She looked happy. And beautiful. She wore a white wedding dress that flared at her hips and followed fit form well. The dress looked elegant and very, very expensive. Her smile lit up the picture with those straight white teeth. They were so white that I’m not convinced they didn't whiten her teeth a bit after the picture was taken. He stood to her left with his hand around her waist. He looked happy, too. I could see in his eyes that any smile bigger than the one he was wearing would look goofy. He had to tone down his happiness to look “normal for the picture,” and that was… beautiful. His eyes were dark and so full of life. They both had great tans, too. I guessed she had planned for their skin to look “picture ready” on that day, and it looked good on both of them. The picture was vivid, with green trees in the background. They were standing in a vintage white gazebo with chipped paint and a rough look to the wood. It worked well with the aesthetic of the picture. The happiness seemed to jump out of the frame. The edge of the frame is where the happiness ended, though. Outside that picture frame was a dimly lit wall that was a dark blue with white trim around the bedroom door to the left and the frame of the bathroom door to the right. It didn’t quite sit well with the bright, wonderfully happy picture within that frame. 

The lighting didn’t align right with it either. I enjoy museums so much that I know the lighting of a picture can make or break the entire essence of a good scene. This picture needed museum-quality lighting to pull that happiness further into the room. Not all pictures are worthy of lighting like that, but this picture was. It had all the makings of an art piece that would never be fully appreciated. This picture was surrounded by blue, slightly crusty walls, bad lighting, and death. 

But that wasn’t them. That was a picture. Right now, she was behind me down the half flight of stairs. She was pacing back and forth in the living room while he lay to the right of the picture, right outside the bathroom. She was also with her teenage son, who sat staring at the floor, not saying a word. There was also a teenage daughter in a room directly to my left. I could easily touch the doorknob if I wanted to. She had locked herself in her room before we got there, and I never saw her. A police officer was also standing downstairs next to the wife, ready to assist in anything we might need but also standing close to the wife for support as well. The man lying on the floor was wearing grey sweatpants with holes in them and a stained white T-shirt. His hair was messy and disheveled. It looked like it hadn’t been washed in days, and the dirty hair smell was evident if you got close enough to his face. He looked to be in his late thirties, maybe forties. You could tell he worked out, but he was nowhere near as fit as he was in the picture. He was at least 15 years younger there. He lay under that picture with his head awkwardly under a small table that was in the hallway. He looked like he could have fallen asleep here after a rough night of sickness or maybe drinking. Everything about his physical appearance could have been normal. Except for the fact that his face was a deep shade of purple, his face was ever so slightly swollen, and he wasn't breathing. He was dead. 

I heard three things at that moment. The mechanical whir of the CPR machine (Lucas Device) doing compressions on him, the shuffle of my coworkers doing their jobs without speaking, and I heard a voice as vivid as someone speaking into an earpiece. Oddly enough, I would even say it was a voice in my right ear. Maybe it was because he was to my right? I hear it whisper- almost pausing for effect even before it began speaking- “ You are never going to forget this moment.”

Because I was working the position of “writer” that day, I would immediately jog to the patient before anyone could grab their equipment out of the ambulance. The driver puts the truck in park, and I've already opened the door and unbuckled my seatbelt. (For legal reasons, I have to tell you that I always had my seatbelt on when the vehicle was in motion. Ok, chief? Just to make sure that point is crystal clear.) With experience and confidence, good medics can usually get to a patient in under 15 seconds from the time they arrive on the scene. Usually, the crew has to finish getting their gloves on, grab a plethora of equipment, and, today specifically, navigate the long, icy driveway with all that equipment. We do that so a member of the team, with radio communications, can get hands on a patient as quickly as possible. There are times when the dramatic saying “seconds count in emergencies” rings true, and we plan for it. 

Today, I stepped out of the ambulance and reported over the radio, “Rescue 1, Engine 1 on scene,” and walked quickly to the door of the house. I was greeted by the panicked wife. She was wearing shorts and a tank top. She appeared older than the picture, but she had maintained her health well. You could tell she focused on her body still, and it showed. She was a little heavier now, but it looked good on her. In another life and another time, I would have even said she was attractive. Blonde hair with great high lights and low lights. Light blue, panicked eyes. She even had that great tan and those straight white teeth. 

In my career, I have realized that, at times, pleasantries and formalities go out the window. Emergencies are emergencies, and I may not say hello if I'm trying to save your loved one. You can find a complaint submission request at the end of this book if you have a problem with any first responder being rude during an emergency. (professionally rude, of course). Today, I walked into the house and said three words. “Where is he?” She pointed upstairs to my left. She was standing in the same room that she would stand for the entire event. She never left that thick off-white carpet for the length of this forty-minute call.

As I immediately turned to take the stairs two at a time, I yelled back to her- “what's his name?” I know that she told me his name, but I honestly don’t remember because, in the next five seconds, I knew I wouldn't need to shake him and yell his name. I could skip that part of the ACLS (Advanced Cardiac Life Support) Algorithm because his face was purple. He was dead. When you have seen so many sick, dying, and dead people, you gain a quick eye for knowing if someone is dead. Most experienced emergency medical personnel can walk into a room, look at a patient,  and know if a CPR event is viable or not. I knew within 5 seconds that this man was dead, and we would not be reviving him today. I would even say five seconds is about average or maybe even a little slow to know if someone won't be making it back to the land of the living. 

