Quick Update

I know the posting has been thin this week, something I’ll remedy while I’m off on travel.  I did want to pass on a general, if rare, update on the patient from the “My money is on the Semi” post.  I heard that she never emerged from her coma, and is/was in a vegetative state.  The impact caused massive shearing force inside her head and caused what textbooks call “diffuse axonal damage”.  Who ever she was before the accident, she is no longer, and never will be again.  It seems we saved her life, but lost her.

Why I love to hear babies cry

Okay, so why the thoughts of the pedi-codes from my last post? This past duty, shortly after dinner time, we get punched for an unconscious one year old at a mobile home park in our second due. I’m riding in the back again, Jen is up front getting more seat time. Cat was working that night, so Kelly, a medic student who just needs to test out was riding with us for some medic time. Wayne is off like a shot down the street, as soon as we get in. This particular mobile home park is well known to us, though more for fires than EMS runs. Our engine is placed in service by the first due engine, as is common for calls for kids this young. The bottom line is, I have four on my unit, the engine coming has 5, and what is another crew of fireman going to do for a patient that is less than two feet tall?

Now, one year olds go “unconscious” for two reasons in my experience. One of course is that they are dying, either by choking, or SIDS etc, the other is the postictal phase following a febrile seizure. Fortunately the latter far outnumbers the former, but one never knows. Thinking ahead, I start to gameplan the call with Kelly. We set out who will do what for a code, and both hope for the seizure. I tell her that we are going to focus on the airway if it comes to it, and we can push drugs down the ET tube fast, and worry about that IO option later. I pull out a flip book that I keep in my BDU pants and we go over epinephrine doses quick. I have to admit, I worried about Jen if the call went that way. Not because I thought she would not do well on the call, but I was worried about her afterwards. She’s been something of a death-magnet this year (I’ll tell you later), and I know it has been hard on her at times.

We get to the entrance of the mobile home park and I look out the little window to the front, and I see someone giving the “Steal second sign”. That is, one arm pointed to where we are going, the other swinging big circles, his head flicking back and forth between our unit and the trailer ahead. We see this rather often, and it is almost never a good sign. It does make me kinda chuckle when I see it though. And if I think of rounding third and heading for home as I respond to a call, I guess it only makes sense that when watching the game on TV and I see it I picture the umpire down with the big one. So, I’m a little more tense as we head up the street, slowed by speed bumps, and lead the whole way by the third base coach. Ahead I see the trailer with the engine and a couple of police cars in front of it, and a bit of a crowd around. “Wow, the cops were fast on this one” I think as we come to a stop. The engine hasn’t radioed that CPR was in progress, so that is good, but then I see three firemen and a cop hunched over a baby that is laying unmoving and flaccid on the deck to the front of the trailer. Not good.

“Are we breathing?” I ask as I approach. I have to be honest; I’ve left Jen and Kelly behind me as I moved forward. On the one hand, bad habit as a trainer, on the other hand, it does teach aggression. Anyway, I note that the baby’s color is mostly okay, if a little blue or pale at the lips. The light is not great at night in this park, but I can see the discoloration. “Yeah, but she’s not moving” I get in reply. “OK, get her to the unit, we’ll do this there.” The deck is public, there are lots of onlookers, and somewhere is mom panicked and crying—the unit is home, my world, controlled. The light is good, the people are on my team, and it’s a mobile ER on wheels. The fireguys pick up the baby and we are headed back. I note that the baby is still totally limp as they move, but hey, breathing we can work with.

In the back, Jen gets the oxygen mask ready and I get my first real good look at the baby. She’s out alright, but starting to move some, and her color is not that bad, though not what I’d like. She’s breathing without obvious effort, and I check her lung sounds as they get the O2 going. Her lungs are clear, and her heart is thundering right along, sounds like 160 or so…just about right. (Yes I counted later, but you learn to recognize “fast enough”). She’s also really warm…a fever. Fever and this behavior is febrile seizure, or the aftermath anyway. Okay, the oxygen is on now, and life is good. With little ones oxygen fixes darn near everything, and I see that is the case here too. The color is improving rapidly, and I see the baby is moving more and more. She’s not fighting the mask, which is good for her health, but shows she’s not totally back. She’s postictal, I can ramp down a notch. I look over at Kelly, and can see by the look on her face that she’s come to the same conclusion. The firemen stick their head in and I give them the news. They ask if mom can ride, and I’m okay with it. She’s crying, and pretty worked up, but I explain that this is common, and normal, and that kids grow out of it by age 5 or so. I also told her that her baby will be okay, and while scary, she’s going to be okay. Kelly and Jen pretty much take over the call from this point, monitoring the baby, getting vitals and calling the hospital. I try to calm mom, and think about how happy I am to hear the baby start crying. I swear nothing is sweeter in the back of a medic unit than a crying baby. Crying is breathing. The transport is short and easy, and the hospital is happy to take over. The only thing a bit unusual is that mom gave baby Tylenol at 6 and it’s 8 and the fever is still up, but it happens.

