Category Archives: Trauma

Impact 4/4

Driving home I see the text message from my wife telling me that she couldn’t stay awake any longer and is going to bed. I got held over by three hours tonight and it’s well past midnight before I make it home.

I give my wife a kiss and pet the dogs who are asleep in their monogrammed dog beds on my wife’s side of our bed.  Sleepy eyes look up from the pillow, “How was your day?”

“Busy, I’ll tell you about it tomorrow love, go back to sleep. I love you.”

I spend an hour in the hot tub – cool wind in the trees and stars overhead – tying to let the adrenaline dissipate from my system and introspectively looking for answers while listening to the lonely call of an owl sitting in a nearby tree.

Don goes to the middle east, putting his life on the line for his country, while getting shot at by the Iraqi version of bangers in their very real killing fields. In an effort to help his fellow serviceman even more he starts medical training and gets shot at by local bangers – the very people whose freedoms he swore to protect – in the domestic version of the killing fields.

Of all people to shoot at, why shoot at EMS? We are the best chance a banger has when they get shot. We are their ONLY advocate and our single purpose is to make sure they don’t die – a job that we have become quite proficient at over the years. In the summer months of this year 204 people were shot in the urban city that comprises most of my county. Of those 204 people only 11 people died. That’s a survival rate of 95%.

In the world of modern medicine we are able to keep the elderly alive long past their bodies’ ability to function – giving their families just a little more time with grandma and grandpa. That same modern medicine seems to also be keeping the violent offenders alive through multiple life threatening altercations and solidifying their personal self image of indestructibility – thereby prolonging and intensifying the violent behavior. In the dark ages a ruffian would have died from infection following a minor cut in a knife fight. Yet today I have many patients with multiple laceration and GSW scars that tell the tale of escalating violence – and by extrapolation an escalation of PTSD, dissociative violent behavior, depression, and many other mental afflictions. It’s possible that the ability of the physical body to cope with trauma has out-paced the mind’s ability to cope with the effects of the same trauma.

As I lay in bed – wife and dogs sleeping peacefully near me – I wonder if my mind has the same limitations to cope with the trauma that I bear witness to – and occasionally participate in – on a daily basis.

One week later Jim tells me that the victim in the GSW that we worked was a friend of his neighbor. He was attending a Quinceañera party – the celebration of a Latina’s fifteenth birthday where she transitions from childhood to being considered an adult. He had a perforated right lung and ruptured pancreas as the bullet had a straight trajectory in a downward angle from right mid-axially, bouncing off of the left iliac arch. He spent three days in the ICU under sedation. Upon waking up he told the nurses that he wants to meet with Jim and I to thank us for saving his life. That should be interesting.

His shooter was arrested one day later and is expected to be charged with assault with a firearm and attempted murder. The motive for the shooting was a gang initiation test to shoot a random person.

The suspect that shot up our ambulance is still unknown…

Impact 3/4

Thwack…..Thwack..Thwack.

“Drive!” I tell Jim to get us out of here now after hearing the metallic impact noises to the back of the rig. The dark streets of the killing fields become a blur as Jim accelerates away from the shooter and adrenaline floods my system while narrowing my field of view to a small tunnel with a blurry periphery – it’s the definition of “fight or flight” response.

I’ve slumped down in my seat a bit, unconsciously lowering my profile in the rig and putting more metal between me and the outside world.

“Anyone hit?” Communication is truncated to just specifics as Jim chirps the siren through a few stop signs and gets us out of the area. “I’m good,” comes the answer from Don behind me – the closest one of us to the shooter. Jim is the definition of concentration as he deftly maneuvers the rig through the hood, “Good.”

I pick up the radio, “Medic-40, priority traffic.” I really hope I’m keeping my voice calm.

“Medic-40, go.” The stoic dispatcher comes back quickly.

“Medic-40, we’ve taken shots to the rig. Relocating now, Code-4, non-injury. Shots fired at our previous staging area with four suspects heading east.”

“Medic-40, copy that, sending PD now, go with suspect descriptions.”

“Medic-40, four suspects, African-American, ages 15-18, one in a white hoodie, three in black hoodies. One black hoodie has white skeleton bones on the front and back.” I think I just described half the population of my mostly urban county.

