I spent many Saturdays riding the volunteer fire department ambulance as the EMT-in-charge. I often rode with Frank during my rookie year. Frank had one more year of volunteer experience and was a qualified ambulance driver. Frank told me on December 18th that he got a job as an emergency department technician. He would no longer be part of the volunteer fire department. Frank was moving on to another medical school resume-building activity.

Christmas Eve fell on a Saturday and the fire station was noticeably empty that evening. There was minimum career staff working and most of the volunteer Saturday night duty members would be “monitoring their pager” from home. Frank was gone, pulling his first overnight ED Tech shift at the hospital. The career county firefighter assigned to drive the ambulance decided we would use the Cadillac instead of the Ford.

It was unusually warm that day, almost getting to 60. I started what would become a career-long tradition by wrapping my Christmas presents at the fire station. The ambulance made a handful of responses with 3 trips to the hospital by the time I hit the bunkroom at 11 pm.

The Red Phone Rings

She woke up to her husband gurgling in bed around 2 am. When he did not respond to her shouts, she called the county emergency number 691-2233. The Red Phone rang in the fire station bunkroom and we were headed out for a “trouble breathing” call.

There were no dispatcher CPR instructions, no paramedics, no defibrillators, few EMTs and a rare fire company response with an ambulance for a medical call. Just an 18-year-old volunteer EMT/firefighter and a 24-year-old county firefighter in a Cadillac ambulance with a 472 cubic inch motor.

If we needed assistance once we arrived, I would need to call dispatch on a telephone or run out to the ambulance to use the fire radio. We were still responding when the engine company was dispatched to “… assist the ambulance with a cardiac arrest.”

Suction, Oxygen, CPR, and Gasoline

We took oxygen, suction, and the ambulance aide bag into the house. Her husband was still face-up in bed, but now his face was purple. We pulled him off of the bed. We rolled him on his side and suctioned his airway. He was not breathing. Rolled him back onto his back, inserted an oral airway, and started 2-person CPR with demand valve ventilation.

The next clinical intervention would be gasoline. Rapid transport to the emergency department was all we had left to offer. I was so happy to hear the wail of the engine’s Federal 2QB siren getting louder.

“The Latest in Resuscitation”

The volunteer fire department purchased a Heart-Lung Resuscitator (HLR) to be used while transporting CPR patients. The firefighters became proficient in setting up this oxygen-powered plunger and ventilator.

An early lesson learned was that using a Reeves stretcher with the HLR machine made it easier to move the patient to the ambulance.

You had to use cravats (triangular bandages) to tie the plunger to the Reeves stretcher handles. This kept the plunger from traveling from the sternum to the throat during ambulance transport. The automated ventilation feature was never utilized – it was designed for intubated patients. We used a bag-valve-mask or demand valve resuscitator.

With thin staffing Christmas Eve, the three-person engine company immediately set the ambulance up for a fast departure and brought the HLR and Reeves into the house.

None of us had training in customer service or crisis counseling. We rocketed out of the house with the HLR thumping on his chest. We left the wife with a medical mess in the bedroom and no updated information on the condition of her husband. The police officer at the scene helped her get to the hospital.

No Clinical Change In The Patient

Beyond the skin color going from purple-to-gray, there was not much else that changed during the high-speed 16-minute transport. We probably exceeded 90 miles an hour on Interstate 495. I was glad that we were using the Cadillac instead of the Ford modular rig.

I sat in the captain’s chair operating the demand valve resuscitator and monitoring the HLR plunger position. His pupils remained fixed and non-responsive to light.

It was cumbersome getting the HLR unattached to move the patient onto the emergency department stretcher. When I stepped up on the stool to start chest compressions in the emergency department I could see the soft tissue damage done to the patient’s chest by the plunger as it walked around the sternum. The patient remained in cardiac arrest. The physician looked into the patient’s eyes and said “I see boxcars” and stopped the resuscitation.

Boxcars refer to a pattern that occurs in vascular stasis with the segmentation of the venous column—of blood in the retinal vein—after central retinal artery occlusion. It was used as an early indicator of brain death. (1979)

A Devastating Night 

A 16-year observational study that looked at holiday-related triggers for acute myocardial infarction showed that Christmas Eve poses the highest risk in Sweden. (2018) .

Frank did not know that when he started his first overnight shift as an emergency department technician. Since 11 pm most of Frank’s work has been processing patients who have died in the emergency department.

That includes inventorying their belongings, putting the corpse in a body bag and moving the corpses to the morgue.

Frank processed 1 trauma, 1 suicide, and 2 cardiac arrests between 11 pm and 3 am. Like the fire department, the hospital was thinly staffed.  The emergency department manager told Frank that his EMT experience should make it easy for him to process the dead without a lot of hand-holding.

Our patient was declared dead at 3:07 am on Sunday. This was going to be the 5th corpse Frank would have to process and transport over to the morgue. He was starting to get that two-thousand-yard stare.

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Feher, J. & Antal M. (1979 June) Ischemic retinal alterations in cardiac arrest.  Annals of Opthalmology 11(6):909-13.

Mohammad Moman A, Karlsson Sofia, Haddad Jonathan, Cederberg Björn, Jernberg Tomas, Lindahl Bertil et al. Christmas, national holidays, sport events, and time factors as triggers of acute myocardial infarction: SWEDEHEART observational study 1998-2013 British Medical Journal 2018; 363:K4811 https://www.bmj.com/content/bmj/363/bmj.k4811.full.pdf 

Ward, Michael (2018 December 31) The Two Thousand Yard Stare: 4 ways to Improve your Resiliency. CompanyCommander.com Reston, VA: Gold Badge Enterprises LLC. http://companycommander.com/2018/12/31/the-two-thousand-yard-stare-4-ways-to-improve-your-resiliency/

Feature photo is a representative of the type of high-top Cadillac ambulance used.

Elements, identifiers, and sequence of events may be altered in “war stories” to protect the innocent or work better as an example.