The side door of the ambulance slams, and the lever locks down. I inhale deeply from the rubber and metal of my seat as I buckle myself in shotgun beside the paramedic, my mentor for the evening. He is a short man, shorter even than I, with a worn uniform and a countenance far older. "Hi, I'm Jacob, you must be the new medical student." He pats down the gray pepper of his hair, then readjusts the rearview mirror.
"So -- have you ever ridden in an ambulance before?"
"No," I answer, though perhaps "not exactly" would be more accurate. For in my imagination, I have ridden hundreds of miles -- and in my evening studies, read hundreds of pages.
Jacob starts the engine and gears the van back into a slow reverse. Now I look into the mirror, hoping to catch a parting glimpse of my medical school, but it angles back for me only a blurred image from within our ambulance cabin. I stare again into the mirror, only this time more deeply -- and staring back is the image of my textbooks come alive. Along the walls, doors, floor and ceiling of our cabin hang mobile back boards, c-spine collars, emergency splints, intravenous fluid bags, cardiopulmonary monitors, shock paddles, endotracheal tubes, laryngoscopes, oxygen tanks, face masks, scissors -- so many objects, large and small, complex and simple -- even two boxes of Band-Aids taped to a shelf. I smile; a little boy stirs excitedly for adventure every piece of equipment in this vehicle. I have used them all -- in my imagination, and many in my classroom -- on myself, on classmates, on mock patients, on dummies. But despite the seemingly endless lectures, labs and simulations, I have yet to use even one piece of real equipment on a real patient in a real emergency. I lick my mouth and wet the dry roof with my tongue. The distance between learning a thing and knowing a thing, between understanding a thing and doing a thing, this distance is very palpable to me, and it tastes empty and dry.
"No," I answer Jacob, as we pull out onto the road. "I've never ridden in an ambulance before -- but I'm certainly looking forward to the experience." For that matter, any experience at all.
The radio squeals a sequence of tones; Jacob barks a string of code numbers in return. He lowers the microphone, then raises an eyebrow: "I think you've jinxed us." He speeds us toward the intersection. "There's a man down, near to us over on the West Side . . . control says to go stat . . . we'll pick up my partner later . . . here's your chance to 'experience' turning on the sirens." He gently folds his fingers over mine and guides my hand down across the panel. We flip a switch and turn a key. Suddenly, outside our van, flashing lights appear and horns howl.
My driver's instincts take over, and I startle, looking out across the traffic to avoid the approaching ambulance -- only we are the ambulance. Rows of cars melt away to either side, and these driver's instincts are once again assailed: we accelerate through one, two, then four red lights, running six stop signs before bursting onto the highway.
A few miles pass quickly before Jacob slows our van into the exit lane. He drops his right hand to downshift, then pauses to stroke his right leg. I stare at these motions long enough to notice a deformity shortening his right thigh, more than long enough to notice a familiar book propping up this thigh from below. In answer to my unasked question, Jacob winks, "I figured the Good Book was good for something," then grins, "I mean besides giving people first names."
His name is indeed prophetic, perhaps for him even prophecy. This biblical namesake was traveling to Canaan when he was attacked by a "man" with no name. And Jacob was left alone; and a man wrestled with him until the breaking of the day. When the man saw that he did not prevail against Jacob, he touched the hollow of his thigh; and Jacob's thigh was put out of joint as he wrestled with him. And although Jacob's leg was terribly wounded, he wrestled the "man" into a stalemate; but as the morning sun arose, the man had to flee. Then he said, "Let me go, for the day is breaking." But Jacob said, "I will not let you go, unless you bless me." It was victory by default. And he said to him, "What is your name?" And he said, "Jacob." Then he said, "Your name shall no more be called Jacob, but Israel, for you have striven with God and with men, and have prevailed." And so Jacob was renamed Isra-el in the ancient Hebrew, meaning "to wrestle with God."
As I imagine it, the limping prophet wrestled God into a stalemate. I hope soon to see my limping paramedic wrestle Death into the same.
We turn off the highway and enter a maze of gated streets and grated doorways. A single police car, red lights flashing, guides us quickly to our intended port. "Grab the gurney and O-2." Jacob motions me to the back of our van. I pack a portable oxygen tank and extra blankets onto the mattress as he unfolds the gurney legs on the walkway.
Two policemen hold open the door as Jacob and I go in with our stretcher. Jacob enters the house quickly, with what I imagine to be a practiced calm, but I feel like an uninvited dinner guest. This idle fear proves fact as I inhale the aroma of turkey: the family had been eating dinner, and their large television set still broadcasts the evening news. One story that will not be covered, however, is that tonight a 50-year-old businessman, husband, father of three, was having dinner with his family when suddenly he vomited, stopped breathing and fell to the floor unconscious. A paramedic and a medical student arrived to find, standing in one corner, two large policemen; huddled in the other, a distressed mother and three shaking children; and finally, fallen in the center before us, father, unconscious, frozen in agony.
