I can’t exactly remember how many hours I worked that day, but let’s say it was only a 24-hour shift, just to keep things easy. It was my first Independence Day after transferring to my new location. I’d been laying some steady groundwork getting to know the area and protocols and establishing myself as someone who knew what they were doing. At this point, I was working on, what many would consider, the worst truck in the quad-cities. The hours were midnight-to-midnight out of a busy station, which meant I was leaving for work when most people were just lying down to go to bed.

For the first 18 hours, I had been working with Briana – an EMT I was familiar with, and I felt we worked well together. But she was getting moved to another truck, and Dustin was coming on at 18:00 (6pm). I’d never worked with Dustin before, and as a new person in the area, I was always hesitant about working with partners I’d never met. I wasn’t concerned with his competency – so far, everyone I’d worked with had surpassed my expectations. But you never know how you will vibe with someone who sits two feet away from you for 24 hours (in this case, I only had 6 hours to go in my shift).

Dustin and I clicked pretty much right away. It was the height of the pandemic, and I’d noticed many people in the area were sick of being cooped up in their homes. It seemed people thought the virus would die off in the summer heat, like the flu and other winter illnesses. We sat in the truck and swapped stories of our careers so far.

He was (and still is) very young but was doing well for himself. He made a similar commute to work, although he was coming from the north and I was from the south. He described his drive home after a long shift in the middle of the night on dark, windy roads and I was glad my commute took place on the freeways that were typically better lit.

Around 21-22:00 (9-10pm) a call kicked out for “difficulty breathing” for an elderly female in respiratory distress – something we’d gotten all too familiar with during Covid. I ran down my list of expectations for the call and told him how I usually run this scenario but that if he noticed anything I missed or wanted to perform any interventions within his scope to clue me in and treat the patient accordingly.

Of course, like all good EMS stories, this one took place on an unlit dirt road way back behind all the trees. It took us a good ten minutes to get through town and find the address in the pitch black. And of course, like many of the neighborhoods way back in the woods, the house sat on top of a steep, unfinished dirt driveway that had a clear bend toward the house.

Not that I didn’t trust Dustin’s driving, but I got out and guided him up the small hill, watching my footing on the tiny craters made by the pickup trucks parked in front of the garage – and wishing I’d zipped my boots up before I got out of the ambulance.

As I crested the hill, a man in a wheelchair sitting on the front porch waiting by the door. Occasionally, our dispatch information is incorrect so I assumed he was the patient. He looked like he was doing okay and I could see that he was breathing – so I continued to back the ambulance to get a bit closer to the house.

“Hi there!” I called out over my shoulder to the man. “Are we here for you sir?”

“No! For my mother!” He called over the sound of the engine and the backup alarm.

Okay, so dispatch hadn’t gotten it wrong.

“Oh, I’m sorry. Is she still having trouble breathing?” I asked, waving my arms at Dustin through the sideview mirror to continue moving back.

“Well…” he paused, “I mean not anymore. She’s stopped breathing.”

WHAT.

I threw my arms in an X to signal Dustin to stop immediately and I threw the backdoors open. “We might be working a code.” I called to him up front as I frantically threw our gear onto the gurney. We threw on our N95s and bolted through the door.

We were inside within seconds and found our patient – an 84 year old female – unconscious and not breathing lying on her bed. Dustin checked for a pulse at her throat and wrist on one side and I checked on the other. I shook my head and Dustin confirmed he didn’t have a pulse either. She was warm, meaning – hopefully – she hadn’t arrested too long ago.

Seamlessly, we lifted her limp body to the floor and both of us noted the foul stench of urine that now covered our arms and pants.

No, we didn’t pee ourselves. When we had lifted her, we hadn’t realized she was incontinent and that we were now elbow deep in urine.

I started compressions while Dustin fished out the defib pads from our cardiac monitor. He handed them to me and took over pumping this poor old lady’s chest. I grabbed the defib pads and started to peal off the backing, but something didn’t seem right. I think I stared at them for a solid 5 seconds before shouting, “These are peds!” and throwing them over my shoulder.

Since Dustin wasn’t a regular on my truck, he knew precisely where the defib pads were in the monitor, but he’d grabbed the pediatric pads on instinct. After I discarded the pads over my shoulder, never to be seen again, he said, “Oh, I grabbed the ones out of the left side because that’s where we usually keep the adult pads on our truck.”

