Look of death

A new partner and I respond to the home of an elderly female for difficulty breathing. We mark en route with our dispatch, and light up the night sky with flashing red lights. I have a habit of cracking jokes and making wild guesses as to what the diagnosis will be, my partner laughs loudly as I tell her I am too sore to do CPR because I have been "workin on my guns" all day (as I flex my embarrassingly small biceps). The jokes are simply a stress reliever for both our benefits, not meant to poke fun at someone at their time of need.

We pull up to an older, well kept house, and grab our kit. My partner and I make our way up the stairs and knock on the door. I open the door to an ominous site, a lady lies helpless on the couch, staring at the ceiling, working as hard as she can to breathe.
I kneel next to her, and place my fingers on her wrist feeling her weak pulse. I call out to her as my partner places a non rebreather over her pale-blue mouth and nose. She moves only her eyes to look at me, unable to speak.
I place my stethoscope on her chest and listen closely, upper lobes of her lungs sound like a popcorn machine, lower lobes are silent. It is obvious this lady is full of fluid, flash pulmonary edema at it's worst. I quickly sit her up to allow gravity to pull the fluid to the bases of her lungs allowing more surface for gas exchange. I notice a younger woman standing in the corner of the room, I ask her a few questions.... but the reality is, it does not matter how this started, this woman will be lucky to make it to the hospital.

I again recognize my lack of ability as a basic life support provider, I look my now flushed partner in the eyes and say "skip that (noting the blood pressure cuff in her hand) Let's go"
She immediately tosses the cuff in the kit and zips it up. My new partner having only 3 months experience, looks to me to identify immediate life threatening illness and relay the urgency to her.

I crawl behind my patient and cross her arms with mine, my partner supports her legs and we simultaneously lift and set her on our cot. I sit the cot up as high as I can, and do up the seat belts. I tell her daughter who has been watching from the corner of the room, she should follow us to the hospital. My partner lifts the cot into the ambulance and I follow close behind.

I plop myself onto the bench and wrap a blood pressure monitor around her arm. I grab a bag-valve-mask, and explain to the patient I am going to help her breathe, she pushes the bag away and does not allow me to assist her respiration's.
I pull my radio off my hip and call the receiving hospital, short and sweet I say "We are bringing you a flash pulmonary edema with global hypoxia, prepare for respiratory arrest, ETA 3 mins"
The nurse recognises my voice and replies "OK Mobey we'll set up the tray". I am lucky to have earned the trust from the nurses at our hospital, they know when my voice changes pitch, I will deliver a critical patient!

The blood pressure monitor finishes as I apply the leads for the ECG.
BP 178/102 Pulse 164 ECG Sinus tach Respiratory rate 36 laboured and shallow O2 sats 76%.
We are now only blocks from the hospital, there is no time for any other treatments.

We back into the bay and pull the stretcher out, I note that her resps have become even more shallow and the patient looks fatigued, she is lying her head back on her pillow, and closing her eyes frequently. I grit my teeth, knowing she won't keep this up much longer.

As I wheel her into the trauma room, passing her daughter in the hallway, the doctor, 2 nurses and 1 student, listen intently as I tell them a story like an actor from ER the TV series.

The nurses grab the sheet from beneath the patient as I count aloud 1-2-3, we all lift and plunk our tired hypoxic patient onto the hospital bed.
As soon as she is on the hospital bed I grab my stethoscope for another listen...... nothing... the silent chest! She is full of fluid, no room for air anymore. I wrap my stethoscope around my neck and grab her hand, I say in a stern voice that demands attention "she is no longer moving air, her chest is silent". The tired old lady squeezes my hand as the nursing student clumsily assembles the bag valve mask. For only a moment my eyes directly connect with the patients, she has a look that cannot be explained, if you have never seen terror in a humans eyes, you will never understand what I saw. My eyes stay locked with hers, and I say in a soothing voice "Work hard for me, I know it is hard, but you are not alone", urging her to work as hard as she can to move air. The student applies the bagger to her face, and with her last bit of strength the patient bats it off her face.
Her eyes still locked with mine I watch her pupils suddenly dilate, and see her chest has stopped rising, her body goes limp and life slips away.
I lay her bed flat and signal the student to start bagging her, I check for a carotid pulse and find nothing.
A nurse tries time and time again to start an IV in her arm, but the lady's veins are so fragile they rupture with the slightest prick of a needle.
The doctor calls out "I need a line... now." I ask for an 18 gauge large bore cathlon, the student looks at me and asks where I am going to put it. I smirk at her like the cocky PCP I am and ask the nurse to elevate the patients legs causing her jugular vein to engorge. I swipe the ropey vein with an alcohol swab and plunge in the large bore IV, time seems to stop as I wonder to myself what the hell I'm doing attempting such a rare procedure in front of veteran nurses and a doctor. I wait nervously to see the flash of blood fill my needle aware that all eyes are on me. I watch the blood flow up into the chamber and attach the drop set, I say with pride "IV established".
The doctor immediately orders epinephrine be pushed through the IV taking note of the flat line on the monitor.... but it is no use. We intubate the patient, start CPR and "work" her for over 20 mins. But to no avail.
The doctor calls the time of death, and I assist the nurses in preparing the body for viewing, I remove my IV I was once so proud of, and show the nursing student how manipulating the head and applying pressure to the cricoid cartilage will stop stomach contents from filling the mouth as she pulled out the ET tube.

I rip my gloves off and push the curtain aside as I leave the room, I pass the pacing daughter and she looks at me with question in her eyes. It is not my place to inform family of a patients condition when they are in the hospitals care, so I drop my eyes to the ground in front of me and show no emotion. Some of the nurses congratulate me on starting an external jugular IV for they have never seen one before, I force a smile out and say thank you, pretending I was not affected by the events of that evening.

I have worked many cardiac arrests, and have seen much tragedy, but I will never forget the day death looked me in the eyes!!