Life On The Front Line

A few seconds can mean the difference between life and death when you are a paramedic.

“Nine-eighty-four for a casualty call please. Nine-eighty-four, can you clear?”

Must be a big job, I think as I move promptly to the radio. It’s the tone in his voice, the way he says, “Can you clear,” that evokes my quick response.

I lean over the front seat of the ambulance and grab the microphone. “Eighty-four, we’re just finishing the cleaning, we can clear,” I state, as I gesture to my partner Amanda that we will have to head off.

“Nine-eighty-four, you are heading to Maroubra [in eastern Sydney] for a toddler of unknown age who is a query code two, address to follow, over.”

My heart jumps. The odds of a young child surviving cardiac arrest are low at best. The only real hope we have is if the information is incorrect­—maybe the child has had a seizure. In any case, I’m flooded with dread.

“This is my first paediatric [cardiac] arrest,” Amanda says. “I’m glad we’re working together.”

Me too! I think. Amanda is a more-than-capable paramedic. We have trained together over the years and it’s a good feeling, knowing you can trust your partner.

“Take a left here,” she says. “Second street on your left is a laneway.”

I throw the ambulance around the corner and see a man waving his hands frantically. He indicates that we should head down the laneway. Then I see a woman with her arms in the air. There are people along three blocks leading to the address, signalling us in. There’s a real sense of intensity and urgency. I’m grateful for their forward-thinking. It has now been nine minutes since we received the call and we’ve travelled about 15 kilometres. It’s nothing short of a miracle that we got here so quickly.

There is already an ambulance at the address. This is typical for such cases, as it takes a minimum of two crews to manage the task. A supervisor would usually be dispatched as well. There can be difficult issues to address, such as the welfare of the parents and other people in the area, and unhelpful inputs from bystanders.

I come to an abrupt stop alongside the ambulance crew, which is working on a small, lifeless child lying on the grass beside the footpath. He is waxy white, and looks dead.

There must be 15 people standing silently around. All eyes are glued on us as we approach.

The houses look warm and inviting, and the area seems affluent. It’s the kind of street kids would play cricket in, with lots of picket fences. I catch a glimpse of a rose bush in full bloom.

There are two primary care paramedics. The trainee is performing external cardiac massage on the child.

“Two, three, four, five,” she counts as she pumps the small, lifeless chest.

The senior paramedic, a man I recognize, is holding a resuscitator mask over the child’s face. There is an oral airway in the child’s mouth so he can be artificially ventilated, which involves blowing oxygen into his lungs by squeezing a resuscitator bag.

The woman standing behind the airway paramedic is his mother. I can see the wide-eyed horror on her face. She has vomit on her face, which I assume gurgled up and out of her son’s stomach as she performed mouth-to-mouth. She seems oblivious to the vomit and looks as though she’s in a trance. She is unbelievably calm, something paramedics are always grateful for. The job is so much harder when bystanders are yelling or frantic, even though it would be understandable if they were.

The boy is wearing a nappy and his tiny body is exposed. There are no signs of life and the cardiac monitor shows the heart is completely devoid of electrical activity.

My chest feels heavy and my throat tightens a little. There is absolutely nothing good about this job. It feels as if there has been a terrible mistake we need to correct. We have to give him another chance! I think. We experience this intensity and urgency internally while outwardly we remain focused, diligent and calm. We all have a role to play in this resuscitation, and each part needs to be performed well if we are to gain a positive outcome.

The next steps are to implement more advanced resuscitation, which requires more invasive access to his respiratory and cardiac systems. Amanda will intubate the child and I will attempt to gain intravenous access.

I open the drug bag and pull out a small cannula. I slide the cannula into the crook of his little elbow. Nothing; he is too shut down. If we had access to his veins, we could start to feed adrenaline into his system and possibly excite and activate the heart. I plunge the sharp needle into the crook of his other elbow—another failed attempt.

One of the other crew members gives us a handover as we work. “OK, guys, Toby is 13 months old.

Apparently, his mother found him floating face down in the play pool. She did CPR immediately and we took over. Total down time so far is about 12 minutes.”

The four of us are working on the child in a tight circle; we all have our defined roles. I don’t think anyone present believes the child will survive. Of course, this doesn’t change our treatment; we give it everything we’ve got.

We insert an endotracheal (ET) tube into the child, give him a dose of adrenaline, then roll our little patient on to a spine board so we can carry him to the stretcher that awaits. We maintain cardiopulmonary resuscitation throughout, knowing that if we stop even for a second the boy will become deprived of oxygen and suffer brain damage.

I force my dread and anxiety down so I can remain focused and drive the 10 minutes to the hospital safely.

“How did it happen?” Amanda asks again as she draws up another dose of adrenaline.

“Yesterday he couldn’t unlock the gate, but today he could. He lifted the latch, crawled over and tipped himself in,” Mark, one of the other crew members, says as he maintains compressions.

“The mum had just done a first-aid course last week. She was doing a great job.”

We pull into the hospital driveway feeling grim. Our little boy is still showing no signs of life, meaning this is a failure, a terrible, unsuccessful resuscitation.

The medical team is all gowned up and ready to receive Toby. We’ve completed the job in less than an hour.

