It had been another busy day in Rockingham County. It was hot and very humid, typical weather for summer in North Carolina. The pager sounded while I was finishing the paperwork from a call and was walking out of the emergency entrance of Annie Penn hospital in Reidsville. As I recall, the telecommunicator reported a possible "code 44", the Rockingham code for dead person. Communications reported that this individual was a juvenile and would be located under a house. The residence was located only a few blocks from the hospital, and I informed communications that my unit would be responding.

It goes without saying that Paramedics deal with calls involving the dead very often. By far, most of these deaths are of natural causes as in the elderly or severely ill. It doesn't take a new Paramedic very long for any interest or excitement in responding to these calls to wane and be replaced with the reality that the dead simply generate paperwork. Despite what many people think, most Paramedics aren't morbid enough to enjoy this type of call. My business involves the living. I can do nothing for the dead but write a report and sometimes transport the body to the morgue. So in effect, I can't help the patient and I have to watch the devastation visited upon the family.

A possible death involving a kid however is another matter. Kids aren't supposed to die. Sometimes they do. Paramedics, even with all of their experience with death, have as much trouble understanding and accepting this as anyone else. All of us respond to these calls determined that we will not allow this unnatural event to occur.

When a call involving a possible dead child comes over the airways, everything seems to move into high gear. In a real sense most Paramedics do everything the sames he or she would do while responding to any other emergency call. We don't drive any faster, get to the patient any quicker or assess and treat the patient with any more completeness than we would anyone else. But there is a definite increase in the tenor of the incident.

From the moment the call is received from communications, the pulse beats faster, the minutes until arrival seem endless and the radio seems painfully silent as you await word from the first responders. They will get there first and will hopefully tell you by radio that CPR is in progress, which implies that at least there is a chance. A chance is all you want. One chance to change the verdict. One chance to use your skills to appeal to God, to ask him to change his mind. Even those who hear it and are in other areas and therefore will not be responding feel it. It effects all of us.

I don't remember who I was riding with that day, but I do remember that we didn't say much in route to the scene. There is never a lot of conversation when responding to the calls that sound serious. Each person is locked into his or her own thoughts and counting the seconds until arrival, willing the truck to move faster, anxious for, and dreading the moment when we would arrive. And then the battle.

The first responders from Reidsville Rescue had arrived while we were still a few minute to the scene and radioed back that the patient was possibly electrocuted. They also reported that they were not yet in contact with the patient and were relaying information passed on to them by people on the scene. They said that further information was forthcoming but we would arrive before they could send it. Electrocution. Under a house. That meant that we were dealing with at most 220 volts. Without any more information, I had to assume that there was still hope if he wasn't down too long.

Rick T.. was the training officer for Rockingham county EMS. He was also in the area and heard the call. He responded in his staff car and arrived just after I did.

We arrived finally at the house. I grabbed my aid bag and monitor and moved quickly to the rear of the residence. There I found several people and squad members gathered around the entrance to the crawl space. Seeing us arrive, they parted somewhat to allow us access to a small doorway. "Is the power off?" I asked to no one in particular. We had no idea at this point what had electrocuted this boy. To enter the crawl space without turning off the power could result in us suffering the same fate. I was hoping that an officer from the Rescue Squad had taken care of this precaution and I was told that the power would be off any second and, as if on cue, shouts came from the front of the house that the power was off. Rick appeared at the doorway. I saw him but did not take the time to acknowledge his presence. When I prepared to enter he took the bag that I had placed on the ground. I saw him do this as I went into the darkness to find the patient and I heard him say that he was right behind me. I was soon to find that the person who had discovered the patient was still under the house. I placed my mag light in my teeth an followed his cries for help. It was not easy to get to the boy. My mini mag light offered very little light and the crawl space was no more than 3 feet at its tallest point and at many places the clearance was barely enough for me to pass through lying flat on my stomach due to the ductwork which extended down from the floor of the house to a point only inches above the ground. I removed the monitor from my shoulder and pushed it ahead of me on the damp loose dirt. I still remember the musty smell of the crawl space and the faint smell of something burning. The darkness made estimating distances very difficult. This was a fairly large house and the small amount of sunlight allowed in by the ventilation ducts was no help. The voice I was using to guide me to my patient seemed miles away as I pressed as close to the ground as possible in order to get under the ductwork. I was growing concerned that I had chosen a path that seemed to take me toward the cries, would not allow enough clearance to reach the patient. Rerouting at this point would take more time than the young man who I was trying to reach had. Each of the heating ducts seemed to be lower than the last and I had to exhale forcefully to pass under the last of them. When this last obstacle was passed, the small circle of dim illumination from the mini sized flashlight fell upon my patient.

