The Paramedic’s Role in the New Era of Dying: An Excerpt From Death Interrupted

Looking back on my first week as a paramedic, I recall running into a house for a VSA call. I remember his sunken temples, his stick legs, and his vacant eyes. He was just 24, dying of cancer. He had a pulse - barely - and I was so blinded by the adrenaline that all I could do was extricate him from his bedroom to the waiting stretcher to take him down the stairs. I’m convinced he died somewhere between the second and first floor of his childhood home, laying on that ancient canvas stretcher. Rather than recognize that death was arriving, I deprived that young man - and his family - of a few peaceful moments as his life ended.

In my role as a paramedic, death was usually clear-cut. Then again, there have been several incidents where I’ve failed to accept it, putting patients through the trials of modern medicine, knowing full well that there was nothing we could do to stop it.

As I changed careers to now work in hospitals, these challenging moments became increasingly more common, so I wrote a book about it. And as I interviewed experts and colleagues, I realized this dilemma we all face is probably stressing you out too. And it’s time we all started to talk about it.

The following excerpt has been taken from Death Interrupted.

CHAPTER 1:  Policy 4.4 

It all started in the bow of a canoe. I couldn’t tell you the when, exactly, since I was just eight weeks old, but in northern Ontario we canoe only three months of the year, when the long summer days make the experience enjoyable. My parents were traversing Crab Lake, which, contrary to its name, has no crabs in it, and the splashes dripping from the blades of their wooden paddles were hitting my face— something I strangely didn’t mind, they tell me, and a hint what was to come. A few hours later, in the middle of a black, quiet lake, my dad took me for a swim. I took to water like a fish. When I was old enough, swimming lessons became the weekly event to look forward to. When it was time to head to Buckler Aquatics, a private pool in an industrial area near the train tracks, I would happily abandon friends, toys, and Thomas the Tank Engine on TV. 

When I outgrew Thomas the Tank Engine, I became obsessed with dramas like ER and Baywatch. These were shows in which heroes would rush to perform mouth-to-mouth, or CPR, or defibrillation or emergency surgery, saving lives while looking damn good doing it. According to a study of TV resuscitations, survival rates on television dramas are far higher than in the real world. But I was hooked on a fictional world where lives could easily be saved.  

I continued my swimming, earning Bronze Medallion and Bronze Cross awards, which qualified me to join the National Lifeguard Service. I timed my lifeguard examination to come just after my sixteenth birthday, the earliest I could qualify. That summer, I began working at swimming pools at apartment complexes, a boring gig that bore no resemblance to the action-packed episodes of Baywatch that had glued me to the television screen. 

But at the birthday party of a fellow lifeguard, I was introduced to a couple of paramedics, and this eventually led me to chase in their footsteps. I enrolled in a paramedic program at a college just down the road from where I lived, and by 2006, a week after turning twenty one, I was a full-time paramedic, proudly suiting up in reflective pants and collared shirts to drive, lights and sirens blaring, from call to call, saving lives and looking, in my own mind at least, like one of my old heroes on TV. 

In my work as a paramedic, I pronounced dozens of people dead. It was, at the time, a relatively easy decision to make. The Ministry of Health in Ontario, where I served on ambulances and helicopters for a decade, had a list of things that qualified someone as being “obviously dead.” It’s the type of list paramedic trainees have to recite for exams and was colloquially known as Policy 4.4. 

It included things that didn’t really need to be spelled out in a list, like decapitation, rigor mortis, gross charring of a burned body, and obvious decay, which is a far more common thing for a paramedic to find than you might think. In some memorable cases, I pronounced people dead as soon as I stepped off the elevator; the stench coming from their apartment was unmistakable, and the superintendent of the apartment building always knew just as well as I did what we would find on the other side of the occupant’s door. 

I suppose that would make all the other deaths not obvious, at least if we apply the sterile language of Policy 4.4. But it wouldn’t take me long to make the decision. Pulseless, breathless, lifeless. We would perform an assessment, apply a heart monitor, but it was mostly perfunctory. Dead people have a look. As a paramedic, I knew it well. 

