Tag Archives: MVA

Twisted 3/3

“Did she just say ‘car vs train’?” I’m asking Louis as the radio was a little scratchy while the dispatcher gave us the call information.

“Sounded like it. I’ve got my money on the train.” Louis pulls his gloves on and flicks on  the lights and siren to get through the traffic, and heads in the direction of our call.

It’s dark and the strobes illuminate the fields and scrub brush of the landscape in this rural corner of my mostly urban county. We’re heading down a well-traveled arterial yet we’ve taken it to the point that it’s turned into a dirt road. I’ve actually never been this far down this road so I check my iPad to make sure the railroad crossing is still in front of us.

Eventually we see the flashing red lights of the fire engine and the heavy rescue rig. They send out the heavy rescue crew when there is a possibility of extrication. It’s like a giant drivable toy box. Every external cabinet holds all kinds of great toys for guys that never grew up: jaws of life, pneumatic spreaders, inflatable bags, etc. Both rigs are parked next to the railroad crossing where a huge train blocks the road. The lights are on in the train and I can see it’s a passenger train by the many heads that are silhouetted in the windows. It’s not one of our light rail commuter trains. This is a heavy rail interstate train with maybe thirty cars.

We park next the the other rigs and start walking down the tracks towards the flashlights that are visible one hundred yards in the distance. As we’re walking I’m using my flashlight to illuminate the uneven gravel that is littered with car parts and huge gouges in the direction of travel.

Once we get to the front of the train we finally see the car – or what’s left of the car. It looks like a hungry train decided to eat the car for dinner and got interrupted half way through. The car appears to have been “T-boned” by the train and it’s looking like a tin can that was stepped on so the middle is flat and the ends are just twisted heaps of metal that were dragged for the last hundred yards until the train stopped.

I catch the eye of the LT as I recognize him from other calls that we’ve been to in the past. “Please tell me no one is in there.”

“As far as we can tell it’s empty but they’re getting the thermal imager to confirm.”

We have city PD Officers and County Sheriff Officers on scene now and I see that the conductor has made it down from the driver’s seat to see the damage. I confirm with the conductor that there are no injuries to the passengers in the train. They had people walk the length of the train in the passenger space and basically no one even knew what happened. The inertia of the train was such that a little car didn’t even interrupt people’s dinner or spill their drinks. That’s great because I had a brief moment of panic thinking that I was going to have to take 100 sets of vitals and have everyone on the train sign out with a release form.

Not only does the thermal imager show that there is no trapped warm body it the car it shows that the engine was cold when the train hit it, so it was parked on the tracks! We have to do our due diligence to make sure we didn’t miss a patient that may have been thrown from the wreckage. Using flashlights and the thermal imager we cover a hundred yards in either direction of the point of impact with no visible hot spots.

As we’re getting ready to clear the scene I ask one of the County Sheriffs why a car would be parked on the tracks at this time of night.

“Yeah, well, it happens a few times a year. Gang bangers from the city will steal or car-jack a car, joy ride all day, then park it here to destroy any evidence and maybe just watch from a distance to see if it explodes. We didn’t find the license plate so we’ll have to run the VIN to confirm – if we can find it.”

Taking the long walk back to the flashing rigs I’m thinking about the utter disregard for human life that someone would have to park a car on a train track. I don’t know what the chances of derailing a heavy train are but had it happened we would have had a serious MCI (Multi-Casualty Incident) on our hands. Even still, the conductor spent a few minutes wondering if he just took a life while driving his train. As a matter of procedure he’ll end up peeing in a cup and handing over his cell phone to make sure he wasn’t at fault for the incident.

I often joke with my wife that I’m in the business of thwarting Darwinism. We save the stupid and negligent people of the world so that they can go on to propagate their genetics and make Mini-Me’s just like them. A thousand years ago they would have been run over by a water buffalo while crossing the trail. Today we patch them up and send them on their way to make more kids. One of these kids has just endangered over a hundred people with a senseless act. I wonder if the genetic pool of humanity is forever degraded as our modern medicine does its magic.

I guess that’s a question for future sociologists to ponder. Meanwhile, we in EMS continue to do our job and hope that in some small way we have the chance to make a difference for the better.

Twisted 2/3

“I guess it actually is a car fire, there’s the smoke.”

Louis and I are out on the fringe of the county in the rural affluent suburbs. We’re responding to a car fire that came in as single car fully engulfed. To be honest, most car fires that I go to are smashed radiators with steam escaping from under the hood. Cars don’t usually just burst into flames as Hollywood would like us to believe. But as we’re driving through the quiet neighborhoods we can see the smoke cloud coming up next to the road. Looks like it’s a real car fire.

