Warm And Dead

You’re not dead until you’re warm and dead!

It was a beautiful Alaskan early summer morning. Spring does not really exist in the 49^th state. You have winter, mud, and summer. Followed by winter. One day you are enjoying barbequing salmon in the backyard and having the snotlings yell pull every time you down another mosquito with the twelve gauge, the next thing you know snow is flying over the green grass and the truck is back in 4X4 mode. The twelve gauge doesn’t actually kill the mosquitos, but the noise scares them away.

Mark four years old, his dad Kevin and Mom Patti, were looking forward to spending a day on the river fishing. Not yet salmon season the family hoped to hook into some trout and spend a day puttering up and down the river just enjoying the outdoors. Kevin wheeled his pickup into the boat launch area and Patti helped guide him down the ramp. Mark, excited at getting the chance to go fishing, ran to the end of the dock. As four year olds are want to do he misjudged the ramp and his stopping point was about two feet past the end of the dock. A bystander saw the small boy accidentally hurl himself into the river and began screaming to Kevin and Patti. In moments a small crowd had gathered and peered into the murky water. The river at this juncture was neither deep nor swift.

Frantic with fear Patti hollered to several boats on the river that her son was in the water. Kevin joined in the ruckus and soon several small boats were circling close to the dock looking for the small boy. Kevin laid on his belly on the end of the dock and struck at the water with his hands. Jumping in to look for the boy would be certain death for any unprepared swimmer. This was after all melted glacier, and melted glacier does not warm up. Several people called 911 and in short order (20 minutes) the local jolly-volley crew was in route.

Just over fifteen minutes after the search started, the boy was spotted about 100 feet down river from the dock. A couple of anonymous fishermen pulled the blue and lifeless body from the river and headed for the dock. Even before the boat reached the dock one of the fishermen started CPR.

As they approached the dock Kevin jumped from the dock to the small boat and almost capsized the small craft. Kevin pulled the lifeless body of his son into his arms and sobbed. The fisherman understood this but also understood every second that the boy went without oxygen, was a moment closer to irretrievable death the boy would come. The fisherman asked for help from some bystanders and pulled Kevin and his son up onto the dock. They pried Mark from his arms and laid him on the cold wooden boards of the dock and again began CPR.

They kept up CPR for a short time until the ambulance arrived. The lead EMT unwrapped the BVM and opened the airway case to expose the O2 tank. She was asking an hysterical Patti what happened when she heard a familiar voice. Jason, the fisherman, bellowed out snatch and run, then went back to CPR. She recognized the voice. Jason was a state trooper and friend who she knew from the numerous accidents they had been on together. None of the other volunteers had arrived yet so Janet, the EMT, made a decision to load and go. She threw the airway case into the back of the rig, motioned Jason to bring the child, and climbed into the  back of the rig. The parents tried to follow but Jasons fishing buddy, also a state trooper, pulled them back and told them he would drive them to the hospital. Before they knew what had happened Patti and Kevin were in the front seat of a strangers pickup and headed to the hospital following an ambulance carrying their son.

Another stranger said he would park their truck and bring the keys to the hospital. This was hollered through the closed pane of the pickup window as it rushed from the boat launch area. Patti and Kevin never heard it.

Janet had the other EMT radio another volunteer and arrange to meet them at the main highway. It took about ten minutes to reach the main highway, the EMT driving the ambulance paused ever so slightly, and the side door to the modular rig opened and Betty jumped into the rig. Switching places with Janet she took over the BVM and continued to provide life giving oxygen. Janet told Jason to stand aside while she took over compressions. She asked Jason to pull her trauma shears from its sheath and cut Marks wet cloths from Marks body. When this was done, she directed him where the blankets were and how to crank up the heat in the rig.

It would be a long hour ride to the hospital.

Janet thought briefly about calling for an air ambulance but nixed the idea as impractical. It would take the air ambulance twenty minutes to get off the ground, twenty minutes to reach the scene, and another twenty minutes to return to the hospital. This was the same hour they could spend driving to the hospital, and it was warmer in the rig than it would be in the air ambulance.

After a brief rest for Jason, Janet asked Jason to take over compressions. She needed to get an IV started and get some fluids going. The monitor she placed on Mark just after loading him continued to show asystole. Janet had seen these drowning victims before. The core temperature gets so low they appear dead until they are warmed up. Although, only once in 22 years had she seen someone come back, and then, he never really came back all the way, mentally at least.

She held out hope for Mark. The river was under 40 degrees, and the child was under for a relatively short time. Janet and Betty took turns trading places, and Jason rotated giving compressions. It was the longest ride of their lives. By the time they arrived at the hospital they were drenched with sweat and eager to transfer care to the hospital crew. That would be me.

We were ready. We had a warmer from the OR and buckets of warm water ready to submerge the IV tubing to warm the fluid before it dripped its life giving warmth into his body. Not an approved method to warm fluid because if the IV fluid is too warm, it will cause the blood to coagulate and can kill the patient. We appropriated a thermometer from the kitchen and decided between it and the TLAR method (that looks about right) we went about the business of warming Mark.

Hands covered mark as the doctor rested his gloved digits on the small face and guided an ET tube into place. Other hands found the small penis and guided a foley through the small opening. Still other hands stretched out another limb and started a second IV. If you were to look at the scene as if an angel hovering from above, you might see a sea of hands going about their business trying to save a precious life.

Patti and Kevin looked on in shocked disbelief. Their lives would never be the same. Watching the small frame with tubes protruding from every orifice made them want to recoil in horror. This was their son, their future, the reason they rose in the morning to meet a new day. What would they do if he died. They alternated between streaming tears of grief and looks of tortured pain.

We inserted a real-time rectal temperature probe. When he arrived Marks temperature was 84 degrees. With the application of external warming it began to rise slowly. The problem with external warming is that over 60% of the patients who are hypothermic and need warming, die as a result of the treatment. Hypothermic patients need internal warming. Their core temperature needs to be raised from within as their basal temperature is maintained from without. I have cared for adult patients who we did warm water enemas and even lung lavage via chest tubes. A four year old is different. The body to surface area works against you. The small volumes of warm saline you might be able to instill and remove either through an enema or chest tube, just don’t make a difference.

We kept at it. The small body pinked up and the hum of the fans in the warmer began to sound deafening. An hour passed. No one spoke. What was there to say. Patti and Kevin looked on. As long as there were nurses and doctors and RT hovering around their son there was still hope. The temperature reading climbed. CPR continued. I took my turn pounding life into the small dead body. It was hard to detach yourself for something like this. I was working the 10 AM to 10 pm shift that day. This disaster started the moment I walked through the doors.

Two hours passed. His temperature continued to rise and approached the 96 degree mark. The physician glumly ordered EPI IV.

Administered.

Nothing.

CPR continued.

The physician ordered EPI IV again, followed by defibrillation.

Nothing.

Repeat.

Nothing.

The physician took the parents aside at the foot of the bed. He explained that we had done all we could. The parents reacted as expected, they broke down. The physician nodded his head and we ceased our activity and turned off the machines. We stepped back from the bed and I was left alone with the physician and Patti and Kevin. I draped my arms over them as they wept for their son. I’m sure their hearts turned cold that day, but,

You’re not dead until you’re warm and dead.

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