End of Life Miracles. Awesome!

I’m sitting in one of the most uncomfortable chairs ever made by mankind. Hospital furniture is unforgiving at best and hell on spines, backs, arms, legs, every possible bone in the body that comes in contact with them.

“It is a dark and stormy night,…” actually it is. There’s a tornado watch out for our area until 3a and it’s only 1148p. The big stuff has already rolled through with just some lingering showers still remaining in the line, at least what I see on the radar on my phone.


Room 624 is a rather noisy place. About 3 feet to my left is my wife, trying but failing at sleeping on a roll-away bed and her mother is next to her in another. The nurses up here brought them in here last night when they stayed in here to keep an eye on the room’s patient.


6 feet in front of me lies my father-in-law, all of 73 years young. He’s got a PICC line in his left arm. Hooked up to that is a maintenance line of .9NS, a PCA pump with morphine running TKO @ 2mg / hr and 1 mg boluses q 10 min. He’s on 15 lpm via a partial non-rebreather mask and hooked up to an oxygen “oximiser” which is basically a high pressure / high flow humidified oxygen device. He’s got that hooked to a nasal cannula at 30 lpm. The noise of the high flow oxygen is almost deafening but it’s doing its job.


Pulmonary fibrosis is sapping the life out of Bill, my father-in-law; one of the best men I’ve ever known, ever will know, and an all around fantastic father, papaw, and man. Hard working, educated, sentimental, sensitive, no bullshit kinda guy he is; always has been and still is today. Even with all this he still has a wicked sense of humor.


He was diagnosed with PF about 8 months ago and began using oxygen at home PRN. Then it went to constant use @ 2 lpm, then 4, then 6. A week ago he developed pneumonia which sapped things quicker. The docs told us he had 3 – 6 months to live. After the pneumonia kicked in and really began whipping his ass the docs told us it was down to a couple weeks, if that. The digression in status continued rather quickly from there and still does.


But what this is about, other than the background history, is what I’ve seen, what we’ve seen in the last two days. I can’t explain it, it defies logic, it’s almost miraculous. I don’t think dad will ever go home from here and twice in the last two days I, we thought it was the end. He’s still here and let me tell you about it.


Dad’s a recovering alcoholic and scotch was his drink of choice. Hasn’t had the stuff in a decade since he’d stopped. Went to AA and treatment and got dry. Best move he ever made. He’s slowly been making requests for things and getting affairs tidied up since he accepted the end is near. Three days ago he said he’d like to have a shot of Johnnie Walker, the “best stuff they make.” He’d never had it and I knew it was JW Blue. I’d seen it in duty free shops all around the world. Damned expensive so I never bought any.


I called around to at least 14 area liquor stores and none had it. Went to another half dozen and the same. So I went to work yesterday morning and made a couple calls to find a bottle somewhere, anywhere, regardless of cost. He was worth it and I’d travel if I had to. He’d paid his dues and it was his wish to have that one last luxury of life and I was making damned sure he got it. I made the call to the fourth place in Indianapolis and I asked the clerk if he had a bottle of it. “I have one bottle and that’s it.” My eyes lit up and my hands grabbed for a pen to write down directions. I told the man to guard it with his life, pull it off the shelf, hide it somewhere that nobody else could see it; this was the last request of a dying man who so richly deserved this taste of excellence.


I left work and hurried down the road to get it. It was only 10a and the clerk seemed more happy than I was to sell it to me since I told him what it was for. I paid for it, snuggled it safely in the crook of my arm like a newborn baby, smiled from ear to ear, and hurried to my truck to deliver the fantastic present.


Throughout the day Bill had been declining in status. Sats were in the low to mid 70s, pulse in the 110 – 120 range, doing a lot of belly breathing and moaning, and had us all wondering how long he could work so hard to get his next breath.


I left that afternoon to go pick up our kids to bring them to see papaw. I went to the barn to do some work and forgot my cell phone in the kitchen. #2 went to the house and came running back to the barn carrying my phone. “Daddy, someone’s been calling you. Your phone’s been going crazy!” I saw 12 missed calls, 9 text messages, and 7 voice mails in the last 15 minutes. My wife was frantic, telling me he was about gone, taking his last breaths, and he was asking where I was, that he wanted to see me, “my son,” and his wife. I grabbed the kids and rushed to the hospital in my truck.


I was met by a friend of my wife who’s also a nurse. She met me at the elevator with tears streaming down both cheeks, the corners of her mouth turned downward in a sad frown, and she said, “The end’s almost here. Hurry up and get in there.” I left our kids with her and walked inside. The minister was there as was Bill’s wife, me, my wife, my sister-in-law, and Bill’s brother-in-law. We said a nice prayer, all told him we loved him and that everything would be all right. We were all teary eyed and some crying, knowing the end was in sight. “It’s all right to go. Everything will be fine. Don’t worry about mom, we’ll take care of her. We’ve got everything under control so there’s no need to worry. Rest and relax and go if you want. We love you, we all love you.”


