Sugar Sugar, oh, Honey Honey...

He was a charming old fellow, full of interesting stories and rustic jargon that grew better only from age. As the captivating words continued to pour off the old mans lips, his wife was quick to correct some of his recollections and would abruptly butt in, as if right on cue. An endearing smile spread across his face and he referred to her as the “minister of interior”, alluding to her power in the household. We all had a small laugh about it while gathered together in his living room. It was a cozy setting and one of the better parts of my job. I wish I had time to stay for tea but my presence was more than a social visit. He was in his 70’s and an unflattering site, his dentures had been removed, making it difficult for us not to crack a smile when he spoke. There was sugarpaste glistening all over his leathery face, and a bloody bandage on his arm. He was in this condition because of the way we had made his acquaintance 30 minutes earlier.

 Just 30 minutes prior I walked through his doorway. It was a large apartment and the entire living room opened up into a vast area with vaulted ceilings and decorative lighting. There was a big yellow wrap around couch and a variety of comfy furniture and typical household decor that you might expect. However, even from the doorway he stood out to us like a beacon in the night, slumped over on the couch loudly mumbling incoherently and moving his legs as if he was riding an invisible bicycle. It was a queer site and certainly caught my attention. I took a knee next to him to check his vital signs but had to take evasive action immediately afterward. He starting swinging his fist at me and screaming. While avoiding his flailing extremities, we spoke with his wife. She informed us he's a diabetic and that he gets like this if his sugar gets to low. I caught one of his fist with my hands and held his arm down firmly whilst my partner poked his finger with a small needle. The bright blood slowly began to ooze from the wound and formed a perfect droplet, delicately clinging to the pad of his finger while the rest of his body was busy break dancing. We pressed our glucose monitoring strip against the blood drop and it began to analyze his sugar level. A few seconds later the reading came back as very low. I opened our medical kit and took out the oral glucose, which is essentially just sugarpaste. I began to slowly squeeze the tube of sugarpaste  in his mouth, but he was more interested in trying to bite my fingers off. His sugar level was so low that he was extremely confused and very aggressive. I needed to keep my fingers for other things, so I had to develop another plan. I got his wife to come over, selfishly hoping she didn't need her fingers as badly as I did. However, also hoping he would recognize her enough to calm down, and he did for a moment, which is all we needed. I assisted her with squeezing the remainder of the sugar in his mouth while he continued to scream, kick, and mumble incoherently. He was struggling and sugarpaste was getting all over his face in the process. It took 2 of us to hold him down while giving him the sugar, 15 minutes later and 2 tubes of oral glucose later, he was the same. It was at this point I noticed his false teeth had become loose and he was beginning to choke on them, we quickly removed them, placing them off to the side while trying to avoid being bit He had decimated our entire supply of sugar gel like it was a diabetic appetizer.

I had to move on to more invasive procedures which I was hoping to avoid. We assisted him to the floor and gently laid his head on a couple of pillows. The old man was a fighter, he was not going down easy, he began fighting, kicking and swinging. My fingers wrapped around his his left arm and I held on tightly as the large needle punched through his skin like a pincushion. As expected,  he became more livid and was struggling with more might than ever. I had managed to locate a large vein on his arm which perfect. There was not much time and it took a lot of strength to hold his arm down while the needle was in it. It was like trying to perform surgery on a rodeo bull, one wrong move and the needle would either go through the vein, miss it completely, or destroy the puncture site. The angle of the needle dropped and the teflon catheter surrounding it slid off with ease, advancing deep into the vein. I taped it down quickly, far from a work of art, but it was in. My partner connected it to the iv bag of glucose, but it was imperative the catheter remained in his vein, despite his physical movement. IV glucose can only be administered in a vein, if it touches normal tissue it destroys it. Obviously this was a risk we had to take given his condition, but we had to confirm the IV was good. I aspirated blood from the site, this was my confirmation that I was indeed still in the vein and not in the tissue. So I cranked  the administration wheel to wide open while holding the IV in place, my partner squeezed the bag, shooting the glucose directly into his veins and through his entire circulatory system.  Within a minute the man stopped fighting, minutes later he began to come around. After titrating the amount of glucose and re-testing his sugar level until it was at an acceptable level I slowed down the infusion. He was fine and began speaking with us. He apologized for the inconvenience and thanked us for coming to help. I don’t think he had any recollection of trying to kill me or bite my fingers off, but that's probably for the best. We disconnected the IV and bandaged the site while chatting with him for a bit and giving him tips on how to manage his diabetes.

The Code

I interlaced my fingers, stacking one hand on top the other while firmly placing the palm of my hand on his chest. I pushed down hard and fast, as soon as the chest recoiled I plunged back down on it. The young man was in his late twenties and had called the ambulance for trouble breathing. Unfortunately when we arrived we found him not breathing and with no pulse. As we continued CPR and slipped a simple oral airway down his mouth, I attached the cardiac monitor pads to his chest in order to see what rhythm he was in. We paused CPR for a moment so I could examine the rhythm on the monitor. The room was silent and the family was surrounding us in the living room, hoping and waiting. Unfortunately it was a non-shockable rhythm, so I went back to bombarding his chest with compressions. We really wanted to get him back for a couple reasons, his young age, and the time he had been down. My partner and I switched roles, he took over chest compressions and I began to ventilate the patient. We continued switching back and forth every 2 minutes and even managed to start an IV before our backup arrived.

Once the second ambulance crew arrived we gave them a report and assigned one of them to begin administering intravenous adrenaline, while the other took over chest compressions so I could take a look at the guys airway. I was not sure why this young man stopped breathing. I questioned the family and he had no known medical conditions. At this point we had been doing CPR for well over 10 minutes with no changes, so I went to intubate the patient (place a breathing tube in the trachea). I also began to become suspicious that maybe he had choked on something so I also needed to look for anything that may be lodged itself in his airway. I performed a laryngoscopy and suctioned, but saw nothing out of the ordinary. However, while I was perusing deep into the depths of the man's throat I encountered a problem. The breathing tube was having difficulty passing his vocal cords and I could not get it to advance. I had to go to a backup device known as a "combi-tube." The combi-tube is a monstrous and large device that you blindly insert down someones throat when intubation is not possible. I lubed it up generously and shoved it down his mouth as the family gasp and screamed. After securing it we were getting good ventilations with it and had given the man several rounds of IV adrenaline by now, but still no changes. Normally we would consider terminating efforts after about 20 minutes and pronouncing the man dead, but due to the unusual nature of this cardiac arrest and his young age, a few members of the crew decided they would feel more comfortable transporting him to the emergency department, so we did. They continued working on him at the hospital, between us and the hospital he had been worked on for over an hour, but he was a goner. Although not the most creative writing this week, I just wanted to share what we do on "a code" for those who may not have been familiar. On average we get a code about once a week on my shift.