Tag Archives: GSW

Flight of Fancy Postscript

post·script

1 – a note, paragraph, etc. added to the end of a letter or at the end of a book, speech, etc. as an afterthought or to give supplementary information

Three days after leaving my mostly urban county by helicopter the young man in question was extubated and regained consciousness with no lasting deficits. The trauma surgeons in my county trauma center made the right call in sending him to the specialists at University Hospital. And, as much as I may have some misgivings about the use of an air ambulance in an urban setting, I believe it was the right choice of transportation.

Most forward thinkers in the pre-hospital setting are fairly skeptical of the use of helicopters for all but the extended transport times in rural settings. A flight time of twenty minutes can easily be extended to over an hour when all factors are taken into consideration; travel time to the scene, landing and unloading, assessment and loading the patient, landing and unloading the patient at the hospital. In many cases where the benefit may be minimal the right answer is to drive the patient and get to definitive care faster.

In this case I believe the use of the helicopter was warranted given the time of day and general unstable nature of the patient. In the midst of morning rush hour the normal drive time of 48 minutes would be extended to nearly two hours even with the use of Code-3 lights and siren. The geographical choke points of bridges and waterways create near gridlock traffic situations where an ambulance literally has no place to push the traffic out of the way.

It’s easy to get jaded in a busy urban environment like this. My initial impression of this escapade was that of skeptical acquiescence. The decisions about where and how this patient is transported are very far beyond my control once the doctors put things into motion. It’s also easy to lose a little bit of feeling or caring for someone who intentionally put themself in danger to satisfy the cravings of an addiction. Violence and trips to the ED are unfortunate byproducts of the environment for people who engage in this lifestyle. Just as a Paramedic may have very little sympathy for an injured drunk driver – we may have the same lack of compassion for someone who intentionally drives into the hood at four in the morning to score drugs. As a byproduct of their misadventure lives are put at risk while driving Code-3 and flying helicopters in a very busy airspace. That is a risk we will take when an innocent life is on the line yet it’s hard to justify when we are put in that position by someone’s poor choice of lifestyle.

Yet my impression of this patient changed a few days later when an officer involved in this case told me that the patient had bounty hunter credentials on him at the time of the shooting. Was he actually trying to clean up the streets rather than contributing to the problems in the hood? I don’t know, I will likely never know, but it does serve to remind me that it is not our job to judge people. We are here to fix who we can, keep them alive as long as we can, and deliver them to definitive care with all haste. That’s what it is to be a Paramedic.

 

 

Flight of Fancy

flight

1 – a swift passage or movement

2 – the motion of an object in or through a medium

3 – the action or process of flying through the air; a bullet in flight

 

fan·cy

1 – not plain; ornamented or complicated

2 – requiring skill to perform; intricate

3 – the power to conceive and represent decorative and novel imagery

 

flight of fancy

1 – an idea which shows a lot of imagination but which is not practical

The back doors to the helicopter swing open to expose a passenger compartment where a flight RN sits in a jump seat and kicks a metal sled, loaded with medical bags, towards me. The sled slides free of the helicopter and we ease it onto our gurney and strap it down with seat belts. Pushing the gurney across the mostly empty tarmac of the airport my partner and I load it into the ambulance as the two flight RNs jump in the back. I take a seat in the front to help my partner navigate to the trauma center.

The morning rush hour traffic has the freeways reduced to parking lot status and the side roads are only marginally better yet it’s our best bet so it takes both of our attention on a constant vigil – on the lookout for the motorists who forget what to do when sirens come up behind them.

We pull into the Big City trauma hospital and I jump out to back my partner into the closest parking spot next to the door. As I stand behind a backing rig, annoying beeping sound assaulting my ears, the ER attending doc approaches me. We have had a cordial familiarity over the years.

“Why’d they send you guys? The patient is on a vent and five drips!” He knows I can’t transport a patient like this as we don’t have a drip machine or vents and I’m not authorized to transport someone who is likely on medications that are outside of my scope of practice.

“It’s okay,” I smile, “I brought a flight crew of RNs with me.” He looks a little surprised as two crimson jump-suited RNs fling open the back doors to my rig and jump out.

The flight crew is getting a history on the patient who’s laying in the trauma bay as my partner and I hang back – we’re pretty much sherpas on this call – we’ll leave all of the patient care to them. While they get up to speed on the patient my partner and I talk to a few of the trauma RNs and police officers that we know.