I knew. And my crew would know soon, too. I still had to follow protocols and do what I needed to do. I stepped over him, put my gloved hand on his corroded artery (neck), and felt for a pulse. I knew where to look, but I wouldn't find it, because it wasn't there. I also watched for any breathing in the ten seconds it took for me to “look” for a pulse. No breathing. He was warm to the touch. It’s not a normal warm, but not room temperature either. That also gives a hint as to if a patient is viable. If they seem to be “cooling off” in a normally warm environment, they won't be coming back. He wasn’t coming back.

I grabbed my radio and quickly said, “ Rescue one to engine one, this is a CPR” This tells the crew a few things- Get all the shit. Fill the stretcher with all the gear and get your asses in here. I need help. It also tells them the scene is safe and that I have made contact with the patient. The second incoming engine, as well as dispatch, all take note that this call is a confirmed CPR. It perks the ears of the crews around us that we may need help later on. In just nine words, a lot is said. Efficient.

I put my radio back in my clip and move my hands to the correct position on his chest,   square my shoulders above my hands, and push down hard. What I will describe next is something that everyone who has experienced remembers well. The feeling of ribs cracking under your hands. I push down and feel his first few ribs give way. 

In reality, it's usually the cartilage connecting the ribs that commonly break. Severing the connection between the sternum and ribs. This usually doesn't cause physical damage to the heart or lungs, but it can. Ribs do break and can puncture anything in the chest. In my experience, once this connection has been severed, compressions become much easier. There is much less resistance holding the chest together. This lets you get a deeper push into the chest (approximately 1/3 the depth of the chest or 2-2.4 inches). As I feel this resistance gives way, it gives way in sudden pops. Like the deepest, hardest back crack you can imagine. Skin never breaks, and there will probably be bruising, but you feel it. You can hear it, too. That faint pop. Pop pop…….pop. I push maybe a little harder. Like pushing my head hard into a wave so that I can get to the other side faster. There are only so many ribs. Only so many connections to severe. I push again. Pop. Pop. I hate this so much. It’s like burning memories into my palms. I've felt this feeling before, and I know it goes away quickly, so I push again. Pop. Again. Again. Again. No pops. The second worst part of my day is over. I can start to let my mind go back to what needs to be done next instead of forcing myself to power through this horrible feeling in my hands.

My crew is walking up the stairs. As the “writer,” it's my job to get my hands off the patient as quickly as I can so I can back off. I need to gather medical information and start to piece together what may be going on medically. I need to grab my iPad and start to interview bystanders to see where our efforts may need to go. 

I hear myself say, “No visible trauma. He was lying like this. Can you take over so I can move this?” As I point to the table that is a few inches from my head. The way he was lying and positioned in the hallway made more sense for him to take over compressions as I shifted to remove everything from around the patient’s head. My coworker quickly got on his knees next to me as I shifted away. The small table had a surprising amount of knick-knacks on it, and it would take me several trips to clear it all. I grabbed a handful of things and looked into the room to my right. There was a bed. Good. I start to throw things on the bed. Hey. As long as you have good aim and can hit clear parts of the bed every time, then so be it. And if you break a family picture on accident, I think the family may understand. I don't know. Just a thought.

Well, shit. I can't move the table without hitting his head. The way he fell put him under a support beam, and if I moved it, it could unnecessarily move his head. I tell the crew, “ Hey, we need to move him down like six inches” 

This crew is experienced, and within a few seconds, his head is clear. Now we had a “big” place to work. If a hallway can be seen as “big,” I step over the patient’s head, and around my coworker's back to squeeze by. I need to talk to the wife. I pick my iPad up while heading down the stairs and start my interview. “What was his name again?” She said his name again, but I still don't remember it. I honestly couldn’t legally tell you if I wanted to. (Google HIPPA)

“What Happened?” I say. Nothing but professionalism right now. I know the info I need to get, and I am going to get it. 

“I…I don’t know.” She stammers, ”He hasn't been feeling well and has been sick the last few weeks. He said he wasn't feeling good this morning, then went up to bed.”

“When was he last seen…” I stop myself.  I almost asked her when he was last seen alive. She probably knows what I know, but there is still hope in her eyes. There's hope that help is here and we are going to save him. We aren't going to save him. I don’t want to crush that hope yet. I’ll have to crush it, but I’ll do it in about 35 minutes.

Legally, within our county, we have to do CPR for half an hour, with few exceptions, before we can terminate resuscitation efforts. Studies have shown that performing CPR in the back of an ambulance is much less effective than on solid ground (who knew, right?) Because of that, we have rules (protocols) that dictate when or when we shouldn't transport someone in cardiac arrest. As paramedics using ACLS (advanced cardiac life support), we do everything an ER can do when performing CPR. We give the same meds, the same electrical therapy, and the same level of care you would expect from a team of doctors and nurses in an emergency room. The only difference between an ER and a paramedic crew performing CPR is where we do it. They do it in a well-lit emergency room with a plethora of equipment and staff to spare. We do it all,  and, today at least, in a small, dimly lit hallway up a half flight of stairs. 