He was located near the front of the house at near the farthest point from the entrance to the crawl space. The voice that led me to him was that of his brother. I recall that he told me that at some point. I never saw him in the darkness, and once I found my patient I forgot he was there. The boy was laying on his back. He was not breathing. I reached for his corotid pulse and found none. The ground in this area very damp even muddy in some places. That is why these boys were there. They worked for a company that weatherproofed houses. His brother said he was 17.

His skin was very warm. I positioned myself near his left shoulder. I could not see anything in the immediate area that would cause electrocution. I was beginning to think that maybe the cause was something else when I noticed that my left side was becoming uncomfortably warm. When I turned my light in this direction, I saw, not a foot away from me and only inches from the boy, a large drop light which was off but still very hot. The light was the kind that was large enough that if it were on, would probably illuminate the entire crawl space.

I used my mag light to trace the lights cord to a point where it connected to a large industrial drop cord. This drop cord was loosely wrapped around the patients left leg near the ankle. The patient was wearing shorts. It was instantly apparent what had happened.The boy had been moving under the house with the light in his left hand. He had wrapped the drop cord around his ankle in order to drag it along with him as he moved from point to point. The cord however was frayed and the wires had came into contact with the bare skin of his leg. He would have became immediately immobilized by the current, and since he could not remove the cord from his leg he would lose consciousness and stop breathing in a very short time. The power supply for the cord was 110 volt house current. That is not very high voltage but high enough to be deadly with prolonged contact.

I hope that he lost consciousness quickly. I hope that he did not have time tothink about what was happening. With the current passing through his muscles, he would have been unable to correct the situation even if he knew what be needed to do. The heat from the light had burned through his shirt and left deep burns which had blistered the boys side. I pushed the light as far away as I could and determined that I would try to resuscitate this boy.

I didn't feel good about our prospects for success. I didn't know how long he had been without oxygen, but it took us at least 5 minutes to get to the scene and a few more to get to him. After 6 minutes brain damage begins, after 8 survival is rare and even if the patient lives, brain damage is severe. I knew that the situation was grim. We could only try and hope for a miracle.

Every second that this boy was without oxygen made that miracle less likely to happen. We were racing the clock. In situations like this one you can feel the seconds passing like a progressive weight on the chest. Pressing harder until you have taken measures to breathe for the patient and keep his blood circulating. At least then the cells that are still alive have a chance. If enough of them are still alive then the patient may live also.

I wanted to breath for the patient using a bag valve mask. This is a device with a mask that fits over the nose and mouth and is squeezed to force air into the lungs. When hooked to an oxygen tank this device delivers a very high concentration of oxygen to the patient. I had one in my bag.

It was at this point that I became aware that neither Rick or the first responders had reached this corner of the crawl space. I could hear them coming and I could gauge their progress by the approach of the flashlights. Someone was also taking the same direct approach that I had took. It had to be Rick and I knew that he wouldn't be able to reach us by that route. Rick was bringing the aid bag. Although Rick could pass through just as I did, the aid bag was too large to pass under those ducts. I called to Rick and told him he would have to follow the walls of the house. A few first responders had gotten to us and I had extra hands but no tools. I couldn't wait for the bag. I began mouth to mouth respiration's and instructed the first responders to begin CPR.

As I breathed for the patient I began to attach the ECG leads to the boys chest. I had almost finished when Rick arrived and passed the bag valve mask to me.

The first responders had a very hard time doing compression's due to the low clearance. There was not enough headroom for them to position themselves directly over the patient. This did not allow them to use the weight of their bodies to press down on the patients chest. CPR is labor intensive under the best of circumstances. In the confines of the crawl space, it was nearly impossible and was wearing out responders quickly.

I turned on the monitor and asked the first responder to stop compressions so that I could see if any electrical activity was present in the boys heart. To my surprise, there was.