I looked around and said, “I think it’s time we do this before it’s too late.” I walked to the other side of the room to the closet where I’d hidden my smuggled bottle of Johnnie Walker Blue Label and put it on the counter. I pulled out a couple shot glasses I grabbed form home and poured 4 shots out. I gave one a shot glass to Bill, one daughter, his brother-in-law, and one for me. We made a toast to family and love and downed our shot. Damn, that was some smooth stuff; worth every penny. I’m not a scotch drinker but that stuff was wonderful! Dad's response? "Man! That's goooooood" with a wide smile and twinkling eyes.


Now for the good part.


In about 30 – 45 minutes after that shot Bill was talking normally. Even though he was still wearing a non-rebreather he wasn’t gasping for air. His pulse dropped to below 100. His sats climbed in to the mid 90s. He was visibly relaxed and breathing wonderfully. I grabbed the ears off of the RT and he was clear. No wheezes, no congestion / rales / crackles, nothing. We were talking like normal. We began talking about family, old times, work, making jokes and laughing; it was comical. We had gone from doom and gloom to laughing and cracking up. The scene reminded me of the movie “Awakenings” when the patients “come back to life” from their frozen Parkinsonian states. It was a miracle! It was neat as hell. It was something that I couldn’t explain. This 180 degree turnaround could only be attributed to a shot of scotch! For the next 4 hours it was like this. Simply fantastic; unexplainable but fantastic. Wow! Even the minister commented that he “now believed in the power of Johnnie Walker Blue Label.” We all cracked up on that one, even dad.


After about 4 hours things began going south again. I likened it to patients I’ve had before who had a fantastic turnaround for a short time before the end crash. Seen it happen before and I thought this was that too.


Through the night things steadily got worse. During the next day things continued downhill to the point of putting on the high pressure oxygen and adding a PCA pump. He was working hard, harder than before. Coughing came more frequent with blood tinged sputum. He was tired. He said he was and we all knew it. It couldn’t be much longer.


I went home to get our kids again and bring them up. When I got here I was met by my brother-in-law who brought in Bill’s other two grandkids. We all went up to the room and the boo hoos began again. It was a repeat but worse of yesterday afternoon. We all said a big prayer and were hugging, crying, and saying our “goodbyes” all over again. I looked at my brother-in-law who knew the story of the day before’s events and said, “Let’s do another round and call it ‘the Final Shot Round 2.’ “ He smiled and agreed. All of the immediate close family was present. All the grandkids and relatives who were close and tight knit gathered around the bed. I poured 7 shots, enough for every adult present. We said another toast as I asked dad to offer it. He passed that honor to me. “Family” was all I could muster out between sobs and caught breaths. Dad finished it with “love and togetherness always.” We all clinked our shot glasses and plastic cups and downed our Blue Label again.


And it happened again. In about 30 minutes the breathing eased, the sats skyrocketed to 98, 99, 100%, the coughing ceased. The speaking was easy but slightly labored. But the conversation came again. The jokes, the stories, the laughs, anything and everything. Twice in two days. Another day, another brief miracle of a couple hours to spend with this fantastic man just talking and living as normal, even if we were in a hospital room. The kids were eating popsicles courtesy of a floor tech, we sat and talked and joked as the kids played. Dad even removed his NRB so he could talk easier and hear better as we all talked, seemingly at once. It was fantastic. The emotional roller coaster had made another stop in his room yet again.


So now it’s after midnight and he’s lying on his right side, moaning with each breath. The belly breathing has resumed again, the PCA pump still running in its medication. The RT just gave him a nebulizer treatment, shortly before his nurse gave him some haldol to relax him so he could sleep a little. He’s struggling for each breath. I know he’s worn out and tired. He’s worked harder in the last couple months than he has all of his life. This damned disease is sucking the life out of Bill, the man who has to be the best father-in-law a person could ever ask for. A friend, a mentor, a papaw, a gentleman, protector, and just all around fantastic person to everyone he met.


But we all got to see not one but two huge rallies. Unexplainable by any means. I’ve seen it once but never expected twice. I still can’t figure it out and I don’t want to try. I just want to remember these two “awakenings” as they happened. The love, laughter, conversation we all had for those 3 or 4 hour windows was truly fantastic. I still shake my head and smile about it.


We’ll try it again later today if we get the chance. If not I’ve already decided to take the rest of the bottle and do a toast graveside with all of us who witnessed those rallies. It’ll be a fitting tribute to this man, this terrific man, father, and friend to us all. The bottle will go with him, one way or another. It’s his bottle, not mine.