I help Jim navigate to the well lit commuter train parking lot, hoping it’s a little safer than our last location. I heard our supervisor requesting our location from dispatch who has been watching us on the GPS and gives him our new location.

As we get out of the rig to check the damage, police cars start to show up. City PD, county sheriff officers, and the commuter train officers followed by our supervisor. Descriptions of the suspects are given again and the officers race off to canvas the area. I doubt they’ll find the shooter as all of the suspects were wearing the uniform of the hood: sagging jeans, black hoodie pulled over the head. You can never pin a crime on one person when everyone dresses the same.

An inspection of the back of the rig shows three impact points to the metal. They are small circular impacts that chipped the paint and dented the metal but didn’t go through. Given the distance of the shooter we’re assuming it was a small caliber pistol. Fortunately bangers are notorious for shooting with the gangsta-sidewise grip and usually can’t hit anything. In this case they did hit us and that’s really messing with my head. There was a time when everyone in the hood had an unwritten rule: no kids and no ambulances. It seems that rule is no longer in place – we saw that memorial to the kid today and we just got shot at.

I’ve had my body armor on since the last GSW we went to so I guess I was somewhat protected but it’s really just random happenstance that I was wearing it at the time when I got shot at. Yes, I have good instincts, and take every precaution. But honestly this could have happened anytime of the day or night. The rule of thumb for staging is to be 6-10 blocks away without a clean line of sight to the scene – and that’s exactly what we did. But it’s hard when we’re in the middle of the killing fields and there’s twenty blocks of unsafe hood in every direction. I doubt the shooter had any connection to the assault we were staging for. I suspect it was just a random, spur-of-the-moment crime of opportunity. Like so many things in EMS I I’ll probably never know the reason for this act or even the final outcome. As usual I just showed up for the exciting middle part – however unwilling that participation may have been.

The end result of all this excitement is an hour spent filling out paperwork and making police reports.


Impact 2/4

After missing out on an interesting call we’re still posting near the killing fields when we get a call for a GSW about twenty blocks from the one that went out only fifteen minutes ago. Finally, something interesting!

It’s dark now and Jim is navigating through the hood with our strobes illuminating graffiti covered fences as I map out the call location on my iPad. Given the close proximity and time-frame to the last GSW it’s reasonable to suspect that this may be an extension of that scene or possibly a retaliation by affiliates of the victim. Either way it means the vibe in the hood has changed and this is a very dangerous time to be traveling the streets. I pull my ballistic vest out of my bag and strap in the velcro attachments as I’m giving directions to Jim. It’s not something I wear all the time but it seems appropriate right now.

When we’re maybe fifteen blocks from the scene the dispatcher tells us that we’re clear to enter and police have secured the scene. Making the last turn to the street we see the fire engine and six police cars that were parked in a hurry. I tell Jim and Don to get the gurney as I want to get to the patient quickly – this is going to be a stat call and I want to be able to visualize any wounds before the patient gets bandaged up or put on a back board.

Walking up to the scene an officer meets me and accompanies me to the victim. We have to push past a crowd of people who look as though they were having an outdoor barbecue with party tents and folding tables and chairs. I can see the firefighters kneeling in the grass with officers holding back the onlookers. Secure scene my ass! There are way too many random people standing around just feet from my victim – and me.

I’m happy to see Darren, my neighbor, who’s the lieutenant on the fire engine that beat us to the scene by thirty seconds. “Hey KC, good to see ya. We’ve got a twenty year old male, single GSW under the right armpit, no exit wound. We’re working on getting him boarded now.” I thank him as I head over to check out the patient.

Darren’s crew is as dialed in as they come for this kind of call. They have the patient stripped to his boxers, the oxygen mask has already been applied, and they are about to slide the back board under him as I kneel down at his head. A quick greeting to the patient tells me that he’s alert for now and that his airway is good. I give a quick listen to lung sounds to confirm that he’s moving air and feel for a radial pulse which tells me he still has a decent blood pressure. All good so far.

I inspect the wound, which is just where Darren said it would be, and I start looking for additional wounds or an exit wound. As I run my hands down the ribs on the opposite side from the GSW I feel a lump under the skin that moves around when I push it. Fuck me! That’s the bullet! It entered under the right armpit, mid-axillary, and is now resting right next to the left floating rib. That’s directly through the kill zone!