Everyone on scene seems pretty calm as we pull up – County Sheriff officers are standing around while the fire department gives the car a thorough dousing, and neighbors are watching the commotion from down the road. It seems as though the car hit a rock that’s about the size of a small dumpster, and the rock went straight into the engine compartment.

The rock is at the side of the road where the road just plain ends. As housing developments push into the rural areas they are built in different phases. They provide the infrastructure, in the form of access roads like this one, for future phases of development. But until they start the next phase this road stops abruptly at the end of the neighborhood.

By the looks of it, the driver didn’t know the road would stop so abruptly and veered off to the side, hitting the rock which is now sitting where the engine should be. The lack of skid marks speak to the level of damage that was transferred to the car.

I don’t see the fire department doing anything medical, just pulling hose and squirting water, so that means one of two possibilities: the driver is either uninjured, or crispy beyond recovery. Walking up to a Sheriff Officer I ask if there are any patients. He points to a boy standing on the other side of the road with another officer – the boy looks to be maybe sixteen. I’m surprised – he looks completely fine from where I’m standing.

Louis and I walk up as the officer is finishing his initial questioning. “Hey, were you the driver?” He nods his head up and down. He’s a bit flustered after watching his car burn up – that’s understandable. “Are you hurt?” He says no. “Okay, so tell me what happened.”

“I was driving about thirty-five miles an hour, talking to my friend, when I guess I was distracted, I missed my turn and didn’t see the road end until it was too late to stop.”

“Okay, so where’s your friend, is he hurt?” He’s thinking a little too hard right now. He’s carefully fabricating a story on the fly and he’s not really bright enough to pull it off with any credibility.

“Uh, I guess he ran off.” Seriously? He ran off? That’s lame.

“You sure you weren’t talking to him on your cell phone?”

“No, he just ran off.” Okay, have it your way.

I give him a full assessment and he checks out fine. Just a little bit of a rash on his face from the airbag deployment. It seems as though he hit the rock, got out of the car, and was clear before it started burning. He’s a minor so I can’t release him unless he has a parent sign a release form for me. Even still, it’s a good idea to get him checked out at the ED. I’m not buying the whole thirty-five miles an hour thing. His little compact car hit a two ton rock hard enough to push it two feet back in the grass and set his car on fire. He was probably doing fifty miles an hour while talking on the cell phone and went straight into the rock without slowing down.

Louis is taking some vitals for me as I go to the car to see if I can learn anything from it before we take him to the ED. The firefighters are rolling up their hoses and the car has stopped smoking. The engine compartment and passenger space are completely burned up – even the air bags and everything fabric or foam in the car has burned up. Otherwise there’s no passenger space intrusion, the seats are still bolted to the frame, the steering wheel is still in place, and the seat belt is locked in the extended position. So he was restrained, and the crumple zone of the engine compartment did its job of stopping the force of impact from extending to the rest of the car. Basically, he was lucky.

I talk to the Sheriff Officer about the “friend.” He tells me they don’t buy it either so I don’t need to stick around to see if another patient shows up. As I get back in the rig to transport the kid is all agitated.

“I have to go get something out of the car.”

“Dude, your car is toast, there’s nothing in there that didn’t get burned or soaked.”

“I don’t care, I still have to get something.”

“The firefighters aren’t going to let you near it – it’s too dangerous. Just tell me what you want and I’ll have a look.”

He doesn’t want to tell me what it is and I’m not letting him near a dangerous car so we call it an impasse and start driving to the ED. During the transport he clams up and I can see that’s he’s working on his story for his parents and the follow-up with the Sheriff at the ED. He probably wanted to try to recover his cell phone so no one could see that he was talking, or even worse that he was texting, at the time of impact. It’s a lost cause, the Sheriff will check the cell records as is routine in this situation. He’s just lucky he didn’t cause any damage to anyone else or himself. But he’s not smart enough or mature enough to understand that.

Twisted 1/3

twist·ed

1:  to combine, as two or more strands or threads, by winding together; intertwine

2 :  bent so that the original shape is change or destroyed

3 to distort the meaning or form of; pervert: He twisted my comment about to suit his own purpose

4 :  a sudden, unanticipated change of course, as in events or story – a plot twist

We pull up in front of the accident so the rig less likely to get rear-ended. We’re at the corner of Really Bad Street and Even Worse Street which is deep in the hood of the large city in my mostly urban county. I saw the car as we passed – a compact two door that was wrapped around the large light pole in the center divide of a busy inner-city arterial. The car somehow turned perpendicular to the direction of traffic and made contact with the pole on the passenger side. It looks like a fortune cookie wrapped around a straw.