“So what’s a clean-cut white boy like this this doing in the hood at four in the morning?” It’s somewhat of a rhetorical question and I can’t even ask the question with a straight face. The most obvious answer is that it was a drug deal gone bad. At least that’s what everyone involved is thinking until proven otherwise.

The officer looks tired; I’m thinking he got held over to stay with the victim in case he wakes up and has anything to say. The kid has two chest tubes in him, he’s on a vent with a breathing tube, he’s got milky white paralytics slowly dripping into his veins; he’s not going to wake up for a long time – if he ever does. “We’re not sure what was going on. We just found him in the driver’s seat of a car that had a slow speed crash into a line of parked cars. When we checked on him we saw the GSW to the chest and called you guys.”

I’m in the back with the flight crew as we traverse the urban streets back to the airport. My partner is in the front alone and the siren and air horn are singing a duet in an effort to clear the way.

The kid’s blood pressure just bottomed out to 70/46 and his end tidal carbon dioxide level just spiked to 76. The flight crew are scrambling to reduce the paralytics and increase the vaso-constriction – yet not so much that he bleeds out faster. The bullet created a perforation to the esophagus and a tear in the aorta that’s creating a slow leak of blood into the thoracic cavity. The blood from this leak is constantly being suctioned by the two chest tubes attached to active suction. Drugs are pushed into IV tubing, IV pumps are re-set with new values – it’s a delicate balance between sustainable vitals and faster bleed out. The only thing that will fix this kid is the specialized thoracic microvascular surgery found at the university hospital. Even the attending trauma surgeons at our world class trauma center decided to pass on the surgery. This kid is well beyond critical.

When the paralytics were decreased his level of mentation starts to increase along with his blood pressure. He starts to choke on the tube – we call it bucking the tube. His eyes look as though they’re coming into focus. One of the flight crew pulls a preload of sedative out of his jumpsuit, makes a quick calculation in his head, wastes some of the sedative so that it’s proportioned to the patient’s weight, and injects it into an IV port. Ten seconds later the patient is back in his comatose state and his blood pressure is at a good level for the next phase of transport. Another unit of whole blood is pulled from the biohazard cooler and added to the many lines of tubing that are keeping this kid alive.

Driving across the tarmac we pass the parked airplanes and helicopters. It’s still early in the morning and there’s not a lot of action on this lazy midweek day in the quiet corner of the airport. We see the crimson helicopter with the pilot doing a pre-flight walk around as he opens the back doors to accept our patient.

After loading the patient into the helicopter one of the RNs is thanking us for the ride. “Hey, do me a favor, stick around until we get in the air. You know, just in case he codes… Thanks.”

BIG CITY, USA — It’s been an especially violent week in Big City. Police are investigating a string of shootings in different parts of the city, believed to be unrelated.

Unfortunately, gun violence is nothing new in Big City, but there has been an increase over the last couple of days and officers are doing everything they can to keep up. Big City police are stretched thin as they investigate five separate shootings in just 12 hours.

“It’s been a busy week. I think we had at least three homicides last week and then one… I know at least one working today,” said Big City Officer Jason Smith.

One shooting happened Thursday morning at First and Union streets as a high school student was riding his bike to school. He was shot by someone who was also on a bike. Crime technicians were delayed two hours getting to the scene.

“There were two other callouts this morning so that’s where we’re at,” said Smith.

One of those earlier calls took police to Lake Street near 23rd, just a few miles away. That’s where a man with a gunshot wound was found inside a crashed car.

“It has been busy. We’re doing the best we can with what we got and we handle each case. And ultimately our goal is to solve every case we get,” said Smith.

Three shootings happened on Thursday and two happened Wednesday night. It’s violence that doesn’t go unnoticed.

“It’s been a little intense here in Big City for the past couple nights,” said Jose Martinez.

Martinez works with youth at the Sojourner Center for Human Rights.

“We work directly with those young people who are involved to try to figure out what’s happening here and how we can create lasting peace,” said Martinez.

He says it will be the community coming together to create lasting change.

“What’s happening here doesn’t have to be and there’s a better way to solve our problems,” said Martinez.

He also says a bullet never solved any problem.