But for now life is again quickly fading away in room 624. I’ll miss you Bill, dad, pal. At least not just me but everyone got to smile and talk with you these last two afternoons like nothing was wrong. It was terrific. It was fantastic. It was a miracle that happened not once but twice. I know the end is near but those extra precious moments we had were just, how to say it and give it justice, were awesome. I’ll always smile when I think about it.


My eyes are welling up as I finish this as he struggles 6 feet from me to breathe. But I’m also smiling knowing what I know, seeing what we all saw, and enjoying those last moments. Take a break. You’ve earned it. You deserve it. Rest and relax. I’ll miss you dad, thank you for everything. I love you.


Love,

Your son-in-law

Death and Dying

Dealing with death is never easy on either side of the fence. I guess I’m lucky in that I’ve not lost too many close relatives or friends. About a week before Thanksgiving in 2004 I lost my gramma, a woman I miss every single day. She was my pal, my confidant, my mentor, everything. She took care of me and I tried to take care of her in return.


She’s the closest relative I’ve ever lost.


In the business of EMS we deal with death frequently. Mind you, it’s not necessarily every single day or shift but in some settings that may be the case. In our small area we see some but not often. We have some from old age, from overdoses, from car wrecks, from other means. We aren’t a homicide mecca around here but we do have one or two a year.


Some of these deaths come from homes. Others come from a retirement home or community, others an ECF, highways, roadways, or even one of our three local prisons. We get the gamut from everywhere. Some old, some young, some too little to walk or talk.


Each person deals with death and dying in their own way. Each has their release. Each handles the scene or the people in their own way. The first time I did CPR on someone I was 17 and she was in her mid 90s. No problem. The first child I did was in the middle of the school day and she was 13. To this day her mother puts a memorial in the local paper on her birthday so I am reminded of it every year. The first infant death I had was Christmas Day 1991. All three of those times I was asked if I was okay, if I needed to talk to someone, if I was handling things all right. Each time I had no problem. I got upset, I cried on one, I still think about all three as they’re still fresh in my mind even all those years ago.

I’ve dealt with screaming family members, fights by bystanders who were like warring factions, loud noises and distractions from roads, fires, a little bit of everything. Most every time I’ve had to, in some way, deal with the family. Some of those times it’s been “pleasant,” if you will, while other times it’s been a nightmare. More so now than in the past I try to make sure the family is addressed by someone else if not by me. They’re a part of my scene and my patient and they need to be dealt with too. They may need a shoulder to cry on as nobody else is there. They may be too distraught to call anyone. They, like us, deal with death and dying in their own ways that may not mimic the way we do. “Normal” people don’t see death as often as we do nor do they deal with it in the ways we do. They have an attachment to our patients where normally we do not. We may not know them. In a small area like ours we may well know the person or a friend of family of the patient. Usually around here most deaths touch someone on our service in some way, close or distant.

We aren’t nurses who see these patients for an entire 12 hour shift or weeks or months in an ECF and get to know them. We don’t get to know their quirks, their personalities, the way the smiled or looked at someone. We normally don’t know their families and if they were visited or abandoned. We see them for a short time, carry them to the hospital or simply wait for the coroner or local funeral home to come and collect the body.

Some people are in denial. Some people cry hysterically. Some people pass it off as, “it was their time.” Everyone’s different. The one big thing I try to do other than deal with or make sure the family is dealt with is keeping some form of dignity with the patient. If they’re pronounced on the scene we need to let them keep their dignity. I’ve seen scenes before where all the clothes have been ripped off, the crew pronounces them, then leaves the immediate area while others are milling around this now naked dead body. Dignified? Professional? No. If I were a family member and saw that I’d want someone’s head. I’d try to have someone’s job. I wouldn’t treat someone like that and I damn sure don’t want my family treated that way.

I’ve also seen providers lose sight of the picture because they have an attachment to the patient and not provided standard care. Happened? Yep. Understandable? Yep. That’s where the others need to step in and help out, get them aside and let proper care happen.

Probably all SOPs or protocols address DNRs, advanced directives, or living wills. At times the family forgets where they are. They may change their mind at the last minute and want everything done. They may not want anything done yet the patient DID want something done. I’ve seen it all. It’s hard to comfort a patient’s family as we’re pounding on their chests, sticking needles all over the place and pushing all sorts of drugs and putting tubes here, there, and everywhere. We’re working hard in an effort to save people. We don’t always succeed but we give it our best shot.

