Tag Archives: Trauma

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.


Suicidal Ideation 2/3

An officer meets us as we walk up to the apartment building. “She’s in that apartment. Watch your step as you go in, there’s blood all over the place. Looks like she bit her tongue. We’ll have a green sheet for you in a few.”

We were called here for a 5150 but it’s looking like there’s more going on than someone who voiced suicidal thoughts. Once an officer hears a person say they want to kill themself, they have to write up a Form 5150 – it’s on green paper so we just call it a green sheet. Basically the 5150 is a tool used by law enforcement to hold an unstable person for 72 hours during which time they are psychologically evaluated. More often than not they are not “suicidal” – they just said the wrong thing at the wrong time or PD has nothing else to hold them on so they get the person off the street using the 5150 because it’s less paperwork for them.

Walking into the apartment I see two more officers standing in front of a slim woman in her forties. She’s sitting on a chair in front of a closet with blood dripping down her chin –  enough to saturate her shirt. She has ligature marks around her neck which are consistent with the belt that is sitting next to her. Looking in the closet I see the closet rod is broken in the middle.

The officer lets me take it in before he gives me the update. “Hey guys, this is Sandy. She’s been going through some pretty rough times and she tried to kill herself today. She drank a bottle of wine and put a belt around her neck and tied it to the closet rod. She hung there for maybe ten seconds before the rod broke. When she hit the ground she bit her tongue pretty bad. The blood freaked her out so she called 911.”

As I kneel down to examine Sandy I see the bottle of wine on the side table – it’s a Mondavi Pino Noir; not the usual crappy two-buck-chuck that they sell in the local liquor stores. Sitting next to the bottle is a Riedel Vinum wine glass. Riedel is known for being shaped so that the wine lands on your palate just so, and you pay for the privilege – a single glass can cost $25 or more. Well, she gets points for taste even if she can’t calculate load bearing stability very well.

“Hi Sandy, I’m going to be taking you to the hospital to get you checked out. Can you open your mouth so I can see what’s going on?” Sandy nods her head and opens her mouth. Pulling out my flashlight I see that she’s nearly severed the end of her tongue – it’s being held on by less than a half inch, yet the bleeding has slowed to a small trickle. I pull out a sterile piece of gauze and tell Sandy to pinch her tongue with her fingers as we walk out to the ambulance.

Once in the rig I can assess Sandy a little better. She checks out fine aside from the tongue and a minor abrasion to the chin. My only real concern is if the attempted hanging caused any damage to the throat that could cause airway obstruction issues or if her tongue were to swell to the point that it blocked her airway. Admittedly these are big concerns, yet I don’t find anything that would make me light up the rig and drive fast.

Sandy’s not much for conversation – partially because she’s holding her tongue (literally) and the reality that if not for the closet rod breaking she would be dead right now. We start driving towards the trauma center – I don’t plan to trauma activate her but I want her in the trauma center where they are prepared – in case the swelling causes any issues over the next hour or so.

I dim the lights in the back and tap away on my laptop as we take a quiet drive to the ED. I’ve watched partners in the past who will talk to people on a 5150 to try and figure out where they went wrong and offer advice. I have mixed feelings about that as it’s not necessarily our function in the medical community. Although I’ve probably taken more psych classes than my peers I feel it’s my job to treat the physical condition and understand the mechanism that led to the injury – so as to give as much information to the nurses and doctors that will continue to care for the patient. I feel it’s inappropriate to play Paramedic Psychoanalyst.

I’ve transported more people on 5150s for voicing suicidal ideation than I can even count – one man was even placed on a hold for texting it. But this is a different presentation. Sandy wanted to end her life so desperately that she put together a plan and acted on it. The carpenter that installed the closet will never know that had he put a third closet rod support in the middle, as he should have, a woman would be dead right now.

Suicidal Ideation 1/3

sui·cid·al

1  :  intending or wishing to commit suicide

2  :  likely to lead to death, destruction, ruin, or very much against somebody’s best interest.

 

ide·a·tion

1  : The faculty or capacity of the mind for forming ideas; the exercise of this capacity; the act of the mind by which objects of sense are apprehended and retained as objects of thought.