There are basically three possibilities: straight trajectory through the torso; ricochet trajectory bouncing off of bones to end up on the other side; or the luge option where the bullet entered at such an angle that it skated to the other side following the ribs in a circumferential trajectory and bypassed the internal organs. I really hope it’s the last option.

We have him loaded in the ambulance and start transporting in an incredible four minutes and thirty seconds. I brought Darren’s fire-medic with me and I have Don in the back with me. Treatment is fast and methodical from two medics that have done this many times: bilateral sixteen gauge IVs, Asherman chest seal over the wound to reduce the chance of a sucking chest wound producing a collapsed lung, keep re-assessing and go find a trauma surgeon.

After all of the basics are covered I turn it into a teaching case for Don. In an ambulance, traveling with lights and sirens, bumping down the road, I’m walking Don through everything we did and having him re-assess. I have him take a blood pressure in the most challenging of environments using all of the tricks I’ve shown him today. I quiz him on the anatomy that is in danger given the different possibilities of bullet trajectory. I have him feel the abdomen that is now filling with blood and appreciate the rigid distention that only comes from internal bleeding. He then feels the bullet under the skin as I guide his hands and I watch Don’s eyes get big and round. And finally I point to the trends that we’ve been watching over the last six minutes; skin signs going shocky, heart rate increasing by fifteen percent, blood pressure dropping by ten percent, respiration increasing, oxygen saturation dropping. I’m explaining shock and compensation as I roll into the trauma bay filled with this year’s new crop of doc-lings and the rest of the trauma team.

If you wish to make an impact for one year, plant corn; if you wish to make an impact for a generation, plant a tree; if you wish to make an impact for eternity, educate a child.

Anonymous

Impact 1/4

im·pact

1 : the striking of one body against another

2 : the violent interaction of individuals or groups entering into combat

3 : to have an effect upon; a positive impact upon the community

Words can never adequately convey the incredible impact of our attitudes towards life. The longer I live the more convinced I become that life is ten percent what happens to us and ninety percent how we respond to it. 

Charles R. Swindoll, 1934

We’ve been staging for the assault in progress for almost a half hour and all three of us are starting to get a little tired of just sitting in one place as we wait for PD to secure the scene so that we can safely enter. Normally we would be parked behind the fire engine, as they stage with us, yet this call came in as a Code-2 so we’re running it solo. The police are stretched pretty thin right now as they’re working on the aftermath of two shooting scenes within twenty blocks of us.

My military EMT ride-along is in the back and I have a float EMT partner as Kevin and I got split up today by scheduling. After the excruciatingly slow pace of the day we finally got an interesting call an hour ago – for a GSW that occurred about 20 blocks from our current scene. We rocked that call to perfection and I’m going over the specifics with my ride-along as we sit waiting for a secure scene.

Four young men in the hooded sweatshirt/baggy pants uniform of the hood walk past the rig and down the dark street behind us. One of the black hooded sweatshirts has the white bones of a skeleton on the front – the harbinger of death. My partner is keeping an eye on them in the side mirror when one of them raises his hand pointing at us from fifty feet away.

Thwack…..Thwack..Thwack – three metallic impact noises come from the back of the rig. Don, my ride-along, yells over to us, “Oh shit! They’re shooting at us!!!”

While checking out my narcotics, computer, and miscellaneous equipment from the deployment coordinator I’m told that I have a military ride-along today and head off to the lounge to pick him up for his training day in the hood. He’s an energetic man in his late twenties named Don. I spend a few minutes getting him familiar with the rig and explaining expectations for the day as Jim, my EMT parter for today, shows up.

As usual we seem to have a heavy dose of “third man syndrome” today as it’s very slow and I’m only getting the absolute mundane calls – a fall from a ladder with minor injuries, the febrile seizure, the sixteen year old girl with a tummy ache consistent with menstrual cramping, and an old man who had a seizure in a skilled nursing facility. I do my best to involve Don in everything but there’s really not that much to do on these calls and we have over an hour of posting between each one so we get a chance to talk all day.