What I saw was not good, but it was more than I had expected. The boys heart was not beating but the tissues were not completely dead. There was electrical activity which was evidenced on the monitor screen as sharp jagged irregular lines. This is called ventricular fibrillation. Our objective in the presence of this is to try to organize this random electrical activity into a heart beat. We do this by passing an electrical current through the heart. Most people have seen this on TV and think that when we defibrillate a patient, we are using the electricity to start the heart. In reality we are doing just the opposite. We are momentarily stopping all of the electrical activity in the heart in hopes that when this activity resumes, it will be in the form of an organized heartbeat.

Rick prepared to defibrillate the boy. The defibrillator is connected to the monitor and has controls for the different power settings that it can deliver. When it is charging, it makes a sound like a camera flash only louder and longer. As I listened to this whine I noticed something which could be important. My knees were wet. We were preparing to deliver an electrical shock to a patient who was laying on wet ground and we were on that same ground. I honestly didn't know if the shock that we were about to deliver would be strong enough pass though the ground an into us, but I wasn't taking any chances. I Stopped Rick and told the first responders to move away from the patient. Rick and I made sure that our knees were off of the wet dirt and only our boots touched the ground. This was not easy feat in this cramped area.

I held my breath and Rick delivered the first shock. I felt no shock and figured that we were safe to continue.

The monitor still showed ventricular fibrillation and I considered moving the patient to an area with more headroom. Someone even suggested moving the patient out from under the house and resuming the resuscitation. I was tempted to go along with this idea because I kept banging my head against the floor joist while we worked. I decided against it. The clearance was not more than 2 feet throughout out most of the crawl space except toward the door. We would have to interrupt our efforts for the amount of time that it would take to move the boy. To drag him toward the door and into the area with more room would have required all of us and then would have been difficult without space. I didn't think we could spare the time. The boys chances were dwindling with each second. No, if we were going to do any good, we would do it here and now.

After increasing the power, Rick again defibrillated the boy. I was preparing to place a tube in his airway. This would keep the airway open and stop air from going into his stomach which would inflate it. This would put pressure on the diaphragm and make ventilation more difficult. This was very difficult. In order to do this I needed to insert a tool called a laryngoscope into the boys mouth and lift the epiglottis in order to visualize the vocal chords. Then I would place the tube between them. This requires a certain amount of distance from the patient to do properly. I didn't have enough distance. In addition to this, The second defibrillation was not successful and now there was nothing on the screen but a flat line. Without the tube in place or an intravenous line established I had no way of giving any medications that might induce more electrical activity in the heart. Some drugs, including the specific ones I needed to give, can be placed directly into the lungs for absorption. I couldn't visualize the cords. I couldn't place the tube. I had never been unable to place a tube before but I needed more room. I hadn't counted on this. I knew then that we had lost the boy.

We didn't stop the efforts but it was apparent that we could do no more under the house. An IV started under the house would have been useless. It would never have stayed in once we began to move the boy. We began CPR again and after a brief discussion it was decided that due to the lack of room, the first responders would exit around the walls of the crawl space but the patient would go out the way I came in. A Stokes basket was brought into the crawl space. This is basically a 7 foot platform with wire sides. A rope was attached and I would accompany the patient back the way I came, doing CPR as best I could. There wasn't enough room for any more people to do any good. Personnel on the outside would pull the rope on my command. We had great difficulty getting the boy into the basket because we could not use our backs to lift. If you would like to know what this is like, try laying on your stomach and using your arms to lift 200 pounds off of the floor.

I went ahead of the boy, using my legs to lift the ducts up as much as I could. I crawled along beside the boy when we were in between the ducts, doing the closest thing to CPR that I could. I would do some one handed compressions, squeeze the bag a couple of times and call for the rope to be pulled another few feet. It wasn't very close to proper CPR but I knew at this point it didn't really matter. The boy was gone and I silently cursed myself, the darkness and the crawl space.

When we finally cleared the last of the ducts, we had reached an area where there was room for more people to take the sides of the basket. I left my patient for them to carry out of the space and steeped into the bright sunlight. From the looks on the faces of some of the first responders, I must have been quite a site. Our stretcher was waiting just outside the door. Rick was standing beside of it. I walked to the unit to set up the IV and drugs that I knew would do no good. Rick had the first responders stop at the stretcher and placed the tube. The patient was brought to the truck and loaded. Someone had reattached our monitor which was now covered with mud.