“Thanks, everyone,” Amanda says.

We look at each other, pulling off gloves and straightening our hair.

I take a big breath in and out.

We hang around feeling pretty sad about the whole affair and go through the motions of cleaning up. When we finish, we make our way to the emergency department to see what the team is up to. To my shock and surprise, they’re still working on Toby.

I had assumed that by now the little boy would have been pronounced dead. But what I see tells a very different story: Toby’s dad is holding mum. They’re standing on the outer circle as the team of doctors and nurses continues working on their son.

“Come on, Toby! Come on, little mate, pull through!” the father cries.

The staff specialist stands at the end of the bed directing his team. It’s as if he’s conducting an orchestra. Everyone with their clearly defined roles responds to his commands.

Then the doctor crosses his arms and says, “OK, stop compressions. Let’s see what’s happening.”

To my absolute shock, there is a response. Little Toby’s heart is generating a pulse.

“Come on, baby!” cries the father again. The emotion is intense. It feels as if we are all urging the spirit back into his little body.

Duty calls us to the next case and we reluctantly leave the emergency department. There is no immediate closure for us, no opportunity to express our support to the parents. With heavy hearts, we move on to the next case of the day, unaware that Toby is being wheeled upstairs to the intensive care unit.

“Nine-eighty-four, sorry to do this to you, but there is a motor vehicle accident down the road. I am going to have to ask that you clear.”

“Nine-eighty-four, copy that.”

I was 15 the first time I saw ambulance paramedics—known in Australia as ‘ambos’—at work. I remember the relief that came over me when they arrived to help an elderly man who had fallen over in the gutter. He had blood pouring from his face and I wanted so much for him to be all right. They confidently and quietly went about their business, assisting him to his feet and cleaning his face. They were respectful, which I liked. There was something about seeing this old man dusted off and returned to his feet that made me so grateful.

More than 10 years later I was that ambo, restoring chaos to calm and cleaning the streets of the fallen, wounded and unwell. At times I felt invincible, completely unaffected by the trauma and tragedy around me, hungry to improve my skills and increase my experience in the field of pre-hospital care.

In the first few years in the job, I learnt that a great day at work for me is often the worst day in someone else’s life.

We ambos describe ourselves as family. We see each other in our best and worst moments. I see my colleague sweat as he tries in vain to resuscitate a child, as he tries to hide his tears. And he will see me hold a grandmother's hand as she passes, quietly saying a prayer to honour her when no relatives are there to do so.

Most of the time we don’t shed tears. If I cried at every sad event I simply wouldn’t be able to do my job. The truth is I sometimes have all of 30 minutes between jobs and the next patient also deserves my attention and care, so I need to move on swiftly. Natural human emotions get stuffed inside us and it’s not until tragedy hits my own world that I’m even aware of the deep emotional pain I have buried inside of me.

My dad has always supported my work as a paramedic. At the age of 50, he decided to have another child, me, despite the fact he already had 10. The only downside to this, of course, was his advanced age. When the time came to sit with him in the intensive care unit following major abdominal surgery, every defence I had was stripped.

Convinced he was about to die, I got to experience what it was like to be on the other side of health care. Now I was the terrified family member. Dad’s heart rate jumped to almost 200 beats a minute, and I observed what I thought were his last moments in complete agony and despair.

Dad survived, and even though he was unconscious, he had one memory from his near-death experience: “It was beautiful, Sandy. I saw thousands of blue lights raining down and I knew they were blessings on us all. It was the most incredible thing I have ever seen.”

Dad’s experience changed my world. I knew that what we see with our eyes gives us limited perspective. When I was in terror, Dad was in bliss.

Since then I have continued to be aware that these two perspectives, peace and terror, are simultaneously possible. In every heartbreaking moment there is hope; with every death there is a dawn; and from every experience of being crushed, there is opportunity to rise.

Paramedics see terrible things, but we also see inspiring things. We see the great capacity of the human spirit, the generosity of the human heart and the good nature of most people.

So many people remark, “I couldn’t do your job. I can’t stand blood.” I don’t like blood either. I do my job for the love of it, for the love of life, for the experience of hope and goodwill and the desire to be of service. Yes, there is blood and sometimes plenty of it, but long gone are the days of chasing trauma. What excites me now is experiencing the remarkable resilience of the human spirit.

Waiting at the ambulance station six weeks after we last saw Toby, I feel strangely nervous. We’re exchanging pleasantries when I hear a voice calling out “Ambyonce! Ambyonce!”

There is a pitter-patter of small feet and a mother’s voice says: “Toby! Here, darling, let’s see the paramedics, then look at the ambulance.”

I turn around and see Toby running towards me. Everyone’s face lights up with wide smiles and tears fill every eye. Toby happily extends his arms for a hug.

“The doctors tell us he has some deficits, but we can’t tell,” Toby’s mother says. “It’s like it never happened. He is not even afraid of the water.”

We spend an hour together, taking photos and playing. I am awestruck as I witness what can only be described as miraculous.

This is an edited extract from Paramedic: One Woman’s 20 Years on the Front Line by Sandy Macken. Now available from Rockpool Publishing, (rockpoolpublishing.com.au) or amazon.co.in.