Sick of trying – what’s the point

Sick of talking – no one listens

Sick of listening – it’s all lies

Sick of thinking – just end up confused

Sick of moving – never get nowhere

Sick of myself – don’t wanna live

Sick and tired – and no one cares

Sick of life – it sucks

Suicide is an alternative

 

Suicidal Tendencies – “Suicide is an Alternative

(80’s punk rock/crossover band)

We’ve been standing in front of the house for maybe ten minutes and police cars keep arriving: plainclothes detectives, gang unit, even the brass – I’ve never seen this level of response to an active case. All of the officers on scene are quite emotional and that’s not normal for this group – they rarely get broken up on scene and they see some of the worst things humanity can dish out. Something is definitely wrong but no one is talking to us.

It’s nearing dusk and the fog has started to build in the city next to the water. All members of the light bar fraternity (Police, Fire, EMS) are represented here with their strobe lights cutting rays into the fog as the city gets colder from the encroaching marine layer.

Every type of call in EMS has a vibe and all of the responders seem to pick up on the collective unconscious signals. Some are humorous to the responders – like when a gang banger shoots himself in the groin while stuffing his Glock-19 into his pants. Some are all business – like when a child is having a severe asthma exacerbation. Some are just sad – like when an elderly person dies in their sleep. Yet this is a vibe I’ve never felt before – I just can’t quite put my finger on what’s going on and the officers aren’t talking to us or letting us into the house. They just talk quietly on radios and phones as more police cruisers keep arriving.

Another five minutes and an officer comes out of the house – I can’t even count how many stripes he has on his sleeve but it’s obvious this is his crime scene. He’s emotional but he’s stuffed it down into the closed recesses of his mind so that his professional side can run the show. He’s all business as he fills us in.

“Thanks for standing by so long. We had to do a thorough search of the residence before letting anyone inside. We’ve got a fifty-two year old male in the garage; apparent suicide, GSW to the head. It’s obvious he’s dead but I need you to pronounce so we can get on with the investigation. When you go inside don’t touch anything – just get in, pronounce, and get out. It looks like he fell on the gun and we can’t get to it so don’t move the body at all; he may still have a finger on the trigger. And guys, one more thing – he’s one of us.”

My heart just dropped into my stomach and I’m having a hard time breathing. Now the collective vibe of the scene is hitting me full force – an officer just committed suicide.

I follow the officer with all the stripes on his sleeve through the back door of the garage, carrying just the ECG monitor and my stethoscope. The officer stands aside so I can do my assessment.

Crumpled face forward in the middle of the garage is a body in dark clothing. There’s a small pool of blood near his head and blood splatter on the ceiling of the garage. I’m being careful not to step on anything as I kneel behind him and see a forty caliber shell casing on the floor to the right. I smell the metallic scent of fresh blood from the pool that is slowly coagulating as I put my fingers to his neck to feel a warm body without a pulse. A single slice with my trauma sheers up the back of his thin shirt exposes his back to me. As I’m listening on the back for any breath or heart tones I see the exit wound the bullet made as it went through the back of his head. Without moving the body I place my electrodes on his back in the same configuration I usually use on a person’s chest. I don’t want to roll him over since I don’t know where that gun is pointing right now. The monitor shows the flat line of asystole that I expected to see. I print out six seconds of flat line and rip the strip off the monitor and put it in my pocket. I disconnect the monitor and retrace my steps out of the garage without disturbing anything.

The officer with the stripes was watching me the whole time from the doorway. I tell him what he already knows. “Yeah, he’s gone.” Looking down at my watch, “We’ll call it confirmed at 1855.” He nods his head and writes a note in his little book.

I walk back to the rig to start my paperwork. Sitting in the passenger seat with the laptop open on my knees, I’m typing as my partner comes back from talking with the fire crew that’s packing up to head back to the station.

He gets in the driver’s side. “So, I was just talking to fire and I got the story. He was a detective on the force for fifteen years but he’s been on administrative leave for the last couple of months. He’s got some alcoholism issues and his unit commander was on his way here today to drive him to get checked in for detox. The commander is the one with all the stripes. He got here an hour late because of a case and found the guy in the garage…”

 


Lachrymatory 1/3

lach·ry·ma·to·ry

1 : of, pertaining to, or causing the shedding of tears

2 : a small, narrow-necked vase found in ancient Roman tombs, formerly thought to have been used to catch and keep the tears of bereaved friends

We’ve been sitting here in the rig, parked deep in the hood, for the last 25 minutes. Scottie is playing a word game on his iPhone and I’m checking e-mail and reading EMS blogs on my iPad. There’s an assault going on six blocks from us but there are no police officers on scene yet so we have to stage here until they tell us it’s safe to enter. It’s been raining all day and the wipers are on delay; going off every few seconds to wipe the rain from the windshield.

“Anything new in the notes?” Scottie doesn’t even look up from the game.