Jacob kneels over our patient and begins to mumble the paramedic's ritual first blessing. He listens for breath sounds, feels for pulses, looks for skin signs. A rapid physical examination produces what is known as the initial assessment. "Breaths are short and shallow, less than five a minute. Pulse is strong and bounding at 60. Blood pressure is hypertensive at 180 over 100. Skin is acyanotic, good color, no diaphoresis. Left pupil is blown, right is mildly reactive to light. No spontaneous movement, vocalization or response to stimuli. No obvious sites of external bleeding. No evidence of trauma prior or secondary to fall."
Jacob turns his eyes up to mine as his mumble descends into a whisper: "Lower the gurney, this one's a catch and carry."
And with these few simple words, time -- my sensation of time -- is altered completely. The speed of each moment feels the same, yet somehow each holds more time than a mere quantum link to the next. My paramedic mentor has declared this a "real" emergency, and so we must get our patient into the ambulance and drive him to the emergency room as quickly as possible. Speed counts. Time has become a reality, this man's reality, our shared reality.
I hit a lever, and our gurney drops to the floor. The patient is a large man, easily weighing more than 200 pounds, and so it takes the four of us, Jacob, the two policemen and me, to roll him onto a bedsheet before lifting him onto the gurney. Jacob tilts the man's head and lifts his jaw forward to open his mouth. He lowers his own head first, to listen for breath sounds, then quickly locks down a mask across the patient's head. It is a face-sized plastic pyramid. The base is cushioned and opened to cover a patient's mouth and nose; the top is attached to a tube, then a bag, and then another tube, with oxygen flowing in from a small tank hanging over the side of the gurney. I lift a lever, and we four pull up the bed. Then Jacob and I march out the door and duck into the back of the van. "He's got a stroke, a CVA, I've seen this a hundred times; we've got to hyperventilate him, and I can't intubate him without trouble, his neck is way too short and fat for me to get a tube down his throat." Jacob begins squeezing the air bag rapidly between his elbow and knee; his other elbow levers up to point above his head. "Grab a nasal trumpet -- there, above my head -- and get a cream packet."
I rip open the packet with my teeth and coat the flanged rubber tubing with lubricant. "Insert the tube into his nostril as soon as I lift the face mask," Jacob says. "Remember to aim straight back; the nostrils go straight back." He lifts the face mask, then I push and twirl the tube into the man's nose. It slides in without resistance, and the flange settles onto the outside of his nostrils. Jacob replaces the face mask, then grabs both my hands and switches them with his own. "Keep him hyperventilated. Bag him as fast as you can."
Our horns howl, and lights flash. I kneel over the man and his head rolls between my legs like a limp, lifelike dummy. Only this head is far more than lifelike -- it is much warmer and coated in flesh, which wriggles with each bounce of the van. But, in this moment, in the ways that matter to me now, I discover that this human head is not really all that different -- in weight, in size, in anatomy -- from the medical mannequins upon which our class practiced the many techniques of airway control. And so I give myself up to this training, and it takes control of my limbs.
My right hand flattens across the forehead and presses down, placing the patient's head into the "sniffing" position, which should further open his air passage. My left hand presses the face mask over his mouth and nose. My ring and pinkie fingers cup his chin, pulling his jaw out, upward and open; the middle finger folds above his chin and against the base of the face mask; the index finger and thumb brace the mask spout between them. One knee steadies his rolling head, while the other fixes the air bag against my elbow, compressing the bag as rapidly as it fills.
There are moments in your life that change you for a lifetime. I will never know how many minutes tick before our arrival in the emergency room because, for me, time slows, then halts. I enter a Zen place, a centered moment in the eye of the storm, the calm in my battle. And in this sacred grove, colors are at their brightest, sounds at their sharpest. I feel as if I have awakened from a dream, from a long slumber, and this now-ness is my first moment of consciousness. I focus into a crystalline purity of purpose and thought. And this purity becomes one sacred act -- hyperventilation.
I look at the man's chest: his tight blue polo shirt expands and contracts with each compression of the bag. Despite his fat, or perhaps because of it, I see this chest clearly rise and fall, and my hope that his lungs are ventilating, hyperventilating, becomes more certain. Jacob believes that this patient has had a CVA, cerebrovascular accident, more commonly called a stroke. Given the patient's age, his gender, and what little medical history we acquired, it is probably an intracerebral hemorrhagic stroke due to uncontrolled high blood pressure. An artery has burst within this man's brain, and the blood is expanding and pooling within this sensitive tissue. Getting him to hyperventilate is in no way final treatment, just a "temporizing measure" prior to definitive care. It will decrease the concentration of carbon dioxide in the lungs, and therefore in the blood, tricking the brain's blood vessels into constricting, which lessens brain swelling and slows the bleeding. By hyperventilating stroke patients en route to the emergency room, paramedics can sometimes buy these patients and their doctors more of what everyone needs -- time.