 

 

Necromancy Revisited 2/2

Walking through the door I fight the adrenaline-induced tunnel vision. As team lead it’s my job to keep the big picture in sight and not focus on the minutia. I have four EMTs following my lead as we make it into the lobby. My boots make sucking noises with each step I take on the blood-soaked carpet; spent bullet casings litter the ground. With the smoke still clearing from the room I can smell residual cordite from the weapons fire mixed with explosive residue. I almost trip over the body in front of me because of the low visibility.

A quick check for a pulse and a reposition of the airway tells me he’s non-viable – blast injury to the torso and GSW to the neck. I pull a black ribbon from my triage waist pack and hand it to the EMT behind me. “Black tag – keep moving.” My EMT ties the black ribbon to the wrist of the dead body behind me as I continue in to the room.

With the smoke clearing more I can see the extent of the room. Vinny’s men are holding down the corners where they have a visual to every angle; two of his men have fallen into ranks with my team and two others are securing the egress route at the front doors. Vinny gives me a head nod – letting me know it’s secure and giving my team the floor to do our jobs.

In a loud voice I address the room. “If you can walk I need you to exit the building now. EXIT NOW!”

Nobody moves. Hell, nobody even says a word! I focus in on the six people sitting on sofas in the corner. I’m fighting with balancing the big picture and noticing the minute details – macro vs micro, the eternal battle of EMS. Micro wins out when I notice that everyone in front of me has their hands and feet duct taped – they’re incapable of walking out of here because they are bound hostages.

Six people with big round eyes are following my movements as I quickly scan them for injuries and I hear the muffled screams from under the duct tape. That tells me enough for now. Turning to the next EMT behind me; “Cut the tape on the feet, clear them, and get them out of here.” I want to quickly reduce the number of people in this room so that all I have left are wounded, and I want to keep the hands bound in case any of these hostages are tangos in disguise.

Moving on I see a man convulsing on the ground with a blood saturated shirt. While I reposition him to check his airway bright blood erupts from his mouth missing my leg by inches. Bright red blood – probably from a perforated lung – gives me an idea of where to look for the wounds. I rip his shirt off and see the entry wound to the right side of his chest. Feeling around his back I find an exit wound near the right scapula.

I turn to the next EMT behind me and hand him two occlusive dressings to seal the wounds, as well as a red ribbon from my triage pack. “Chest seal front and back; keep an eye on his airway. He’ll be one of the first out.” I move on in my clockwise lap of the room.

There’s a man laying supine on the ground, eyes open, not following me or reacting to me when I give him a knuckle rub to the sternum. There’s a mid-axillary GSW to the right flank with no exit wound. A quick listen at the neck with my stethoscope tells me he’s still moving air for now. Shrapnel is embedded in his torso with minor bleeding. I’m getting closer to the blast sight and this guy took more of the blast. Turning to the EMT behind me; “Compression dressing to the flank, he’s critical.” I hand him a red ribbon and move on.

Moving closer to the blast site I find a secretary wedged under her desk. Damn! She looks familiar! She’s screaming and tracking me with her eyes. Arterial spray is coming from her arm and her entire torso is covered with embedded shrapnel. I slide her out from under the desk and turn to the EMT behind me, “Tourniquet to the arm. She’s delayed,” and I hand him a yellow ribbon to tie around her wrist. She’s still screaming as I continue my clockwise lap.

Closer to the blast sight now I see the man laying on the floor screaming and clawing at the blood saturated carpet with his fingers. The source of his discomfort is fairly obvious as I almost trip over a leg that used to be attached to him. I pull a tourniquet to hand to the EMT behind me when I realize I’ve run out of help. Fuck! Micro wins out for a moment as I apply the tourniquet and tie a yellow ribbon to his wrist. Macro takes over again as I walk away from him. Sorry sir, some people are more critical than you are today.

Coming around to the front of the room I’m by myself as my team is caring for the people left in my wake with ribbons tied to their wrists. Two more bodies laying in front of me have further saturated the now ruined carpet. A quick check for vitals tells me there is nothing for me to do here. Judging by their military style clothing I’m thinking Vinny’s operators are very good at their job and left the tangos non-viable. With black ribbons tied to their wrists I walk off.

