The EMS Diaries - Gogo Miriam, Pandemonium and the Grim Reaper

So close to saying goodbye to her daughter, but the Grim Reaper wasn't waiting

We picked Gogo Miriam up in Adderley Street, outside the Cape Town Station, at 09:00 AM on a Saturday.

It was pandemonium.

Flanked by old buildings filled with offices, banks, insurance companies, financial groups, fast food restaurants, grocery stores and shopping centres, the iconic Adderley Street is Cape Town's commercial centre, and at 09:00 AM on a Saturday, it's thronged with pedestrians. But the street is not just a means to an end, not merely a way to get from one store to another, the street is one large store. The Business Act 71 of 1991 says that, as long as they abide by local bylaws, street vendors do not require a licence to trade.

Makeshift shops, erected on the pavement, offer everything from fresh vegetables to prepared foods, building materials to garments and crafts, and consumer electronics to auto spares. Services such as haircuts, hair braids, and head shaves are performed quickly and cheaply on the spot. Shoppers didn't need to go into the brick-and-mortar stores, everything could be bought outside.

But unlike St. Georges Mall, two streets up, which is a pedestrian-only street, Adderley Street is Cape Town CBD's transport hub, linking incoming and outgoing public taxi, bus and train services. Gogo Miriam had gotten off a long-distance bus from the Eastern Cape earlier that morning.

My partner and I double-parked our ambulance in the street, grabbed our gear and waded into the sea of pedestrians. It took us a while to find her, quietly seated upright in a bus shelter, protectively clutching a large travel bag. You're probably not going to be shot at, or attacked, but treating someone in a busy downtown crowd has its challenges. There's very little space and as soon as two guys show up, kitted out like Mad Medic, on a Saturday morning and start treating an old African lady, there's even less space.

My partner handled crowd control and I introduced myself to Gogo Miriam and got consent to assess her. Alert. Maintaining own airway. Strong radial pulse, 96 bpm. Lungs sounded clear.

"Gogo, what's wrong, why did you call for an ambulance?" I asked her.

"I am going to die," she said, "I came to Cape Town to say goodbye to my daughter. Please help me."

"Am I going to die?" This is a question I've been asked regularly. Scary gangsters ask it when they've been shot. Generally, if they are well enough to ask, chances are high that they're not going to die. It's a valid question if the person is trapped in an overturned car and they're haemorrhaging from one or more compound fractures. I'll honestly tell them we were all doing everything we could to ensure that didn't happen.

But when someone states that they're going to die, that's very different. A sense of impending doom is a medical symptom that consists of an intense feeling that something life-threatening or tragic is about to occur, despite no apparent danger.

The Grim Reaper announces their intentions. It may be a locomotive horn before impact, a shout in a bar before a fatal scuffle, a crack of a pistol, a fainting spell on the toilet, a debilitating pain in the chest, tunnel vision, or an insistent dreadful voice in your head.

I turned to my partner. "Primary survey secure but we're transporting to the hospital."

"Are you sure?" He looked at me quizzically. I nodded and turned back to Gogo Miriam.

"Gogo, I will get you a stretcher from the ambulance. Please wait here."

"No," she said defiantly, "I must walk."

I wasn't going to argue with a proud, old African woman. I smiled, helped her up, slung my jumpbag on my back and guided her through the crowd back to the ambulance. At the ambulance she politely refused oxygen. She was perfusing at 100% anyway. I wanted to establish IV access but she wouldn't consent to that either. She wouldn't lay down on the gurney either, instead, she sat up and leaned back against the side of the vehicle. My partner called in one green patient, 10-49 to New Somerset Hospital. It was only six minutes away.

Cape Metro EMS is a state service so it's under-resourced. To try and service as many residents as possible, we run two gurneys in the back of an ambulance and unless we have a red patient onboard, i.e. primary survey compromised, Ambulance Control can divert us to another call if required. That's what happened to us. En route to the hospital, my partner informed me, from the front of the vehicle, that we had to go via Sea Point for another medical call. I wasn't comfortable with the idea but I had no clear medical grounds to upgrade Gogo Miriam.

I was sitting in the back of the ambulance with Gogo Miriam, periodically checking her vitals. Everything was well within normal ranges.

"Gogo, did the doctors at the clinic say you were sick?" I asked her.

She shook her. "I told them I had a sore head. They gave me some Panado tablets and told me not to worry. But, I am worried," she said. "I must see my daughter," she repeated.

My partner pulled off High Level Road in front of a block of flats, killed the engine, grabbed his jumpbag and went to look for our second patient. Gogo Miriam and I sat quietly in the back of the ambulance.

Gogo Miriam looked at me, her eyes twinkled, she smiled, reached forward, clasped my hand and crashed. Her eyes closed, her head lolled sideways and her body slumped forward. I caught her in my arms, laid her back down on the gurney and simultaneously checked for breathing and a pulse. Neither were present.

Fuck.

I thumbed my radio. "Ambulance Control. Priority call from ambulance eleven, double-one, eleven. Patient coded. Resuscitation in progress."

It was pandemonium.

No, it was a witnessed arrest. I started the resuscitation protocol. CPR, monitor, no shockable rhythm. I was still bagging and trying to maintain uninterrupted chest compressions when my partner opened the ambulance sliding door two minutes later.

"What happened? I heard your call on the radio. I came as quickly as I could." He climbed into the back of the ambulance to assist.

"She crashed. Apnoea. Asystole." I continued chest compressions. With the two of us working together, we could get further along with the protocol. We intubated Gogo Miriam, secured IV access, and with a combination of mechanical, chemical and electrical interventions we achieved a return of spontaneous circulation (ROSC); enough that we felt we could discontinue chest compressions and resume our journey to the hospital.

Watching the resuscitation, our second patient had decided that he was feeling better, and elected not to accompany us any further. I manually ventilated Gogo Miriam en route to the hospital and we weren't diverted this time around. When we handed Gogo Miriam over to the ER team at New Somerset Hospital, she still had a recognisable sinus bradycardia, but unfortunately, the rest of her vitals were very poor.

We checked on Gogo Miriam when we came back into the ER two hours later with more patients. Her condition hadn't changed. On our next check-in, the attending physician informed us that Gogo Miriam had arrested again, but this time they hadn't been able to resuscitate her. They had declared her deceased approximately forty minutes before our second check-in. She never recovered consciousness. They had x-rayed Gogo Miriam's head in the ER and they'd identified a tumour on her brain stem. Rural medicine in the Eastern Cape was not equipped to diagnose or treat brain tumours and by the time Gogo Miriam arrived in Cape Town nothing could help her.

The Grim Reaper had spoken, and he wasn't interested in our efforts today.

Note

The EMS Diaries is a collection of stories, recounting actual emergencies that I attended while working with Metro Emergency Medical Services (EMS) in Cape Town, South Africa. Patients' names have been altered and locations, though named, do not identify any individuals.

Some calls have stayed with me, over the years, for one reason or another. They are recounted here.