Don tells me he’s been in the Army for six years with a tour in Iraq and one in Afghanistan. He switched from infantry to a medical focus and is getting his EMT certification so he can feel like he’s helping his fellow servicemen on future deployments.

Jim and I tell him about calls that we’ve been on and talk about treatments and patient presentations. We pass the time by quizzing Don on how he would do assessments and treat fictitious patients.

We’re finishing up a call and hear another unit get dispatched to a GSW (gun shot wound) with possibly two patients on scene. It’s too far away for us to jump the call from the other unit but the dispatcher sends us to a post that’s near the scene. If there happen to be two patients then I’m sure we’ll be sent in for the second patient so maybe our luck is turning for the day.

I explain to Don how we call this area the killing fields as it’s a flat, 60 by 40 block area of the county where a lot of assaults and gang violence take place. I point out a street memorial – stacks of stuffed animals surrounded by candles and flowers – for the three year old child that was the unintended victim of a recent drive-by shooting. Then we pass by the street where the four officers were killed a few years ago by a banger with an assault rifle. Don’s having a difficult time believing this is happening right here in America. He’s a combat veteran who is no stranger to violence but he didn’t know it existed to this degree in the forgotten urban wasteland of my mostly urban county.

He tells us of his experiences in Iraq where his convoy was often shot at while driving from one base the the next and how IEDs (improvised explosive devices) were a constant source of annoyance and often death.

I hear the unit that responded to the GSW start transporting Code-3 to the trauma center without having called for an additional unit. It appears that there was only one patient and our “third man syndrome” is still in full effect.


Service 4/4

As I open the back doors of the rig I see the two extra firefighters in the back of the patient compartment. CPR is in progress and having extra people to help out is always better so the medic took a few riders. We help them unload the patient while keeping an eye on IV lines and monitor cables. I hand the monitor to Brittany and tell her to keep close as we roll the gurney into the waiting team of doctors and nurses. One of the fire fighters is “riding the rails” – he’s standing on the bottom rail of the gurney, one hand holding on and one arm applying as much of a compression to the patient’s chest as is possible on a moving gurney.

As the paramedic is giving a verbal hand off to the medical team we disconnect the monitor leads and transfer the patient over to the bed. A flurry of motion ensues as the hospital staff go to work picking up the code where we left off. I take Brittany to the corner of the room where we are out of the way and I can explain what’s happening as the team administers more drugs and shocks the patient a few times.

After ten minutes it’s obvious this person isn’t going to come back to the living. They are going through the last few motions of working a code – throwing the “Hail Mary” drugs at him in the hopes that something was overlooked or an underlying unknown condition is preventing the resuscitation from working. The ED tech doing compressions is a friend of mine and he’s getting a bit fatigued from doing CPR for the last five minutes.

“Hey Nick, you want some relief? My ride-along needs the practice.” Nick gives an exhausted nod of his head as drips of perspiration land on the pale patient below him. Brittany bounds up to the step stool at the side of the bed and trades off with Nick without missing a beat. I coach her on hand placement and compression rate as she furiously puts all of her heart into keeping this man’s heart working.

While Brittany continuously pumps on the man’s chest, I’m standing next to her explaining some of the things she’s feeling and giving pointers. “Don’t worry about the broken ribs, keep pushing, he’s got bigger problems. Give the chest a full recoil, let it inflate after every compression.” I push my fingers into the man’s femoral artery. “Push a little harder, there you go, now I can feel his pulse in the femoral from every compression.”

After two rounds Brittany is completely exhausted but she’s still pushing for all she’s worth. Nick catches my eye as we stand behind Brittany. “They’re about to call it, you want me to take the last round?”

I pull Brittany from the stool as Nick jumps in for the final round of CPR. Nick’s a good man – he knows that we were all just going through the motions on this one but Brittany doesn’t need to be the last person doing CPR when they decide to stop. She did a great job and it’s best to leave on a high note rather than a depressing coast out.

This was our last call of the day and as we take the quiet roads back to the deployment center Brittany has a flurry of questions and observations from her day on the streets. Kevin and I have quiet smiles on our faces as we discuss the day and her performance. Her enthusiasm is contagious and we were just happy to provide her some experiences to help prepare her for the unknown that awaits her overseas.

