with a 1hr 40 ALS on a PEA arrest, ROSC in ED and although the pt didn't survive the day it was long enough for family especially they had started the CPR!

  2. There is a great story in the med journals of a Volunteer FF/paramedic in a small town (2K people or so) in Michigan (maybe) closer to the Canadian border than any us city. He was walking into the only grocery store in town and had dropped while saying hi to a nurse. The nurse immediately started quality CPR and within minutes the Volunteer FF/medics start showing up with drugs and shocks. Soon dozens of people are in line to do CPR, the nearest hospital was contacted, and they worked the drugs, sent a helicopter etc. The man was eventually revived but here is the amazing thing- the helicopter and hospital were hours away. I am doing this all from an old, faulty memory, but it was between 4-6 hours of CPR, shocks and drugs. An amazing write up, and I apologize for any mis-remembering. I think I have the citation somewhere, so DM if you want it. Thanks for this, and all your blogs. I am a volunteer, so I mostly help people with water, sun screen, directions and the odd patch up from issues with gravity and rocks. I learn a lot from you.