“When was he last seen normal?” I ask as I start to type on my iPad. There’s a lot of information that will be coming at me, and I'll need to be able to type and hear at the same time. I can hear her voice as she tells me his medical history. I can hear the hope fading as she stands and stares at the backs of my coworkers while they work on her husband. This is the worst day of her life. 

Her voice begins to become more distant, and I know. I know that look. I don't even have to look up to see the look on her face. I don't want to look up and see it, but I do. I see the blank stare. The look of disbelief. As much as I want to say something comforting or give her hope, I know I can't. I can't give her hope when I already know her husband isn't going to be revived.

My job isn't to comfort her, though.  I want to, but I can't. I get the rest of the information I need, then turn and go back up the stairs. As I get to the top of the stairs, the image of that picture is seared in my head. I let myself look at it for a few long seconds. That was when I heard that voice tell me I will never forget this moment. And it was right. I never will.

My crew fills me in on what I already know- no heart activity is being shown on the cardiac monitor. He's been in asystole since the beginning, meaning the monitor has shown the infamous “flatline” the entire time they have been working on him. The worst part of my day is going to happen soon and I start to steel myself to the thought. The worst part is I know how much longer, down to the minute, before I have to tell her. 

Once the thirty minutes of ACLS (Advanced Cardiac Life Support) is done, I call the doctor who reviews this specific case before we stop resuscitation efforts. He agrees that its time and gives me the official TOD (time of death). My crew looks at me for the official nod that they can stop, and I give it. Now its time. Its time to tell her the news. I had done the rest of my reporting in the empty room to the patients right, where all the contents of the table were still on the bed. Now I have to step over him and weave around my crew who are beginning to clean up the equipment they were using.

I go downstairs, and all of this seems like a formality. I could probably not make a sound and walk out of the house right now and she would know exactly what's happening. She had been pacing back and forth and, when she saw me, froze. Her body half frozen in place, awkwardly turned away from me mid-pace. Her face is frozen. She knows.

I hate this. This was so hard, but I had a job to do. I didn’t want to see that look in her eyes. That lost, empty look. But it's there. 

“Can you please have a seat?” I say in the most respectful solum tone I could muster. I didn’t have to say anything after that. She knew. I knew. Her son knew. We all knew what I was about to say. 

“Oh god, I know what this is.” She whimpered.

I didn’t know what to say. She was right. She knew what this was, and I still had to do it. I still had to tell her. I spoke slowly and deliberately, but my voice was shaky. I couldn’t hide my emotion. I tried to be professional, but I knew the room knew I felt it too. I felt that look in her eye.

“When we first arrived, there was no cardiac activity. We have been doing CPR for half an hour and we haven’t seen any change in his heart rhythm. I just got off the phone with the hospital, and they have agreed for us to stop our resuscitation efforts.” …I must be direct. I feel like I’m being so cold. Should I let myself show my emotions too? Should I be professional? I hear myself say “I’m sorry to say this, but he is deceased.” Professional it is. I’m sorry I sound so cold. I’m so sorry he is gone. I’m sorry for the look in her eyes. I want to say sorry over and over, but I still have a job to do.

She finally turns her body to sit down, but she can't. “I don’t know what to do,” she stammers.

I’m throwing so much on her right now. I want to hug her. I want to let her cry and tell her it’ll be ok. I can't though. I have more. I have more to say, but I want to walk out. I want to leave this room. I want to stop seeing that look in her eye. 

“We are going to clean up and head out, and this police officer here will walk you through the rest of what's going to happen now. I am so sorry for your loss ma'am.”

“I don’t know what to do.” She says again. 

I know. I know what she meant. Just like that, he’s gone. She doesn’t know what to do. I wouldn’t know what to do if I were in her shoes either. I’m sorry I can’t help more. I turn to the police officer, seeing it on his face. He can feel the room, but he has a job to do too. He takes the opportunity and begins to tell her the next steps.

Thats it. The worst part of my day is over. I just told a woman that her husband is dead. I've done it before, and it won't be the last. But I fucking hate it. I turn to leave and I’m thankful that is over. I don’t want to turn and see her face anymore. I don’t want to see that empty face full of disbelief. I can leave now, and I do. 

 As we clean up, there's a sense of solace among the crew. We all just experienced a very traumatic event. We all feel it too, but this is the job. The mood soon begins to shift back toward positive things. Finally, after talking about what needs to be restocked and technical things, someone cracks a joke and we all start laughing. As I settle in the passenger seat, I tell dispatch “Rescue 1 clear of the scene. We’ll be en route to the hospital for restocking”. We are done with all the report writing that I’ll have to finish up before lunch.

Lunch! I forgot that lunch was taco salad. Taco salad is my absolute favorite lunch, and I'm excited to get back to it. I hope we don't catch another call before we can get back to the station.