Back at the deployment center I’m filling out Brittany’s evaluation form where I give her high marks in all categories. Brittany puts her form in the camouflage backpack and joins her camouflaged classmates in the lounge as they compare stories of their day in the Big City. I suspect Brittany has some of the best stories of the group today.

She’s a shining example of the young people that are making sacrifices for our country every day. These are young men and women from across the country who take an oath, put on a uniform, and deploy across the world. Many of them will find themselves in dangerous situations, and maybe some of the things they learned in our Big City will be of use in future deployments.

Service 3/4

After the call I’m driving through the hood so Brittany can see some prostitutes as our last call brought that into the conversation. With Brittany squealing with excitement after watching a young woman get into a car with a complete stranger I’m passed by the Big City PD who’s moving fast.

“Brittany, you might actually get a real call today. PD just passed us and another one is coming up behind us.” We get used to the driving patterns of PD as they have a particular mode of travel when going to a real call. Despite the cop shows that depict officers traveling Code-3 to every call our local PD tends to just light up at intersections and occasionally hit the air horn to get someone’s attention. They are the urban land-sharks of the hood that gracefully slide through traffic following the scent of blood to the crime scene.

A few seconds later the radio comes to life. “Medic-40, respond code-3 for the GSW at the corner of really bad street and even worse street, please stage out, your scene is not secure.” Brittany has her gloves on before the dispatcher finishes the sentence and wearing her camouflage battle dress uniform all I can see in the rear view mirror are her bright shiny teeth in a big smile. I light up the rig and head in the direction that PD was going.

Just as I’m thinking about shutting down to stage and wait for the officers to secure the scene the dispatcher comes back and clears us to proceed. We arrive to find police cruisers blocking the street and yellow tape being rolled out to keep the crowd back. There’s a cluster of officers standing next to a young man who’s collapsed on the sidewalk with a small pool of blood forming under him. It’s Kevin’s tech so he’s first out and walks up with the fire crew that just arrived. Brittany is staying with me as I’m getting the equipment out of the rig.

I hand her a set of trauma shears and motion towards Kevin who’s kneeling by the young man. “go on – get in there and cut some clothes off.” I don’t think I’ve ever seen anyone skip in combat boots yet that’s pretty much what it looks like as Brittany joins the others in cutting clothes and looking for bullet wounds.

It’s the perfect textbook scenario for rapid assessment and treatment of a trauma victim. Four minutes from the time the call went out to arriving on scene with fire and EMS pulling up at the same time. Seven minutes spent on scene stripping clothing off, controlling the bleeding, and putting the patient on a back board. He has two entry wounds, one in the neck and one in the upper chest. Both appear to be small caliber and bleeding from the chest wound is controlled with a chest seal to reduce the possibility of developing a collapsed lung. We decide to use a hard back board because of the close proximity of the neck wound to the spinal column.

With strobes flashing and siren wailing, I make the five minute Code-3 drive to the trauma hospital with my police escort just behind me. Kevin’s reassessing for neurological deficits and starting IVs as Brittany is doing her best to take vitals in the back of an ambulance running Code-3. She’s using all the techniques we showed her on the previous non-emergent calls: slipping the bell of the stethoscope under the cuff so you can corroborate the auscultation by feeling the palpated systolic pressure with the other hand, and supporting the arm on your leg while lifting the heel of your boot to isolate noise and vibration. She’s a quick study and is keeping her cool on a highly stressful call. Seventeen minutes after getting the call we are pushing the gurney into the trauma bay, which is already crowded with the trauma team of doctors and nurses. By the time Kevin is finished with his paperwork the young man was already headed for the operating table.

Brittany is helping me clean up the ambulance as another rig comes in to the trauma bay. I could hear the siren from a few blocks away and see their lights flashing as they entered the parking lot. Brittany and I change gloves so we can help out the crew – they are bringing in a critical patient.

Service 2/4

As we drive from call to call and post to post in the Big City, Brittany is a constant source of questions and enthusiasm. Despite the poverty stricken streets that are ripe with urban violence, gangs, drugs, and everything else – I actually like my Big City and enjoy the opportunity to play tour guide to the underbelly of urban street life.