When death was clear, my work was done. There were no lights and sirens, no hustle, no TV-drama moments. With a look at my watch and a nod to my team, a life was determined to be over. Out came the shrouding white bedsheet (actually, they were a halfway between salmon-pink and faded orange), and I would head out of the room to shatter the life of a stranger. 

“I’m sorry to tell you this, but she’s dead.” 

Yet sometimes death was less clear. There would be no obvious criteria — the look of death had yet to set in— and my mind would race to determine what I could do to pull a person back from the cliff edge. Those were the times adrenalin junkies like me trained for, like an airplane pilot in a simulator when both engines fail. We had a term for patients like this: we’d say they were circling the drain, and we knew that look well too. We’d initiate a choreographed attack on death, two paramedics almost silently executing a series of steps drilled into our minds such that they were as automatic as blinking. 

We’d pound hard and fast on the rib cage to eject blood out of the heart. We’d place a breathing tube into the trachea and attach an oxygen-filled bag to it, squeezing air into the lungs like bellows blowing into a fireplace. We would slip a cannula into an arm vein to inject adrenalin directly into the blood so it could reach the heart expeditiously. And, if the stars aligned and we could detect electrical activity in the myocytes of the heart, we would defibrillate with an electrical jolt of 200 joules. Zap. 

Zap. Zap. Zap. My record is thirteen defibrillations on a single patient, far beyond the protocol’s threeshock requirement. On-scene in a kitchen, then in the driveway, then all the way to the hospital. That time, teams of firefighters rotated through the exhausting chest compressions, keeping blood flowing to the oxygen-sensitive brain, while another paramedic squeezed a ventilation bag. We used our knees and elbows to brace ourselves, sprawled out like spiders for stability, as the rig swung around corners and bounced down city streets, lurching us from side to side. 

Zap. Zap. Zap. 

We screeched up to the garage door adorned with its electric-red sign that said ambulances. With the sirens off, as we waited for the world’s slowest garage door to peel open, it was eerily quiet. We looked at each other, anxiety high. The patient was only forty years old and had collapsed in front of his wife, who immediately began CPR while his daughter dialed 911. If anyone could be saved, it was this man. I zapped him again as the back doors of the truck swung open. 

After an hour or so, the electrocardiogram was flat. The emergency doctor placed an ultrasound probe on the patient’s chest, angling it upwards to show an image of a heart that was still. The only thing left on the list of possible causes was a massive blockage high up in one of the two main coronary arteries that deliver oxygenated blood to the ventricles of the heart. Back in 2007, there was no fix for that. And the dozen or so professionals in the resuscitation bay looked around at each other, drenched in sweat, and sighed or frowned or closed their eyes or did whatever they did when a person was dead-dead. Then I went and got a latte because I was exhausted and there were still nine hours left in my shift. 

As a paramedic, I always felt limited: limited by my training, by my equipment, by the ridiculous rules that seemed to be written to make my shifts in the field feel like a job in a cubicle. I hated the feeling of dropping off a critically sick patient in an ER, never to hear of them again. Was my diagnosis right? Did my treatment work? As a paramedic, I never really knew. 

I was hungry for more than I could offer in my role. I didn’t dislike being a paramedic; in fact, I loved it, and I often think it was the best job I’ve ever had. Whether on an ambulance roaming the streets of Toronto or in a helicopter two thousand feet over rural Ontario, I had found my calling. But something was missing, and I wanted to find it.

Excerpted from Death Interrupted by Blair Bigham. ©2022 Blair Bigham. Published by House of Anansi Press www.houseofanansi.com.

Blair Bigham, MD, MSc, EMT-P, is an award-winning journalist, scientist, and physician who trained in emergency and critical care medicine at McMaster and Stanford Universities. He spent the first decade of his career as a flight paramedic before pursuing medical school. He was a Global Journalism Fellow at the Munk School of Global Affairs and an associate scientist at St Michael’s Hospital. His work has appeared in newspapers, magazines, newscasts, podcasts, and medical journals. His first book, Death Interrupted: How Modern Medicine is Complicating the Way We Die, was published in September 2022. He is a member of EMS World’s Editorial Advisory Board.