Medical professionals deal with death. But when it’s us who’s on the other side it’s the same as above. We now become those who may be hysterical, crying, upset, screaming and hollering, lose sight of what’s best for the patient, anything at all. When it’s our loved one everything we know and have been taught kinda goes out the window as it’s now our crisis, our family member, our loss; not someone else’s that we need to console their family. We want someone to console us, to give us a shoulder to cry on, a door to punch, something to help ease the loss of our close family member right in front of our faces.

Remember that we see one side of death and dying. We’re not usually on the other side. If you ever are, God forbid, and experience that loss please remember how you were treated, what you felt, the profound sense of loss and emptiness you feel or felt. The next time you have a patient that dies on you or you are called to work on and you’re around their friends or family, remember those things. Remember what you craved and needed during your event. Remember those things and try to make them feel better, more comfortable; be empathetic. Keep the patient’s dignity intact and help the family all you can. It may be staying on scene to talk to the family, making calls for them, waiting until someone else shows up.

It could be you in that scene. How would you want to be treated? Death and dying is never easy, for anyone. Keep those things in mind and let your best judgment and conscience be your guide.

Change,.. for the better?

Think back when you first got in to EMS. What type of equipment did you have? What was the quality? Were they things you thought would be around forever? Were they techniques that were the "latest and greatest" only to be superseded in 5 years? What about personalities, traits, and qualities of our people? How about our patients?

Used to use a Datascope and LP5. Now we're up to a LP12 or LP15. 12 leads in the field, capnography, pulse oximetry, all that from one monitor. Used to be everything separate and HUGE.

Two man cots were the norm. What a pain! The amount of back injuries had to have been astounding during those days. Saw one a couple weeks ago and thought of how long ago it was when I used one. Then the one man cots came out with the Teflon runners. Still a pain to put in a bus. Now we have electric cots. Nicer to maneuver around but the added weight may be a concern for some. I think ours is about 27 lbs heavier than our old ones.

The old gumball lights on a truck's exterior used to be "it." Now a vehicle can be "Griswolded" up with LEDs. Man, what a difference! Sirens also have made neat changes. The old "Q" to the Rumbler, which I think is neat. I do like how a lot of departments have a Q on their vehicles in keeping with tradition or just because it's always been a reliable warning device.

AEDs have progressed mightily. They've been out since 1979. We got our first one in 1989 for $12,500 and it was the size of a large carry-on luggage bag. Had a nice screen to see the rhythm and it was damn heavy. Now ours are about the size of a big laptop and cost around $1400. The new ones can be "automatic" and do seemingly everything for you. Long battery shelf life, lighter, smaller, cheaper.

@IRLMedic mentioned BSI. Holy cow! Didn't it used to be a sign of a busy or "good" shift because of the amount of blood you had on your uniform? It was for me! Never brought another uniform to work if one got dirty. Nah, it just showed the other crews how busy I had been. Gloves? Safety glasses? CO detectors and monitors? I gripe at new EMTs and our rookies if I see them without gloves on, regardless of who the patient is. I'm not the best example but I also do a good job of keeping clean and not getting anything on me.

We are lucky enough to have received a grant for a Glidescope. It's a terrific tool that, in my eyes, is making intubation a lost art form. I love the fact that it helps keep our faces away from a patient's face in case of unexpected showers of vomit and other nasties and that it gives us a great color picture of what we're after. Expensive, yes. In a couple years the cost will probably be cut in half.

Our CPR changes have been rolled out this year. Seems like every couple years there's a change or two in store for us. This year they remove drugs and have even less emphasis on respirations. Used to be hyperventilation was good and airways were paramount. We could push drugs through an ET! Now if we can't get them tubed and no peripheral line we just put in an IO. With BIGs and EZ IOs IV problems are seemingly a thing of the past. IOs didn't used to be thought of in adults, just kids. Now they're becoming more and more standard first attempt on certain situations for time's sake.

We used to treat HTN in the field. We used to give a lot of bicarb, calcium and mag. Some of the other meds I used to carry were Brethine, Lanoxin, Mannitol, Decadron, nitro paste, among others. I think I'd be hard pressed to find those on a bus now with short transport times, if at all. MAST pants were the norm; Sager splints and build-a-boards; steel O2 cylinders. Just a year or so ago I got rid of an old bicycle pump suction unit I had in my supply closet. I remember when V-Vacs first came out and they were lauded because of the way they could suck up a can of Chunky soup in no time flat. Remember the old blue laptop case looking suction units that never seemed to have enough power to suck anything?

So, what's next? What else can be improved on? I'm trying to think of different ways things will be improved in the next year, 5, or 10 years. I'm amazed as I look back and see all the technological changes I've witnessed, how treatment modalities have changed, and how everything in EMS continues to evolve in to a new form of medicine, rife with technology and knowledge, fueled by exuberance, dedication, and longevity.

EMS will always be around and we will continue to change with it as it changes. How will you accept the changes we make?