This is Brittany’s first visit to this state and only the third state she’s ever been in. Having grown up in Maine, she lived a rather sheltered life up until now. She’s loving every minute of the day even though we are getting the less than emergent – some might even say annoyance – calls all day long. We call it “third man syndrome” – it seems that every time we get a rider we get the nuisance calls and seldom get the dramatic high profile calls that the rider is hoping for.

Brittany was a good sport when we got called for the fifty year old lady who had a headache for the last three days. There’s really nothing to treat here yet it was a chance for Brittany to practice taking a history and get used to the frustrating reality of how difficult it is to take vitals in a moving ambulance.

From the mouth of babes come the rational observations, and Brittany made a very apt one after the call as we’re cleaning up the rig. “Why didn’t she just take an aspirin?” I don’t have any good answers for that one except to say that calling 911 is a learned pattern from her environment and when someone demands that we take them to the hospital we are obligated to do just that.

As if to hammer the point home our very next call is to an address that I am familiar with as I’ve been there many times. It’s a woman with every chronic problem you can imagine, taking all the regular medications, with the same complaint every time. Yet today we’re here for her twenty two year old daughter – I’ve never transported her before.

It turns out she has a back ache because she slipped yesterday. Of course she’s wearing five inch stilettos – my keen diagnostic abilities tell me they may have contributed to the slip. Dressed like a prostitute in tight pants, high heels, and a skimpy halter top she struts to the gurney and plops down so we can transport her to her favorite hospital.

It’s an interesting situation that boarders on scamming the system. Her mother is considered disabled by the state due to so many chronic illnesses. In conversations with her over the years I come to find out the daughter is listed as her “home health care provider” despite having no medical training. The state pays her $800 dollars a month to live at home with her mother. And the daughter has apparently learned from the mother that you call 911 whenever you have a problem because it’s cheaper to let Medi-Cal pick up the tab than to call a taxi – and a taxi is exactly what we are on this call.

Service 1/4

ser·vice

1 : of or relating to the armed forces of a nation

2 : work done for others as an occupation, business, or calling

3 : services, such as free medical care, provided by a government for its disadvantaged citizens, often used in the plural

4 : the act of a male animal copulating with a female animal

Consciously or unconsciously, every one of us does render some service or other. If we cultivate the habit of doing this service deliberately, our desire for service will steadily grow stronger, and will make, not only our own happiness, but that of the world at large. ~Mahatma Gandhi

“Prostitute at five-o’clock, look out the back window to your left.”

“Really!!?” Brittany scuttles to the back of the rig and peers out the rear windows like a ten year old looking under the tent flap at the circus.

“See the bored looking guy with the baggy pants, about twenty yards up the street? That’s the pimp.”

“Oh my god!! She just got in the car!” Brittany is actually squealing with excitement.

The back of the rig is dark and I can just barely make out Brittany’s silhouette in the rear-view mirror as her digital camouflage fades her into the background.

I met Brittany this morning as I was checking out my equipment from the deployment coordinator and he told me I have a ride-along today. Looking behind me I see a young woman in military digital camouflage; her hair is pulled tight into a bun at the back of her head and she’s standing in the corner holding a matching backpack, curiously looking around at the ambulance bay and the bustle of other crews stocking their rigs.

We often get EMT student ride-alongs in this county – it’s a mandatory component of graduation to ride with an ambulance crew on the streets. Some ride-alongs are from the military while others are from the local schools, and they span the full range of personalities and competency. For many of the local students, this is just a necessary yet annoying stepping stone on the way to the elusive job in a fire department. Some will make it that far but most will fall by the wayside. The military ride-alongs take it much more seriously, and as a result I much more enjoy having them. We get riders from the Army, Marines, Navy, and Coast Guard. These tend to be dedicated young men and women who are disciplined, motivated, and courteous. Because of the constant state of war over the last decade these young people know that the skills they learn in EMT school could vary well make a difference in future deployments. They tend to be very motivated, ask lots of questions, and are respectful to patients and personnel from the other agencies that we work with throughout the day. The military commanders know that the best chance of seeing domestic urban warfare happens to be on the streets of my Big City so we tend to get a lot of riders from the different branches of the military.