There was some confusion as to the actual location of the accident – probably due to multiple calls from cell phones and people getting their locations wrong. So I want to check with City PD, who are already on scene, to see if there are any other accidents around here. That way I can cancel the other unit and save them a trip if I can handle the patients here. There’s no reason to take up extra resources if I don’t need them.

Checking with the officer on scene I find out that this is the only working accident in this area. Then I check with the fire medic and find that there are only two patients, both with just minor injuries. I can take both so I call to cancel the other rig.

Now that that’s taken care of I take in the damage to the car as Louis helps the fire medic to put a cervical collar on the passenger from the car and get her onto a back board. There are at least 24 inches of passenger space intrusion and the air bags didn’t deploy (or maybe there weren’t any). Fortunately, there are no star shaped patterns on the windshield, which would indicate impact by the occupants’ heads. But because of the extent of the passenger space intrusion I’ll have to trauma activate and go to a trauma center. County protocols require an activation based on the mechanism of injury and I’m obligated to follow protocols when it’s this clear cut – even if the injuries to the patient don’t warrant a full trauma activation.

Louis and the fire medic are almost done with the passenger so I try to find out if anything is wrong with the driver. I’ve been kind of ignoring her since I got on scene – or possibly it’s more that she’s ignoring me. She’s been frantically pacing up and down the scene of the accident hysterically crying into her cell phone and occasionally answering a question from PD when they can get her to focus.

I took a quick glance at her as I was checking out the car – no blood or obvious signs of trauma, moving all extremities, able to focus on the officer when he asks her questions. The lack of proper phone etiquette – especially in young people – really astounds me sometimes. I’m constantly asking people to put down their cell phone so I can finish an assessment.

The fire medic and Louis are loading the passenger into the rig. Louis jumps in to get a set of vitals – he’s a great partner and I trust him to do the initial work up and give me good information once I get ready for transport. I’m still trying to get the driver to focus on me as I follow her up and down the street. Finally I get her to hang up the cell phone.

A quick assessment shows that she has no signs of injury, no complaints, and no neurological deficits. I run a State of Maine neuro exam on her just to make sure. It’s a really effective way of finding any deficits that would warrant taking spinal precautions. As I find nothing noteworthy I walk her to the ambulance and have her take a seat in the “captain’s chair” at the head of the gurney.

Louis gives me his findings and I re-check a few things just to make sure everything is okay. Right before we pull out into traffic the officer hands me an incident report number for the driver so she can track her car as it’s getting towed to the city lot.

Now that we’re driving to the hospital and in the controlled environment of the ambulance I can focus on the patients a little better. They are both 17 year old girls, from the more affluent city on the other side of the county, and dressed like they are going out to club or party. Both of them have high heels, perfect lipstick, tight fitting clothing, and hair that’s done up with highlights.

I’ve said it before and I’m sticking to my guns on this one: Paramedics profile their patients – and these two girls don’t match the situation. They’re too dressed up for early afternoon, this is not the right neighborhood for them, and they’ve been acting just a little evasive when I question them. There’s more going on here and I’m having a boring day so I decide I’m going to see if I can figure it out.

I have to tell cell phone girl to hang up again as she’s trying to call people. I ask her to tell me how the accident happened. I need to know so I can give the MD a decent description, but I also need her to focus as she’s on the verge of hyperventilation – very emotional.

“This car came up behind us and was driving all crazy. It cut me off and I swerved into the pole.” She’s breathing fast and waving her hands around for emphasis.

“So there was no impact with the other car and the only damage was your car hitting the pole?” She nods her head. “Okay, then what happened, were you able to get out of the car yourself or did the fire department have to help you get out?”

She’s waving her arms around again. “No, this guy opens the door, and I like think he’s helping us get out when he grabs my purse. I’m pulling on it when he opens it up and takes my cell phone and money. He takes off down the street and I chase him, I fought him for my cell phone but he took off with the money.” Seriously? Robbed by a bystander after an accident?

“Were you hurt when you fought him for your cell phone?” She tells me no. “What were you doing in this neighborhood when you live twenty miles away?” She thinks about it for a while and tells me they were visiting a friend. “Okay, so how much money did he steal, was it like thirty dollars or three hundred dollars?” She says she doesn’t know. “You told the police all this right?” Yes.

Okay, I’m done. It’s obvious they are both hiding something and not answering questions with complete honesty. I have no doubt that she was robbed. But it’s the circumstances that bug me.