After a later call, I learn that they are concerned about the baby being septic. It’s not just a flu it seems, but the seizure was just that, and they are running a battery of tests to diagnose the problem.

Too Young to Die

Pedi-codes are the worst. I have run three in my seven years (well, 3 under one year old, one ten-year-old too.), and I don’t know anyone personally with more. It is not a personal record that I enjoy, and would rather not have that experience. While not technically challenging, there is nothing more unsettling than performing CPR on someone who weighs significantly less than the monitor attached to them that keeps telling me the bad news.

My first came early in my career, at 730 am on a shift that ended at 8. I was an EMT, and a new lead in the department. I can’t remember why, but there were two medics in the firehouse that morning that jumped on the unit for the call. I suppose we were lucky there, the call went out as a Stoppage of Breathing, and got everyone’s attention. The apartment complex was not far from the station and I was still shaking the sleep off when we arrived out front, our engine right behind. I rode in the back on that call, and I think I’d thought ahead enough to connect the infant BVM to the oxygen bottle. (BVM is Bag-Valve-Mask, the bag we use to breath for our patients.) I opened the door to see the firemen running up the stairs to the apartment, and I went up after them, oxygen bag over my shoulder. Following the apparent law of nature, the patient was on the top floor. I remember just entering the apartment when I hear “COMING OUT, MAKE A HOLE” and see Buddy, a firefighter starting down the hall towards the door, and me. He was coming at me like a running back, one arm holding a couple-month-old baby, doing CPR as he came. I barely got out of the way before he blew past me on the way to the unit. Just as fast as the train of people was heading into the apartment, we were all turning around and headed back. I only remember snippets after that. The baby was so small, and the medics had a hard time with the ET tube. The baby had been down a long time, a fact that never came into play for us. I remember that the got the tube, and we were to the hospital in no time at all. I also remember being met in the bay at the hospital by an over-eager staff who opened the doors to the back of the unit and started pulling out the cot before we were set, and dislodged the tube as they did. I didn’t fully grasp the impact of that at the time, but to this day, that hospital is not allowed to meet us outside anymore. I’d later learn that Dad had fallen asleep on the sofa, with the baby on his chest, and rolled over in his sleep… That call stuck for quite a while, and I spent most of that day in a hot tub dealing with it. I still know that baby’s name, and I know another EMT that was with me that day can recite the date, but that’s one fact I have lost. The next day we met back at the firehouse to talk it though. It was sad, of course, but to this day the sight of Buddy coming out of there, CPR in progress, babe in arms ranks as the most heroic thing I’ve ever seen.

I can honestly say that it wasn’t until after we were at the hospital on my second pedi-code that I realized that that particular task had been passed. It was the afternoon, and the call that went out was for an unconscious. We didn’t know we were headed for a baby until we were on the way, and it was later in the response that we heard the call, “CPR in progress”. This time, the medic was further away, I was the lead EMT on the ambulance, and the engine was coming from somewhere else. I knew we’d beat the medic in by a little bit, and I called on the radio to have everyone meet at our unit, or at the medic unit if it got there before we got back. This time it was me sprinting up the stairs first, past the screaming mom and into the back room of the apartment where a panicked dad all but threw his baby at me. I gotta tell you, lightning strikes you at strange times. Here I was, scared, pumped, and winded, busting into a home I’d never visited, with people I’ve never seen, at the worst time of their life, my mind screaming for control in my head, “STAY CALM, THINK, SMOOTH IS FAST” over and over. And at that moment, Dad, Daddy, is handing over a baby, blue and pulseless to me. He’s never seen me and yet he freely passes to me the source of every hope he has ever had. Woah, how do you deal with That one? Time stops. But, I can’t. Pivoting, I start CPR, and head for the door. I see the “Oh Shit” look on my partner’s face as I go blasting through the door, down the stairs, past the neighbors drawn by mom’s screams and the sound of sirens, and mercifully to the waiting medics. The baby had aspirated formula as it slept. I knew it because I had done mouth-to-mouth on the way out, not thinking about it, and got it full in the face. I later joked that I know why baby’s spit up….you taste the stuff and you will too. (As a note, we Don’t DO mouth-to-mouth anymore, or then for that matter, but they taught it in class, and you really do revert to training in times like that.) I know I helped the medics in the back of the unit, but I can’t remember any details of the run. I know the baby didn’t make it, and I remember being at the hospital, writing report and thinking of Buddy.