Finally, I’ve made a full circuit of the room and have a mental tally of the wounded and an extrication plan to get the most critical out first. Walking up to the man with the through and through GSW I see that my team has him ready to go. “Okay, he’s first out.” Looking to Vinny, “I need two SWAT for a cary out.” Vinny nods his head and points to two of his operators who rotate their M-4s to a back cary position and immediately jump in to help two of my EMTs roll the man on a combat cary tarp.

Just then I hear the call from across the room. “I need ALS over here.” It’s one of my EMT’s kneeling next to the unresponsive man with the mid-axillary GSW and blast injuries – he must have run into a problem that needs a paramedic. “I lost lung sounds on the right side,” he tells me as I kneel down and check his findings.

“Good pick-up. Grab a tarp, he’s next out.” I open my waist pack and pull out the enormous needle. Finding my landmarks I insert it to his chest, pull the needle while leaving the catheter in place, and re-check lung sounds. He’s breathing on both sides now that the collapsed lung has been vented with a pulp-fiction style stab in the chest.

As I stand up and look at Vinny, “Two more for a cary out.” Two camouflaged operators appear with two of my team and a tarp. As they’re working him I walk over to check on the man missing a leg.

One of my EMTs is with him and has check to make sure the tourniquet is doing its job. “Okay, this guy is next.” The first team of two EMTs and two SWAT head my way and roll the recent amputee onto the combat tarp. As they pick him up I check his shoe and see that it matches the one on the severed leg. I pick up the leg and put it on the tarp next to the patient. “Make sure the leg stays with him.”

As I make it over to the secretary under the desk I motion the second returning cary-out team to me and get her rolled onto the tarp. The two EMTs and two SWAT operators pick her up and I kneel down to look into her eyes. “I’m glad we got a chance to save you this year.”

We’re heading to the double doors guarded by Vinny’s men and she stops screaming and gives me a smile.

A man in a reflective vest steps out from a glass office. “END-EX, END-EX, secure all weapons!” End exercise.

Once again we have completed the yearly joint training exercise where SWAT teams from across the world and EMS teams work together. As always the realistic wounds and Hollywood quality makeup is unnerving to look at. The blood in the injuries flows and sprays just as it does on the streets and the actors are true to character. Despite knowing it’s an exercise the adrenaline flows very much as it does at a large unknown incident. The SWAT operators and tangos are using simunition shot from real service weapons and the explosions were controlled pyrotechnics with all kinds of bark yet very little bite. The man who got a needle stuck in his chest was a very elaborate mannequin with moving eyes, chest rise and fall, and accurate lung sound generation. If left alone for too long he eventually stops breathing. Once the computer recognizes the needle-decompression it restores bilateral lung sounds. 

Exercises like this train us for the things we hope we will never see. I performed my duties better this year than I did last year and it helped me to recognize areas where I need improvement. The SWAT and EMS interaction is invaluable for the safety and efficiency of all participants. The sooner life saving measures can be taken on scene the more people we can save. Three recent mass shootings come to mind where this cooperation would have made a difference. 

And yes, I did recognize the secretary from last year’s exercise – she was one of the first black tagged victims/actors. We never get a second chance to make a save on the streets, but it was nice to get a second chance here.  

Necromancy Revisited 1/2

nec·ro·man·cy

1 : the practice of communicating with and learning from the dead to predict the future

2 : see also – necromancer; one who practices divination by conjuring up the dead

re·vis·it·ed

1  :  to visit again

2  :  to re-examine (a topic or theme) after an interval, with the view to making a fresh appraisal

The phone is ringing in the bank manager’s office, which is odd. The last time the hostage negotiator called the phone rang at the teller’s window. Thinking that possibly there has been some progress on getting his demands met, he walks to the ringing phone and picks it up with his left hand as his right hand holds down the “dead man’s switch” – a button that needs to be pressed to keep the bomb from going off. If he takes his finger off the trigger, his vest will explode.

“What do you want?” With the anticipation of talking to the hostage negotiator on the other end he’s already setting the tone with an aggressive stance yet no one answers him. Looking up from the phone and out the window he sees a tiny puff of smoke on the adjacent building that is quickly followed by a round hole in the window and spider web crack lines extending to the frame.

That was the last thing he saw as the bullet from the police sniper travelled through his head. He releases the “dead man’s switch” as he falls back, but he never hits the floor – his vest explodes, sending shrapnel and body parts throughout the building.