First, she’s not being straight with me about being in this neighborhood and “visiting a friend.” They are both dressed wrong for the situation. And if a guy is going to rob them he’s just going to take the purse and run. He’s not going to take the time to open it up while she’s hitting him and rifle through it to find her cash and cell phone.

Think of the audacity the thief would need to have to be fighting with a girl in a car in the middle of a busy street just after the accident. They are actually within sight of the police sub station and he’s got to know that PD/FD/EMS will be there any second. Then the improbable act of chasing him down the street in high heels, actually fighting him for the cell phone and having no marks on her. And finally, every seventeen year old knows exactly how much money is in their purse. It’s just not adding up for me.

I’m reminded of Dr. House from the television show, “Why should I talk to patients? They just lie to me.” That sentiment has rung true for me more often than not. It’s a lot simpler to just treat what I find and move on. In this case I’ve actually got nothing to treat so I do my paperwork on the way to the hospital.

After dropping them off at the ED Louis and I are talking about the call and pointing out all of the inconsistencies. We decide it went down like this: two girls from the affluent neighborhood go to the hood with a lot of money, possibly looking for drugs. The wrong people find out they have money and one of them uses a car to run them off the road into a light pole. He then jumps out and threatens her until she gives him the money. Then he drives off. She then has to make up a story that will explain all of this to her parents who are going to be pissed that she’s in the wrong neighborhood and totaled the car.

Our version of the story is much more credible, but the fact is that I’ll never know the real one. That’s often the case in EMS – we get partial truths, misinformation, and misdirection. It’s an exercise in filtering to weed through the things that really don’t matter and treat what is necessary. It’s the wrong career for people who are dedicated to absolutes. If you’re comfortable playing in the gray area of reality then everything works out pretty well.


Rude Awakening

rude

1 : Relatively undeveloped; primitive: a rude and savage land

2 : Exhibiting a marked lack of skill or precision in work: rude crafts

3 : Lacking education or knowledge; unlearned

4 : Ill-mannered; discourteous: rude behavior

5 : Abruptly and unpleasantly forceful: received a rude shock

awak·en·ing

1 : The act of awaking, or ceasing to sleep

2 : Rousing from sleep, in a natural or a figurative sense; rousing into activity; exciting

3 : to cause to be aware of

Is human life just a dream, from which we never really awake, as some great thinkers claim?

William Shakespeare –The Tempest

We arrive at the same time as the BRT which is taking an angled position across the street to block the intersection with their rig. This provides a degree of protection from traffic. We saw the patient laying in the crosswalk, flat on his back, not moving as we drove into the intersection. He looked like a GSW victim; bloody, laid out, no movement.

Jake, our ride-along EMT student, is excited as it’s the kind of bloody mess of a call that he was hoping to get today. EMT students are required to ride in an ambulance as part of their course completion. The majority of them are here to get their certificate so they can apply to fire departments. Maybe half will go on to be working EMTs, less than a quarter of them will become Paramedics. Along the way a few will get picked up by fire departments. It’s not uncommon in this area for 3000 people to apply for a 15-person academy in a fire department so the odds are definitely against them.

Throughout the morning Jake maintains a constant monologue about the fire departments he wants to apply to, where he wants to work, and the exciting things he did in the fire academy that he went to last year. We listen to him while suppressing smirks at his naivet. Jake quickly became disinterested in the mundane calls of the day; the old lady with weakness for three days, the Crohn’s disease patient with abdominal pain, the pregnant woman with abnormal discharge who is worried about her baby. All of them could have taken a cab to the ED, or made an appointment with their primary care physician, but that’s not what happens in this county. They call 911 because they feel entitled to immediate transport and evaluation at the ED. Anyone who doesn’t think we already have universal health care should spend a day with us and see the reality that we see every day.

My partner Brent and I exit the rig with Jake in tow and approach the patient as the fire medic is approaching from the other side. The patient seems to be a man in his thirties. I kneel down to listen for breath sounds while I’m feeling for a radial pulse; both are present but weak. The fire medic rubs up and down the patient’s sternum with his knuckles to see if he is responsive to painful stimulus; no reaction.

We start cutting off bloody clothing as one of the fire fighters is holding c-spine to prevent further injury to the neck and spine. Brent goes back to the rig to get the back board and straps. Jake is cutting up one of the pant legs. He’s never done this before and he takes slow deliberate cuts with the trauma shears. The fire medic and I strip the rest of the patient’s clothing in the time it takes Jake to do one leg.