As I’m introducing myself to Brittany and handing her my computer to carry to the rig I hear another military ride-along nervously talking to the deployment coordinator. “Are you serious, you don’t issue flack jackets?” Brittany’s eyes get big and round at that question – a look that I see repeatedly throughout the day.

Brittany helps Kevin and I check out the rig as we explain where all of the equipment is stored and promise to get her as much hands on experience with patients as possible. As we clear the deployment center and notify dispatch that we are available for the Big City, Brittany looks down at the body armor poking out of my gear bag and her big round eyes meet mine in the rear view mirror.

“Don’t worry about it, we’ll keep you safe. We haven’t lost a rider yet.”

“So you’re not counting the last guy?” Kevin comes back at me with our well rehearsed schtick.

“Nah, he doesn’t count, he was an idiot! Brittany’s much smarter than him.”


Heart Attack 2/2

There’s a saying in paramedicine: trauma is trauma. Basically that just means that it is what it is. Unlike a complex medical emergency with co-morbid factors on a patient with chronic conditions who takes ten medications, treatment for trauma is actually pretty simple. If it bleeds, plug it. If it’s floppy, splint it. Then go find a trauma surgeon quickly. Yet the real nuance to effective trauma care is staying ahead of injuries by anticipating problems before they happen and caring for the injuries that you can’t see.

All of Maria’s vitals are recovering nicely and she’s answering my questions well enough, although she’s understandably in a lot of distress and on the verge of freaking out on me. I made sure to apply the occlusive Asherman dressing to the chest wound. In a perfect world that will reduce the risk of a collapsed lung. In the imperfect world that I live in I’m not certain I could do a needle decompression to re-inflate a lung on Maria because she’s just too fat. But for now she’s breathing effectively in all lung fields.

I call my vitals up to Kevin as all of my assessments and treatments are pretty much done. I just need to start a couple IVs before we get to the ED. I take the oxygen mask off of Maria, as her saturation is at 100%, and put on a nasal cannula that tracks her expelled CO2 and gives me a visual waveform of each breath. I’ll be able to see a change in respiratory effort if she develops any complications.

She’s still a little scared and crying now and then. I cover her up with a blanket and tuck it around her shoulders. On one hand I want to stay ahead of the impending shock symptoms by keeping her warm yet on the other hand the simple act of tucking a blanket around someone tends to calm them. Despite the constant bouncing of the rig and melodic whine of the siren Maria seems a little more relaxed.

“Maria, you’re doing really well. I’m just going to start a couple IVs in your arm. You can help me out by talking to this nice officer over here. She has a few questions for you.”

The officer has been waiting patiently for me to finish my initial assessment and treatment. Hearing my prompt she stands up so Maria can see her and begins the question process.

“Maria, who stabbed you?”

With tears rolling down her cheeks she answers. “My boyfriend…”

I’m in my own little world as I preform the rote task of starting IVs and reassessing vitals. It’s strangely calming to have a single task in front of me as I’m a fly on the wall listening to the back and forth between the officer and Maria, as she tearfully describes the melodrama of an argument that escalated to attempted murder.

As Kevin and I push the gurney into the brightly lit trauma room we’re met by a room full of hospital staff. Fresh baby docs are pacing nervously wondering who gets to do the chest tube today, seasoned nurses are leaning against the wall, thinking about the twenty other things they should be doing while they are interrupted by this trauma, and the stoic teaching docs are standing in the background to observe everything and be ready to jump in the second before someone makes a mistake.

“Good morning, this is Maria…”

The officer was able to get suspect information before we even reached the ED. His name, vehicle description, address, and associates were relayed to police dispatch during the trip. By the time we rolled into the ED police were already on the man hunt. I heard the police dispatch tell them that he has prior warrants for violent crime and to consider him armed and dangerous. I stood in the corner of the trauma room with the officer who rode with me and explained what the doctors were finding as they did their assessment.

A quick sonogram showed that Maria had plural effusion – excessive fluid pouring into the lungs. And then a second pass showed that the knife tore open the pericardium – the sac that surrounds the heart. The fact that Maria was a large girl actually saved her life. Had she been any smaller the knife would have punctured the heart. She was up in the operating room before I even finished my paperwork. By the end of my shift she was recovering in the ICU and the (now ex) boyfriend was in custody. Had the officer not come with me the suspect information would have been delayed until after the anesthesia wore off and that would have given him a 6 hour head start.

