When the Smoke Clears

Warning: If you are in a great mood, don’t read. Seriously.

My friend brought up some things that still crop up in my life from many years ago. There are sights, sounds, smells that linger in the memory, too harsh to forget, too pointed to endure so they dull the flesh they pierce over time. It still bleeds, but I feel it less, recognizing the pain with detachment, growing stronger from the scars.

One of the most desperate times I experienced was over 12 years ago. A large assembly was gathering for a weekend of fun at a group campground. There were over 150 of us there, families, friends, distant relations. The weekend would include food, campfires, activities out on the lake, in the fields, etc.

That first evening, night was settling in as people drove to their cabins and began unpacking. I was on the western side of the camp with my cabin-mates, getting ready. We had some contingency plans for problems. This was in the days before the ubiquitous cell-phone so we had small radios for communication across the site in cases of coordination or emergencies.

A panting voice came over my radio. “Leslie fell down. We need a medic.” That was a demand for me to drop what I was doing and head over. At first I was asking questions about what was going on, thinking I had another twisted ankle to deal with, but the responses made me change my pace from a fast walk to a concerted run.

There was a circle around a long body on the ground. As I came closer a couple of people were kneeling next to her, shaking her. She was twitching. She wasn’t breathing. Her beautiful hair was bunched up at the back of her head on a pile of dirt where she had clearly fallen. “Sixteen,” I thought. “What could be wrong with a sixteen-year-old? Where’s her mother? Has anyone called her?” I knew Leslie was there with her mother and stepfather, both good friends.

I leaned in. Definitely not breathing, her color, from what I could see, had turned ashen. Someone else felt for a pulse, someone who had received some first responder training. I tilted Leslie’s head back and tried a first breath. It was my first scar of that night. The first responder told me she had a good pulse. I think it was desperation. Leslie was twitching slightly, but I didn’t believe there was a pulse. I turned to one of my friends and gave him a look and shifted my eyes off to the left in a clear, silent statement of “GO!” He turned pale, wide-eyed, but ran to find a telephone. Leslie let out a gurgling sigh. Those around me gasped in hope, I felt mine dropping. Agonal respirations. These are irregular breaths sometimes coming once or twice a minute. They aren’t real breaths. They usually mean the brain is dying of lack of oxygen or else there is a great deal of fluid causing pressure on the brain.

Another breath in and her lungs forced it right back out. I felt for a pulse, there was none. I started the chest compressions. Where was her mother? The sounds around me faded in my head as the world focussed downwards into this sweet, tall girl. I pulled another person over to do the chest compressions as I breathed for her. The occasional twitch gave me a little hope. I know it went on like that for at least 15 minutes but that eternity passed in an instant in my memories. At some point her mother was there, shaking. Then the ambulance.

We loaded her quickly onto a stretcher. They had not sent an “advanced” truck, the county did not have one available. It wasn’t their fault. We put her in the back. I informed the crew that I was also a certified EMT currently practicing and would be willing to provide an extra set of hands. They quickly agreed, a little unsure of what was happening. Leslie’s mother climbed in the passenger seat after being told she could not get in the back with us but could come along.

The oxygen bag came out. As we rumbled across the gravel and dirt for several miles leading to the highway, the hiss from the oxygen whistled in my right ear. The EMT with me was “in charge” and I let him know that, but while he was older, it was clear he was a little less experienced. His registry numbers on his patch were many digits higher than mine, indicating he received his certification very recently, years after me. When Leslie’s brain misfired and she again gurgled and sighed, he looked hopeful and stopped squeezing the bag, a glance at me. I put a hand on his between the compressions and shook my head “no,” squeezing the bag for him again.

Then came the next scar. As the ambulance finally made it to the pavement, through the wail of the siren I heard a scratchy, extremely level, desperately calm alto voice about to break. “S? Is my daughter still alive?” I still hear that question at odd moments.

The medic with me looked at me, nodding his head, eyes wide. They didn’t have an ECG on this truck. It was the most basic of trucks, but I was still holding out hope. However, we are taught to never lie or give false hope. “We’re doing everything we can,” I said.

They had no meds to give but we at least tried to get an IV and eventually established one.

The local hospital was a rural facility that mostly dealt with children with bad colds and the occasional elderly heart attack victim in one of its three rooms. The doctor was a weekend ER fill-in from a nearby university town. He knew what he was doing, in my opinion. The EMT with me gave him report and the doctor asked who I was. After vouching, they let me stay in the trauma bay with them.