Now that we have him stripped the injuries are obvious. Bilateral deformity to the knees, facial and head trauma in the front with matching trauma to the back of the head. The fire captain comes up after talking to some witnesses in the crowd that is growing on the sidewalk.

“Okay, per witnesses, this guy was crossing in the crosswalk when a car traveling at a high rate of speed did a hit and run. They said he went airborne and landed in the crosswalk.”

Looking down at the blood covering the white lines on the pavement I’m confused. “I don’t get it Cap, how did he get hit from the side and end up further down the same crosswalk?”

“No, he was in the other crosswalk, went airborne, and landed in this crosswalk.” Damn, that’s big air!

I stand up to see the street better; two lanes each way with a turn lane in-between. It’s at least 100 feet from crosswalk to crosswalk. That gives me an idea of the speed of the car and level of trauma that was inflicted on this guy. Given the wound pattern it appears he turned to face the car as most people do, and the bumper broke both legs. He folded face first into the hood causing the facial trauma, then was launched across the street landing on his back and causing the trauma to the back of the head on the concrete.

We get him secured to the back board and loaded into the rig. Throughout the process he hasn’t moved or reacted to anything we did — he’s completely out. We’re conscious of the time spent on scene – as this is a code-3 trauma activation we want to hold our scene time to under 10 minutes.

The fire medic looks up at me from outside the rig. “You want a rider?” I tell him yes; I have Jake in the back with me but he really can’t do much to help. I can use another medic with me. He jumps in and I tell Brent to get us out of here.

As we’re rolling towards the freeway I’m setting up my intubation kit while the fire medic is working on an IV and Jake is trying to take a blood pressure. He’s never taken a blood pressure in a moving ambulance with road and siren noise – it’s an acquired skill and he’s got to start somewhere. There’s blood in the mouth, I suction it away and insert my laryngoscope. Visualizing the vocal cords, I pass the tube into his trachea. I inflate the cuff, which secures the tube in the trachea, and attach a bag to squeeze some air in to confirm placement.

The patient, still a John Doe (JD) to us, suddenly starts moving all extremities at once and shaking his head. He’s trying to scream but there’s a tube in his throat so all that comes out is air with a fine mist of blood. I’m trying to hold his bloody head steady with one hand while holding the tube with the other hand to stop it from getting dislodged. Jake and the fire medic have their hands full holding arms and legs. It’s not a seizure – the movements are purposeful, yet unorganized. It’s the flight or fight response of an injured brain manifesting in a combative outburst. JD doesn’t mean to be combative – heck JD isn’t home right now – it’s just the autonomic part of his brain trying to do something, anything, to protect from further damage.

It takes all three of us to subdue him. I’m holding the head and tube, trying to preserve some semblance of c-spine precautions and stop the tube from being dislodged. Jake is holding his legs which are kicking even with bilateral fractures at the knees. The fire medic is using leather restraints to secure JD’s hands to the backboard.

As we’re pulling into the ED I decide to remove the tube. If JD’s moving enough air to be combative then he can breathe on his own – the ED may well re-tube him but that’s up to them. I might have sedated him but that’s contra-indicated for traumatic head injuries, not to mention I couldn’t reach the drugs while all three of us were holding him down.

We roll him into the trauma room where a team of 15 nurses and doctors is already waiting for us. It’s a teaching hospital – one of the best – so a brand new resident gets my attention and says, “You can talk to me.” I’m sure they teach the “baby docs” to say that every time. It always kind of makes me chuckle.

I give the baby doc a full report on my treatment and JD’s condition. All the while JD is screaming and flopping bloody appendages around as they pull him off the board and baby doc orders the RSI kit (rapid sequence intubation – sedate him, paralyze him, and tube him). That’s one that’s not in our protocols but it’s the only way to handle JD right now.

As I walk out to the ambulance bay I encounter a dirty look from Brent as he’s scrubbing the cabinets of the rig to get the blood off. “Sorry dude, we tried to keep it clean.” I’ll do my paperwork fast so I can get back and help with the decontamination of the rig.

While doing my paperwork I’m explaining to Jake the pathophysiology of coup-countrecoup traumatic brain injuries. He’s using some wipes to to try to get the blood out of his white polo shirt. He’s not as talkative as before; the constant diatribe of his accomplishments have dwindled to a morose silence. I don’t think he’ll be one to work as an EMT or go on to be a Paramedic. The reality of our mundane calls interspersed with the insane call isn’t for everyone. I suspect he’ll continue testing for the Fire Department and given the odds that may not work out the way he expects.

I finish my paperwork and head back to the rig to help with the decontamination.