 

 

Heart Attack 1/2

heart

1 : a hollow muscular organ that pumps the blood through the circulatory system by rhythmic contraction and dilation

2 : regarded as the center of a person’s thoughts and emotions, especially love or passion

at·tack

1 : to set upon with violent force

2 : the act or an instance of attacking; an assault

Passion is the enemy of precision. Forget the misnomer ‘crime of passion’. All crime is passionate. It’s passion that moves the criminal to act, to disrupt the static inertia of morality.

Daryl Zero; The Zero Effect 1998

Kevin angles the rig behind the BRT in the parking lot of the apartment complex and puts it in park with the strobes still flashing. I can see the firefighters grouped around some shrubs and by their actions I can see it’s a serious call. All scenes that we go to have a vibe and once you get used to reading body language you can usually tell how serious a call is before even getting to the patient. Bags are open, oxygen is about to be administered, clothes are being cut away, officers are asking questions of bystanders, the police dog is barking from the back seat of the K9 unit… this is a serious call.

Kevin looks over at me, “Just go, I’ll grab everything.” It’s my tech and Kevin knows I want to get to the patient and start my assessment and treatment quickly.

As I walk up to the shrubs I see an officer holding her hand on the patient’s chest. Judging by the amount of blood covering my new patient’s clothing it appears that the officer is holding direct pressure on a wound.

The fire medic is applying the oxygen mask as he looks up at me. “We just got here a second ago. Looks like a penetrating wound to the chest; maybe a stab wound. Unknown downtime; she was found a few minutes ago by a bystander.”

The bloody shirt is finally removed and I ask the officer to lift her hand briefly so I can visualize the wound. She lifts up her bloody glove and I clear off some of the blood with a dressing. I see a three centimeter horizontal stab wound just to the left of the sternum. Pushing my fingers into the chest for landmarks I find that the wound is directly over the 5th intercostal space and it’s likely the knife slipped between the ribs. Judging by the length of the wound the knife likely traveled pretty deep. Crap! That’s a bad place to miss the ribs!

I look over to the rig just as Kevin rolls the gurney next to the shrubs. “I need an Asherman and C-spine.” Kevin nods and rushes to get the supplies, returning in just a few seconds. Kevin and I tend to truncate our communication to the bare minimum on stat calls. More often than not we’re thinking the same thing and we really don’t need to verbalize most things during treatment. It makes things flow so much better when partners are on the same page and have worked together for a while.

As we cut off the rest of my patient’s bloody clothing and look for any additional wounds, I try to get a baseline on her mentation. She’s not tracking with eyes or answering questions yet she has spontaneous, erratic movement of all extremities. Actually a little too much movement – she’s slowing down our attempts to strap her to a board. I look forward to the day that we adopt a protocol that allows us to forego spinal immobilization when a patient presents with no neurological deficits. But for now we have to do it based on an abundance of precaution.

With my patient strapped down and the occlusive Asherman dressing applied, we’re ready to start transporting. It takes four of us to lift the gurney as my new patient is a bit on the obese side. I’m at the head as I push her towards the ambulance. She yells out as we lift the gurney and her big round eyes look up at me with a terrified gaze as she locks onto my eyes.

I smile down at her. “Hi, I’m KC, what’s your name?”

“Maria.”

“Maria, we’re going to the hospital because you got stabbed. I’ll ask you some more questions in a minute.” We load the gurney into the rig and I turn to Kevin before jumping in. “Code-3 trauma to Big City Trauma Center, I’ll get you vitals on the way.” Kevin nods and goes up front to drive.

I turn to the officer that was holding pressure on the wound. “She started talking just a second ago. Do you want to come with us?”

The officer gives me a big smile as she pulls off bloody gloves and tells her sergeant that she’s going to ride with us to the ED. There are usually only two reasons to take an officer with me: to get suspect information, or to witness a dying declaration. As we pull away from the apartment complex I’m hoping it’s the former. I’d really rather Maria didn’t die on me.