It was no big deal. The biggest part of CPR was underway – the compressions.

I applied the adult pads to her chest and asked Dustin to pause compressions.

The line was flatter than my seltzer after sitting in the ambulance cupholder all day.

We resumed CPR and utilized a BVM – a bag-valve-mask we use to breath for patients who can’t breathe for themselves.

One of us – I can’t remember if it was Dustin or me – spotted the fire crew walking up the driveway through the window. At that point, I realized I hadn’t brought a radio inside, and they had no clue what they were walking into. I didn’t know if Dustin had hailed them on the radio before we’d gone inside to give them a heads up on the patient situation.

“We’re working a code!” I called out when I heard their footsteps in the hall.

I didn’t even have time to register who was on the crew because I was flying through all the protocols in my mind at once. So far we’d been on scene for fiveish minutes and we had basic CPR in progress with an EKG.

“What can we help you with Holly?” Brandon asked as he crouched down next to me.

I quickly ran through what we knew so far: 80-something-year-old female. Her son had called for difficulty breathing, but on arrival, we’d learned she had been in respiratory arrest for at least 10 minutes. She was warm to the touch with no rigor and still pink in the face and limbs, so the timeline given to us was probably accurate.

The fire crew began pulling different items out of my jump bag and starting IVs. For a minute, I felt completely useless but I didn’t know what I should be doing. Brandon took over compressions and switched with Dustin intermittently.

The fire captain (who is also sometimes the Battalion Chief, I can’t remember which role he was playing that day) came in with the patient’s information.

“Her name is Linda, she’s 93. Son says she wasn’t acting right so he helped her to the bathroom and back to the bed. She normally gets around on her own without a walker or cane.”

I looked up from my position at Linda’s feet and over my N95 I looked at Dustin. He was sweating bullets. Then I realized I was drenched in sweat too. It had to be 80 degrees when we walked in the room initially (the elderly like it warm) and with 6 bodies working in a cramped space, the heat was unbearable.

“Does she have a DNR?” one of the firefighters asked.

I all but facepalmed. How the HELL could I have forgotten to ask. If she had an order of Do Not Resuscitate then I’d just violated this poor woman’s last wishes.

Captain spoke up. “The son thinks she does but he doesn’t know where it is. Holly, do you have a med list or history?”

I was clearly not needed in this room. The work between fire and Dustin seemed to be running just fine and I needed some air. So I admitted that I hadn’t gotten much information on my arrival and that I’d step out to find it.

Walking into the kitchen, the son and a woman who identified herself as a family member, but wouldn’t say how she was related, was able to guide me to her “File of Life” – a nifty little document that I recommend everyone obtain. There she had her name, date of birth, all of her allergies, medications she takes, and chronic illnesses.

And on the bottom of the list, in pencil, were the words “Do Not Resus” underlined twice.

Of course, some words written in pencil on basically nothing more than notebook paper does not equal a legal document. But it was something. That, and her son’s inkling comment about a DNR made me think it existed somewhere that we couldn’t find.

“Hey, Holls,” Captain said, “I pulled her up in the system and one of our crews ran a call here around one o’clock this afternoon. She had a fall and signed a refusal.”

I looked at her medication list and saw that she took a blood thinner.

“Her son says she hit her head and passed out, but she was really stubborn and refused to go to the hospital. She was vitally stable and oriented so they couldn’t take her against her will.”

I could do the math in my head. Fall with a head strike plus blood thinners in her system equals brain bleed.

“That makes sense,” I said. “The son also said she started losing her mobility suddenly tonight right? She hemorrhaged from the fall and slowly bled into her brain.”

“So what do you want to do? It’s your code.” Captain watched me pull out my phone and start to dial the hospital.

“Can you get me all of the vitals we have so far? Blood sugar, pupils, and print me out an EKG? I’m going to make the call.”

He nodded and turned the corner back into the room. A moment later he handed me the EKG strip – still flatline – and the syringes from the drugs we’d pushed so far.

“She got three epis, and 2 milligrams of Narcan – just in case. She’s got an iGel for an airway and we’re on round 5 of CPR.” I took all of the information and wrote it on the back of my gloved left hand. With the EKG and her File of Life, I dialed the hospital.