Glancing over at the mobile data terminal (MDT) in the center console I see that nothing has changed. “No, still no PD on scene.” It’s unbelievable to me that an assault can continue for a half hour and the police are stretched so thin that they don’t have the manpower to respond. I wish the city council members who voted to lay off the officers six months ago could spend the day with us and see what their decision is costing the public.

At the 30 minute mark the MDT finally shows that two officers have arrived on scene and five minutes later we are cleared to enter. We pull up at the same time as the fire engine who was staging on the other side of the incident. We ran a call with this crew earlier in the day and they were a good group. Walking up to the corner I smell the fresh scent of rain. It’s refreshing how it washes down the hood and makes it a little more pleasant but even the rain can’t change the fact that it’s a dangerous neighborhood.

The officer walks up to me and points to a young woman in tears standing by his car. “Just one vic – looks like a domestic, assaulted with closed fists.”

She’s crying and breathing fast but otherwise she looks okay at first glance; no blood and she’s able to walk and move all extremities. I look over at the LT on the engine and tell him I can handle it so they can clear and go on to the next call. As the engine is pulling away I walk my patient to the ambulance and she climbs in to sit on the gurney.

As I’m doing my regular checks of vitals and cataloging wounds the officer pops his head in the back door. “Hey, can you guys hang out here for a few? My crime scene tech is in a really bad mood and doesn’t want to go to the hospital for photos”

I slam the ice pack into my knee to activate it and hand it to my new patient to apply to her facial swelling, along with a few tissues to wipe away the tears. “Yeah, no problem, I’ve still got a little to do here and she’s pretty much stable.”

As I continue my assessment the officer is standing in the back door of the rig and questioning my patient, Anika. I listen in and start to get the story of what happened. She’s a foster kid who ran away from home with her adult boyfriend. She’s been living with him for the last few months. Today he was angry and and he took it out on her by hitting her in the head, stomach, back, and kicking her when she fell to the floor. She’s more emotionally distraught than physically hurt – all of the injuries are pretty minor. As she’s telling the story the other officer walks up with a gun. That is exactly why we were staging until the scene was secure…

“When he was beating you down did you ever see this gun?” With a cracking voice and uncontrolled tears she tells him no. The officer is looking for anything that would increase the charges on the assailant. Possession of a firearm during the commission of a crime would increase the time he spends behind bars.

Anika asks the officer, “How long is he going away for?” She’s scared yet also conflicted.

“We’ve got him on an outstanding warrant and firearm possession but you need to press charges for the assault to stick.” Anika is holding the ice pack to her quickly swelling face and eye while shaking her head. She doesn’t want to press charges. “Look, I’ve seen this before, it just gets worse; the next time he’s really going to hurt you. You didn’t do anything wrong and you don’t deserve this. It’s not okay to treat a woman this way. You need to help put this guy away so he doesn’t hurt you or anyone else. I’m telling you; it’s going to get ugly next time.”

I’m tracking her respirations on the monitor so I can see a wave form for each breath she takes. The wave form is getting smaller and the duration between breaths is getting shorter – she’s starting to hyperventilate. The officer is pushing her a little hard but it’s for her own good. We all know where this kind of thing will lead. We’ve all seen the final outcome and it really is as ugly as the officer said it would be.


Necromancy

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

The elevator is cramped with all of equipment and people squeezing close together. My partner, Scottie, stands next to me with all of our equipment stacked on the gurney and the strange addition of two SWAT officers with body armor, helmets, and assault weapons. I can smell the cordite from the recently fired weapons. We passed the shooter on the way to the elevator still warm with spent shell casings laying in the hallway; at least a dozen hits to center mass – no need for medical attention. We’re not here for him; we’re here for the unknown amount of victims that he shot before SWAT took him out.

The silence is broken when one of the SWAT officers keys his mic to alert the rest of his team that he’s coming up in the elevator with paramedics. Adrenaline is pushing through everyone’s veins and has been for the last twenty minutes. Sympathetic nervous systems are stimulated; pupils dilate, pulse and respirations increase, we have to fight not to tunnel vision on what we are about to see.

The doors slide open to reveal two more SWAT officers securing elevator access to this floor of the building. I hear the cries for help as we exit the elevator and see the blood splatter on the wall. Following the blood streaks to the ground I see a wounded officer and tunnel vision gets the best of me. I put a hand over the arterial spray coming out of his thigh as I’m applying the tourniquet with the other hand. Scott pulls the quick release on the officers body armor to check for additional wounds. As the bleeding has stopped I stand up and see the elevator doors open again; it’s my second EMS team with their SWAT escorts.