The nurses were in shock from the long, tall, beautiful girl that lay on their stretcher. The doc wasted no time, immediately calling for an endotracheal tube, ECG and additional IV lines. The nurse next to me looked around, scared. Unfortunately I abruptly pushed her out of the way, went to the wall and pulled down a 7.5 F tube, “One of these,” I murmured gruffly, passing by her. I saw an intubation cart in the corner and pushed it in place. “Keep up the CPR!” the doctor ordered her to action. Handing the doctor the laryngoscope, I moved toward the ECG probes, grabbed the sheet of twelve little stickers and started tearing open Leslie’s clothes to put them in place. Another gasp from her, first one in several minutes, and then the doctor set about settling the tube in place.

We started drugs, we monitored for a heartbeat, we pushed on the chest and squeezed pure oxygen through a bag into her lungs. We were sweating hard for over an hour. Normally a “code” will be over in minutes. Doctors and emergency personnel know that with the brain death within a few minutes, there is no point in prolonging the situation. Including the time we started CPR back at camp, we worked on Leslie for well over 2 hours.

During the period in the ER, we had additional time to talk, to learn about who was in the room and I was able to explain who Leslie was. I think I earned the trust of the staff. Eventually the doctor looked at me. “I know you know the situation, but we can keep going if you really want. You make that call.”

Another breath from Leslie, the first in five minutes, and just as useless as all the ones that had preceded it. I knew where we were. Leslie was gray, her lips blued, her pupils “blown” and eyes already fogging over, with early indications of blood pooling. There was nothing, no sign other than that helpless breath.

Sometimes I curse the doctor for putting the call on me. It was his responsibility. On the other hand, I feel he never would have tried so long if it weren’t for my presence in the room, my attachment to this girl and her parents. I was 23 years old. How could I make that decision?

The nurse slowed down the chest compressions, the EMT slowed down squeezing the oxygen bag. And I stepped back with a silent nod. Another scar.

And again, another agonal respiration. “Damn,” the doctor said. “I hate that that happens.” We knew we couldn’t leave the room yet. We had to stand there with Leslie, waiting for her body to finally give up trying to grasp for the soul it lost some time ago. We couldn’t have her mother in the room if it happened again.

So we stood, waiting. Every couple of minutes another guttural sound, then, a very long pause. Ten minutes. Still nothing. The ECG machine was off. The tube clipped, and there we held vigil as the last of the chemicals in her system released, let go. We looked at each other. We talked a little. The EMT left to rejoin his partner and go to another call. Eventually, it seemed safe enough.

I walked out another exit, hoping to avoid my friends and Leslie’s mother for the time being. Someone drove me back to the campground. I can’t remember really how I got there. Everyone had a hopeful look on his face. I said the words to the crowd in the dining hall with no emotion, no buffers. “Leslie died three hours ago. There was nothing we could do.” Another scar, and immediately I became the rock. I was devoid of personal feelings, only facts about what happened and a shoulder for support. I tucked my grief away until later, after the wake, after the funeral, after I had shoveled the dirt for a half an hour into her grave, seeing her to the end. In that period, I had my final break with my father as well, he having gotten on my last nerve while he was drunk, I calmly telling him that he needed to walk away, he trying to beat me up again, but failing. I only speak to him coldly now, many years later, but at the request of my grandfather before he died I still speak.

It turns out Leslie had an undiagnosed condition which led to a weakening of the aorta and eventually an aneurism. From what we were told, even if she were in a hospital at the time she collapsed, it was still very unlikely that she could have survived.

And so things move on, yet the memories of every one of my patients crop up at odd times, thoughts of Leslie and the helplessness of that moment brought recently to my mind as I listened to some of the soldier medics. And there are the scars which I hide, but bear because I was called to that vocation, and I do not regret it: the sound of a mother’s voice searching for answers and hope I could not provide, the memory of standing there, hoping her lungs would stop struggling so we could get all this over with, a happy goth girl who hours before was listening to Cocteau Twins played loudly from her cabin, roughly knocking aside a nurse I barely saw who was unfamiliar with the equipment in her ER, the smell of red clay mixed in with the dirt at her grave. And worst of all, leaning down and forcing air into her dying form. Sometimes I can still taste her.

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