From forty yards away, staging with my police escorts and the rest of my EMS team I see the fifty-foot ball of fire come out of the window. Crap! Now I have hostages with blast injuries. This is going to be a very bad day!

I walk into the command post to meet the SWAT team leader and get the briefing prior to the assault to attempt resolution of the hostage situation. Camouflaged SWAT members are checking gear and loading weapons as the commander calls for our attention.

“Okay gentlemen, this our latest intel.” The SWAT commander is pointing to a rough floor plan drawn on a white board. “We have three tangos holding approximately ten hostages. I’m getting real-time intel from sniper teams who are in place now. They report the leader has an explosive vest and the FBI SWAT team just raided their home base and found bomb-making material. The good news is that it’s just a black powder device so we’re not dealing with high-yield C-4. The bad news is that we don’t know what the triggering device is or how it’s connected.

“In approximately ten minutes your SWAT team will rappel down from the sixth floor to the mezzanine level. You will then stack along the west wall at which time we will call the phone in this office. It is our expectation that the tango with the explosive vest will answer the phone, at which time our sniper will take out the target. We are told that a single shot from a .308 will weaken the window and allow entry. You will take your team through that window and eliminate the additional tangos. Remember, you have a room with approximately ten civilians.

“Once you secure the room you will call for EMS. They will be staging down the block and enter through the front door. You will provide force protection while they address any life threatening injuries and extricate any wounded. EMS, remember you are entering a warm zone which was hot just a minute prior. I need the SWAT team leader and EMS team leader to come together on how to work together and extricate any wounded with all haste while staying safe. That is all gentlemen; you have ten minutes.”

The SWAT commander walks out on his way to the forward command post as the SWAT team leader, Vinny, and I look over the rough floor plan together. Vinny’s a serious man dressed in his camouflage uniform with an imposing M-4 rifle slung over his shoulder.

Vinny is pointing to the floor plan on the wall and walking me through their method of clearing the room. “Once we have the tangos down I’ll set an internal perimeter and secure egress through the front doors. I’ll alert you via radio that it’s clear to enter. We’ll give you two operators, with your team, on force protection. How are you going to work the room?” He’s a no-nonsense, straightforward kind of guy who seems to know his business.

“That sounds good. I’ll start on a clockwise lap of the room to get a patient count and identify the first out critical patients. As I tag the wounded I’ll spin my guys off on treatment and facilitating egress. I’ll want to stage the wounded for pick-up and transport to the left of the entrance. We have rigs staging, ready to do a drive by and transport to the hospital. It would help if I can use some of your guys to help cary people out. If any of the wounded are heavy it may take four people to get them out.”

“Easy enough, I’ll send you two operators at a time when you need them. Otherwise we’ll stay out of your way and let you work on the wounded. You good?”

“Yeah, I’m good, stay safe.” A blue nitrile fist hits a tactical glove fist and we return to our respective teams for final preparation.

From my vantage point, a half block away, I see ten ropes fall to the ground on the west wall of the building. In a silent rappel, ten SWAT operators slide down the ropes and fall into a stack formation at the corner of the building.

The radio on the officer next to me crackles to life. “Sam one in position.” It’s Vinny on his throat-mic, telling the commander that he’s ready in a whisper.

“Tac-com copies, Sam one. Sniper two, do you have visual?” The tactical commander is getting ready to put things in motion.

“Sniper two, clean line of sight, we are go.”

“Tac-com copies. All teams we are go in ten seconds. Out.”

After waiting for what seems like an eternity, everything happens at once. The sniper fires and the sound of breaking glass is quickly followed by a huge explosion; a fireball comes out of the broken window. As soon as the flames recede, Vinny’s team moves around the corner in lethal stack formation and enters the building. A few seconds later the rapid fire of the M-4 can be heard from the inside of the building. Short bursts of six shots followed by another short burst of eight shots. Some sporadic returning fire and then the final burst of six shots echo out of the building.

The radio crackles to life again. “Three tangos down. Initiating final sweep now.”

The officer next to me leads us up to the forward staging area just twenty feet from the front doors. I can see movement through the windows as the SWAT operators are clearing the room and securing weapons. Smoke is still pouring out of the office window where the explosion came from. Two SWAT operators force open the front doors and secure the egress while the radio crackles again; “Code-4, EMS is clear to enter.”

“Copy. EMS coming in now.” I lead my team towards the front doors.

 

 

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.