“This is medic Nasello on Medic 1, how do you copy?” I rambled – this line was starting to become second nature. When the nurse on the receiving end confirmed she could hear me I continued. “I’m calling for a time of death. I have Linda LastName, DOB [93 years old]. Her son called us tonight for her difficulty breathing. On arrival we were informed she had stopped breathing approximately 5-10 minutes before we arrived on scene. She was pulseless and apneic but still warm and pink with no rigor -“

“Does she have a DNR?” The nurse asked cutting me off. Just for the record, I can’t stand being interrupted. I never remember what I was saying.

“Well,” I huffed, “that’s the thing. The son tells us she does but we can’t locate it. I did find her File of Life and written on it says ‘do not resus’. I get that’s not a DNR, but it’s all I got. So far we -“

“So is CPR in progress?”

UGH.

“Yes. We have completed five rounds of CPR, we’ve administered three of epinephrine, and two milligrams Narcan, we are bagging her with an iGel and BVM. Additionally, it turns out she had a ground level fall today with a head strike. She does take blood thinners but was alert and oriented when fire assessed her at around 1pm, and signed a refusal. Son says she wasn’t herself tonight and couldn’t get around on her own like normal. So at this time we are looking to stop CPR and call TOD.”

I knew it was a long patch, and the nurses on the other end don’t have time to listen to a long spiel. But in the end I think most of us can agree that deciding to stop saving someone’s life is a pretty big decision and we need all the facts to make that happen.

There was a short pause and a beep from the recorded line. The nurse came back and said, “per [doctor on duty] time of death is 22:18.”

I copied the TOD and thanked her. Then I hung up and walked back into the room.

“Alright guys, we’re done. Doc called TOD.”

Everyone stood up and immediately wiped their foreheads with their forearms. It was noticeably warmer from all of the bodies and movement than it had been when we first entered. We covered Linda with a blanket and left her in the care of the police until she could be transported to the morgue.

Outside was a different story. I walked over with Brandon, removing my N95, to deliver the news to Linda’s son that we would not be continuing CPR and that she had died. That’s the word you have to use. Died. You can’t say “she’s gone” or “she’s passed.” You have to be direct and clear. And that is still the hardest thing to tell a family member.

As Linda’s son was grappling with the news of his beloved mother, who he had lived with for the last 10 years, he asked so many questions. “What did you do to help her? Why couldn’t you save her?”

I was thankful in that moment that Brandon had my back. He was able to explain the situation in a way that I struggled with. As Linda’s son finally accepted that there was nothing anyone could have done, the tears fell from the corners of his eyes. He started telling us stories of how she’d taken care of him after his accident that landed him in the wheelchair and how he’d taken care of her in return.

My own tears started streaming down my face. In my mind I knew Linda was 93 and we can’t expect people to live forever. But looking at her son grieving at the sudden loss of his mother, I couldn’t stop the waterworks once they started.

The woman who said she was a family member patted his back. “Well, we know she’s got the best firework show going on in Heaven tonight.” Everyone, even Linda’s son, smiled a little. They both thanked us for what we did and we gave our condolences.

Back at the truck, Dustin had already cleaned the equipment and restocked our jump bag. I was ready to bolt but the fire crew and Dustin gathered around me and told me I did great. I told them I felt embarrassed for crying and being bothered by something that was so common practice in our field.

Brandon gave me a hug. Dustin told me he’d give me a hug but that he was covered in old lady urine. That made me crack up. It’s the dark humor that gets us through sometimes.

After that call the radios were quiet until it was time to go home. I thanked Dustin for picking up the last 6 hours of my shift and told him to let me know if he ever wanted to pick up an overtime shift with me.

That call solidified my friendship with a new partner that night.

Holidays can be difficult for people. While we’re supposed to be celebrating, life begins, goes on, and ends without rhyme or reason. I think about Linda’s family on the 4th of July and I like to imagine they choose to celebrate her life. I try to picture them sending up fireworks as a message to Heaven that they haven’t forgotten her.

To this day, Dustin and I still wonder what happened to those peds pads I tossed behind me and will randomly shout to each other “THESE ARE PEDS!”