And so I compress the bag again and again, as my mind drifts. The brain is just like any other tissue, and when it is injured, it swells. But, unfortunately, the brain is uniquely trapped, lying within a rigid structure, the skull, and so it has nowhere to expand. The pressure builds, pushing brain against brain, in this patient's case, superior colliculus against tentorium cerebelli, injuring his third cranial nerve. I stare down at the man's face, and his eyes confirm these suspicions. Anisocoria, a "blown" left pupil, dramatically larger than the right, gazes motionless into the cabin lights. Earlier, Jacob flashed a pen light across the man's eyes, and his right pupil shrank, then enlarged, but his left pupil remained in its grossly expanded state. Such dramatic and sudden unequal pupil size and reactivity is a classic sign of brain swelling.
I continue to hyperventilate our patient, certain of little but hopeful of much -- perhaps it will slow the bleeding within his brain, perhaps it will decrease the swelling, perhaps it will increase the oxygen to his brain. And perhaps we will arrive at the emergency room soon.
Behind me, Jacob recites as we wheel the patient into the emergency room. "This is a 50-year-old white man found unconscious at the scene, pulse 60, blood pressure 180/100, respirations shallow at 5 breaths per minute, anisocoria, with no spontaneous movements but withdraws to pain, Glasgow Coma Scale 7, hyperventilation performed en route for decompression of possible CVA." His voice rouses me from my trance, but still I continue the hyperventilations. A nurse's hand slides beside my own above the face mask, and a second hand replaces mine around the oxygen bag. I lift my linear time. Smells -- rubber and metal and turkey -- these smells have long since vanished, replaced now by the familiar hospital waft of antisepsis and ammonia. Noises return next, the loud hubbub of jabbering voices, and finally images refocus, white coats, sheets and drapes flapping past one another, above my head. I have awakened into the middle of a trauma suite.
Nurses, doctors and respiratory therapists scurry above orderly chaos, a strict economy of motion, with each procedure practiced, skilled hands flowing smoothly beside one another, and each procedure optimized, polished after years of endless repetition.
A hollow plastic breathing tube is inserted down the patient's throat, through his larynx and into the trachea. This endotracheal tube is then secured via inflation of a small surrounding air cuff. An oxygen pump is attached and the hyperventilations continue. An intravenous catheter is inserted into a vein of each arm; a nurse labels a fluid bag, hangs and primes this drip, then connects it to one of the two IVs. It is mannitol, essentially a mixture of water with an acidified simple sugar. This osmotic solution is intended to diurese the patient, driving some of the water his swelling brain tissues into this peripheral circulation and, from there, through his kidneys to pool as urine within his bladder. A catheter is inserted into the bladder via a tube threaded through the penis. This Foley catheter will collect the patient's urine into a clear bag, where it can be measured and even sampled for chemical analysis. The patient's head is scanned with a computerized tomographic imager, which produces three-dimensional X-ray images of the patient's brain to confirm that it is indeed bleeding profusely.
I look at what remains of the man upon the table. Two hours ago, he came home from work to share dinner with his family. Twenty minutes ago, an artery within his brain likely burst open, leaking blood into his skull. And now, lying here before me, that man, nearly dead, is transformed into this patient, nearly alive. A soup of electrolytes and enzymes bubbles within this fleshy sack rolled out across the trauma table. Every orifice has been violated. Attached at each end are tubes dripping fluids in and tubes dripping fluids out -- and somewhere, there is a face, a human face, hidden beneath a tight plastic mask pumping oxygen. Is the man living? Is the patient dying?
Soon, a neurosurgeon will place a shunt draining from the patient's inner brain cavities into his abdomen, where the blood will drip harmlessly away from its entrapment within neurologist will assess the extent of any permanent damage and work to rehabilitate the patient so he may resume his daily activities. And perhaps later still, a community physician will counsel the recovered patient on lifestyle, nutrition, exercise, weight loss, blood pressure, smoking cessation and appropriate medications to prevent future strokes.
But today, did we -- Jacob and I -- save his life? Did our transport speed really increase his odds of surviving? Did our hyperventilations really decrease the bleeding into his brain? If the man recovers, who will have saved him -- the community physician, the neurosurgeon, the neurologist, the emergency physician, the paramedic, the telephone dispatcher, the wife who frantically called 911? All of us?
Jacob is by the coffee machine, drinking from a cup, and he holds a second cup out to me. I savor the aroma. A deep steamy mocha washes away the odors of the night. There is rarely victory for paramedics -- mostly stalemates, mostly "temporizing measures." This night, like many nights, and akin to one long ago, Jacob wrestled Death into a stalemate. And at least for this patient, for this night, I joined in the struggle. And this feeling -- not of victory, but near-victory -- is near enough for now, perhaps more than enough forever.
And this feeling is unimaginable joy.
Adam Strassberg, a graduating medical student, is a frequent contributor to Stanford magazine.