The third was in the evening, and was the first of two back-to-back codes of that day. This time, I was on the medic, but still an EMT. I stayed in the back, and mom came out to the unit as we approached. Mom was scary calm, and got hustled up front pretty quick by the fire guys. There were two medics there that night, and as a technical exercise, it went very well. I hate to say it but that is what that call was to me….mostly. The baby came in, and I started compressions. The tube was in fast, and they even got an IO started. An IO is a large needle that is bored into the shin bone of the baby for access to the venous system. Next to a chest tube, it is the thing in emergency medicine that most reminds me of the fact that we are only a few generations from blood letting and civil war surgery…but it works. We got a police escort that day. Two cars leapfrogged ahead of us closing intersections as we headed to the hospital. I don’t know what the people on the road thought, but I know what I thought, “there is nothing we won’t do for a baby”. If I have to confess that this one was mechanical, then I have to confess that it wasn’t totally so. For a brief time, we got a heartbeat back on this one. Just long enough to remind me that this was not a training manikin I was working, and give me hope. I thought for a flash that three was a charm, and this was a life we’d save. But, it wasn’t to be, and by the time we got to the hospital the pulse was gone, and I arrived angry. Not that we lost, again, but that I’d been allowed to think I was winning. These thoughts were all in my head this week for a call, but it is late, and I’ll have to tell that story another time…

Just a night with the stars

The poker game started late, but then again, at least it started. It had been a while since we’d all sat down together at the firehouse to play. The weather had just broken and the nights were finally cool and dry enough to keep some doors open. That was why we heard the sirens racing past the firehouse as we played. “We’ll hear about that one soon” someone said and folded. Every one chuckled, and turned back to the issue at hand. Not long thereafter the tones could be heard from upstairs through the cinderblock walls. “Medic” says a firefighter as the Plextron in the hall begins to sound. “You too” I say standing and heading for the door.

“Box 1201 for an injury from an assault – Stabbing …L’etoile – advise you stage” says the lady in the ceiling. “L’ETOILE” we all cheer down the halls. L’etoile (not the real name of course) is this little hole in the wall place not far from the firehouse. We know it well. The place is populated most weekend, and many weekend days by a clientele that often provides us with assaults, and pedestrian struck calls. The latter from drunk patrons trying to walk home, at night, across a major road that runs in front of the place.

As we pull out of the station, the callback information tells us that there are reports of a stabbing, the assailant’s location is unknown. I’m in the back of the unit tonight, letting Jen get some time upfront, working the radio and reading the maps as part of her training. “All company 12 units report to the pre-arranged, L’etoile staging area” I hear Matt, our fire capt say over the radio. I smile to myself, this crew is fun, and experienced enough to keep the concern under control. The ‘staging area’ is the McDonald’s parking lot basically across the street from the location. Now, that is a bit close for most calls that need staging perhaps, but the defensive screen of 4 lanes of traffic seems to be impenetrable by L’etoile patrons..hence all the ped struck calls. We only sit there for a moment when more radio traffic breaks out. There is a new call, for an unconscious pt, possibly our stabbing victim at a house a couple streets down from us. Following protocol, dispatch starts a full complement for that call (Another engine, a medic and a basic). So now the scene is on the move, and so are the patients…great, one of those nights.