“Okay, he’s got a GSW to the thigh, arterial spray, tourniquet in place; he’s first out. I’m going to walk the floor and get the criticals ready for extraction.”

Turning from the injured officer to the rest of the room I take in the sites and sounds. It’s a typical legal office with cubicles in the center surrounded by offices. Cries for help are coming from all over the office space. SWAT officers are holding perimeter positions where they can secure the whole room so we can extricate the victims. It’s called force protection; once they eliminate the threat they then secure the scene so we can treat and transport the victims while under protection.

I had a plan before the elevator doors opened but I’ve already deviated from it by front loading the wounded officer for extraction. It’s a natural reaction to take care of the uniforms first; they are here to protect me and I want to protect them first in my treatment; it builds trust between agencies. But the reality is that there are probably other victims that are hurt worse. I need to get a handle on this before the scene gets away from me. I need to get back to my plan.

Standing by the reception desk at the front of the office I yell across the room as loud as I can. “If you can hear my voice and can walk I need you to start walking towards the stairs. Start walking now if you can!” Bloody office workers start to emerge from the cubicles; some limping, starring at blood on hands in disbelief as the SWAT officers herd them to the stairs.

Looking down at the receptionist I see what looks like a shotgun wound to the head. Checking a pulse and finding nothing I move on. A hysterical mother is cradling her twelve year old son who had a GSW to the neck; he can talk but can’t move any appendages, traumatic paralysis.

“Scottie, c-spine this kid, he’s next out.” I see Scottie headed in my direction and the third EMS crew is coming out of the elevator with their SWAT escorts. I need to pick up the pace and sort this chaos out quickly.

I’m making my way around the office with my SWAT shadow. A man in the office clutching his chest, no injuries, probable heart attack; he can wait, I move on. A woman with bilateral GSWs to the knees, arterial spray; two tourniquets and I move on. Another woman with a through and through GSW to the chest; two occlusive dressings to stop the sucking chest wound and I move on. A DOA; I move on. A woman with venus bleeding from a GSW to the leg; pack the wound with gauze imbedded with clotting agents, tell her to hold pressure on it and I move on. An old lady hiding under the desk who was too afraid to move when I called out but has no injuries; I pull her out and have a SWAT officer walk her towards the stairs as I move on. Finally I’ve made it around the room of offices and cubicles and back to the DOA receptionist.

I send another EMS team towards the sucking chest wound lady as the kid with the neck wound is getting pushed towards the elevator on a gurney. Then the two women with leg injuries are pushed out on gurneys. And finally the man with a probable heart attack is wheeled past me while sitting in his office chair. The SWAT officers protected the EMS crews throughout the whole process; they held the perimeter and escorted us too and from the scene.

I’m making a final lap around the office space to make sure I didn’t miss anyone when a man in a reflective yellow jacket steps out from a cubicle wall. “END EX, END EX!”

The SWAT officers repeat the order to End Exercise over their radios. The DOA receptionist gives me a big smile as she stands up and stretches; sore from not moving for the last ten minutes. Her hollywood quality head wound is still glistening with fake blood.

The basic premise of this scenario is that there is an active shooter situation with multiple victims who have been shot and are in various states of severity. The on scene Unified Command-ers propose using a SWAT team to eliminate the threat and once that is accomplished, to escort the EMS team into the scene and be given close quarter force protection while providing the needed medical care (triage, emergent treatment) and then egress the area under cover and protection.

This was obviously a very elaborate exercise in which 29 SWAT teams from various local and international agencies participated. Currently we do not go into the “warm zone” so fast on the heals of SWAT and under force protection protocols. Yet that concept is being challenged on many levels as the necessity of early medical intervention has growing acceptance.

After the exercise I had an interesting conversation with the head of the Israeli EMS training division. He related a situation where a suicide bomber created an MCI with 150 injured people in which EVERYONE was treated and transported within 29 minutes. We are no where near that proficient yet. But with the new reality of global terrorism and increasing frequency of natural disasters we must continue to train for the worst case scenario.

After running the scenario as the EMS team lead I ran it again as EMS support with a different SWAT team and then observed from the sidelines as another group ran through. It was an extremely enlightening experience. Not only in my own shortcomings  but in the tactics and priorities of other agencies. We can’t predict the future or know what we will face but we can train and push our skills in the hopes that we are prepared. EMS does not conjure the dead yet we do quarry the dead; we learn form them so that we can help others in the future.