We’ve been driving for twelve minutes with lights and siren and we’re still miles from the call location. Our ambulance travels further into the hills on this foggy morning, in a desperate attempt to find the curvy ridgeline road where a bicyclist has been hit by a car. The update came in a few minutes ago that CPR is in progress and the Parks Department Fire Rescue is on scene.
I’ve been going over CPR ratios with my military EMT student who is anxiously peering into the front compartment. He’s twenty but looks like he’s twelve with a fresh, bootcamp buzz cut and black-rimmed glasses.
We can tell we’re getting closer as passing bicyclists are pointing back up the hill as we go by. We round the bend to find firefighters doing CPR on a man in the middle of the street. I walk up to the scene carrying my monitor and suction with my student in tow.
I set my monitor on the uphill side of the patient because blood is flowing downhill at every compression. I tap the firefighter who’s doing CPR on the shoulder and ask if my student can get some compression time while I start assessing the injuries and looking for a pulse. The firefighter pulls back and I feel at the bloody neck for a pulse while listening with my stethoscope for heart tones and breath sounds.
“Resume CPR.” My student starts compressions on the chest like a machine and I have to remind him to count it out for the others while I’m attaching electrodes. I’ll get an electrical reading of the heart on the next pulse check but I already know what I’ll find.
I suction out the mouth, which is a reservoir of blood that just keeps filling on every compression. The firefighters have been doing this for ten minutes and they know as well as I do that this guy isn’t coming back. As I’m waiting for the next transition of CPR the lieutenant shows me the helmet. The top is actually concave! Usually I see scrape and slide marks on helmets from a bicyclist. The concave nature of the helmet tells me a lot. I kneel down to feel the section of his head that corresponds to the helmet damage. Palpating the bones of the skull I feel them give away to depress into the brain. I look up to the lieutenant, “You can cancel the helicopter, we won’t be transporting.”
He walks away while talking into his radio as I have my student stop CPR so I can document the flat line of asystole – showing that the heart has no electrical activity – with a long printout from my monitor.
I switch my student into the airway position and show him how to use the suction while another firefighter picks up the compressions without losing a beat. Walking across the road to the guardrail I pull out my cell phone and hope for a signal while I stare at the hillside disappearing below me in the fog. After a few rings I hear a voice on the other end.
“Medical control, this is Dr. French.”
“Good morning Dr. French. This is paramedic KC on Medic-40 calling for base orders to discontinue resuscitation efforts on a traumatic arrest.”
“Okay, Medic-40, go with info.”
“I have a 43 year old male involved in a head-on bicycle vs. auto. BLS Fire has been on scene for fifteen minutes. The patient was pulseless and apneic upon their arrival. An AED was applied with no shock advised. They proceeded with CPR until our arrival. My monitor is showing asystole in three leads. I have a compromised airway that refills with blood upon every compression. I have a concave bicycle helmet consistent with impact to the car’s bumper and skull crepitus corresponding to the helmet damage.”
“Yeah, that sounds non-viable. Is that your assessment as well?”
“Yes sir, that is the consensus on-scene.”
“Okay, let’s call it: time of death zero nine forty three. Have a better day.”
“Thank you sir. You too.”
While on the phone I’ve been standing next the the guard rail at the side of the road and the fog lifts to reveal the hillside extending for miles below me with the city by the water and bridges extending across the bay that disappear in the marine layer. The view is breathtaking and I’d love to be able to enjoy it but I have other business to attend to.
Turning back to the task at hand I give a discrete nod to the lieutenant who’s standing over the CPR efforts. He unfolds the yellow rain blanket and covers the dead body laying in the middle of the road. As the rest of the scene comes into focus for me I see five men in matching bicycle spandex uniforms standing at the side of the road. Underneath the yellow blanket lies their missing teammate who was wearing the same uniform. It looks like I still have some work to do and it’s one of my least favorite aspects of the job.
“Hey guys, come on over here and let me explain what’s going on.” They are crying and shaking from the cold of the morning. I send my student back to the rig for blankets as I position myself with my back to the guardrail – this focuses them away from the bloody mess in the road and gives a majestic backdrop to the difficult speech I’m about to give. They huddle close as my student is draping blankets over their shoulders.
“We’ve been working on him for over twenty minutes now and he wasn’t responding to any of our efforts. I had a conversation with a doctor and we both agreed that it was time stop and pronounce death. What I can tell you is that he had very severe damage to the head and extensive internal damage to the organs. It’s very likely that he died upon the initial impact. I wish that there was more that we could do but his injuries were incompatible with life. I’m very sorry for your loss.”