As I started the IV, Rick pushed 10 milliliters of epinephrine down the tube. Eppi is given to help the heart generate electrical impulses. He followed this with another drug,

Atropine which is given to reduce the influence of the vagus nerve which can slow down the heart. This was before pacing in the field which would have allowed us to use the monitor to attempt to stimulate the heart to beat at a certain rate. All we could do was continue the CPR and give those medications every three to five minutes until we arrived at the hospital. The medications are used to give us a heart rhythm that we can work with rather than a flat line. The medications did no good.

We arrived at Annie Penn emergency department, the point where I started perhaps an hour ago. We turned our patient over to a team of perhaps a dozen doctors, nurses and respiratory therapist. They continued in the well lighted, dry and spacious trauma bay what we had began under such different circumstances only a short while ago.

I gave a report of our actions to the physician in charge and walked out of the ER. I went outside to the unit that was already being cleaned and restocked by the crew of another of our trucks that was still there after a call. I should have helped them, or I should have started to write my report of the incident but instead I went to the wall of the overhead shelter which covered the ambulance and sat down with my back against it. I hadn't wound down enough to feel physically tired despite the past hours exertions. I was however mentally drained, soaked, dirty and what was worse, I had failed.

I had already had enough failed resuscitation efforts to know that even when everything goes right in a "code" (resuscitation effort), people often did not make it. I knew that this boy was probably without hope long before we got there. But I couldn't get that tube when I needed it. I doubt that under those circumstances any one else could have. It would probably have made no difference but there was there was that nagging thought, would it have been different if I could have gotten that tube?. What if...? Its the what ifs that you take with you for the rest of your life. I did the best that I could but what if...

The shift supervisor came out of the ER and informed me that they had stopped the effort. Now it was official, the boy was dead. He asked me if I wanted to talk about the call. No I did not. What was there to talk about. He's dead and I felt like I had failed him. That's the end of the story. I appreciated the supervisors offer buttwasn't necessary.

All I wanted at that time was to finish my report, take a shower and get into a clean uniform, and finish my shift.

The patients brother came out to the ambulance entrance just as 1 was finishing my report. He had to tell me that it was his voice that I had followed to the patient. I don't know at what point he left the crawl space. He was obviously older than his brother by several years. Or perhaps his grief only made him look much older. He was composed but he had been crying. He shook my hand and told me that he appreciated all that~ had tried to do for his brother. He also told me what had happened.

He and his brother were working to waterproof the crawl space. His brother was working for the company for the summer. The older brother left his to perform some task on the outside of the space. When lunch time came and his brother did not come out, he went to the opening and called for his brother. He at first thought that his brother was playing a joke and told him to stop playing and come out. When he received no answer be crawled toward the drop light that his brother had been carrying. He found his brother but did not approach. This may have saved his life. He left the crawl space and called emergency communications and returned. He had the presence of mind not to touch his brother and we soon arrived. He asked me why the breaker did not disrupt the current when the boy came into contact with those wires. I had no answers for him. I was to later learn that it was a violation of OSHA regulations for the boy to be working in the crawl space. That knowledge made his death seem even more useless.

I apologize to those who have grew up on movies and episodes of "Rescue 911" and who probably expected a happy ending to this story. Despite what you may see on TV, in this business happy endings and miracles are hard to come by. They sometimes happen of course, but they are not as readily available as you may have been led to believe. This is the real world and these senseless tragedies happen every day.

To this day when I think of that call I feel bad about not being able to intubate that boy. I have ran this call a thousand times in my mind. I have thought about what else I could have done. I have asked myself maybe if I had moved him a little bit this way orthat maybe I could have gotten that damn tube in. Or maybe I could have digitally intubate him (Intubated him without the laryngoscope). I know that this kind of thought is useless but I still do it sometimes. But I did the very best I could for him. I wanted him to live as bad as I have ever wanted anything. You don't forget the times that you fail whatever the circumstances and you rarely speak of failing to other Paramedics. You just learn from it and try all the harder.