I feel the unit starting to move, and look out front to see that we are following the engine towards the new location. The brush unit, who had been on the road returning from a previous call, marks up on the scene of the Unc. Moments later, they tell us PD is on the scene there, to continue my unit and engine to him, let the additional units from further out handle anything that comes out of L’etoile. Smart move, and away we go. A moment later, he calls for a helicopter. The firefighter there has quite a bit of medical experience, though he hides it, and I know this can’t be good.

Arriving on the scene, I see 4-6 cops in a loose semi-circle looking inward at a late 20’s, early 30’s male who is face-down, shirtless, unconscious and covered in blood from his head to his shoulders. The firefighter who made the radio call is with the pt. As I approach, he tells me that he IS breathing, good pulse, and unc since the firefighter has been there. He wants me to see a laceration about 1-2” long on the back/center area of the patient’s head before we roll him over. I give the pt a quick check to make sure there is no other trauma to his back and legs, and with the help of a third person to hold his head, we roll him over. This wakes the patient up, and he starts yelling. This is mixed news, he conscious which is good, but is trying to move, which can be a problem. He has blood on his chest, but it looks like it came from above, and there is nothing obviously wrong below his chest. At first he’s not making sense, but then starts yelling for his mom, and pointing at the door. It seems he may live here. The blood is considerable, and I spend some time trying to find the source. It takes a bit, but I convince myself that all of the blood is from the one laceration. All that time up close and personal with this guy tells me one thing for sure – He is AOB. That’s Alcohol On Breath, a nice euphemism for drunk off his butt. (See also ETOH positive).

About now, I have all sorts of help. My crew and the engine guys are here with the backboard and collar, and he gets secured quickly while he is still ‘loopy’. As we are starting to move to the unit, Mom comes out by the front gate and starts asking what is going on. She’s a bit panicked, as mom’s tend to be, and I’m still a bit worried about this head injury. I have to figure out if it is bad, and fast…the helo is on the way. I stop by mom and tell her that the guys will fill her in, but that right now I NEED to know if her son is on any medications, or is allergic to anything. She says no, and I leave her with the fireguys for more information.

In the back of the unit, the patient is being more combative. I try to introduce myself, explain that we are here to help, and try to calm him down. He’s not listening, and is insisting on seeing mom, and his girlfriend. We get the ECG on, somehow a B/P and I get set for a line. I’m about to tell him the benefits of holding still while I start the IV, when he “gorks”. He’s mid yell about something when he stops and goes out cold. Not one to look the gift horse in the mouth, I hit that IV immediately, while he’s down. There is nothing by way of reaction to the poke, or any attempts to rouse him. I get the line taped, and the crew gets some oxygen on him. He’s breathing ok, so that is a plus.

The next 10 minutes or so go something like this. Patient wakes up. Patient yells, insists that he wants his mom, strains against the straps, spits, yells more and goes unconscious, Repeat. All the while, we try to maintain our lines from coming out while he writhes, and try talking him down. His pupils are equal, that is good, but one is slower than the other, that’s not. The helo was a good call, his combativeness, unconscious spells and the pupil all say head injury. I hear the radio saying the medivac is close, and I get on the radio to advise them to bring the RSI kit. I tell them what is going on, and that they are going to want to knock this guy out good for the flight.

The nurse and medic from the helo come on, and we are engaged with the combative patient. We give them report, vitals okay, ecg ok, and bad signs for head injury was the jist. The patient grabs my arm, pulls me over and is insisting that I call someone. I say Ok, and give me the number. I get the area code, and then nothing….I hear the flight medic say, “He’s not gonna finish that.” I turn to see him finishing his med push into the IV, and our guy is out. Finally. It’s hard to explain how disruptive and draining it is to ‘fight’ a head injured patient. Clearly you can’t really “fight” but you cant let them cut loose either. Dancing that line is tough, and I was glad to see him out. We get him intubated, breath for him and off he goes in the helo. Just another night from l’etoile.
Someone later told me the wound was from an ASP. I sure hope not, if it was I’m sure we’ll hear more about it later…..

Follow up

Got some rare feedback.  The patient from Friday is still in a coma in ICU, with multiple Fractures (all over actually) and intracranial bleeds.  But, she’s past the 72 hr window…so we’ll see.  Modern medicine is amazing, but a prayer for her wouldn’t hurt either – Never does.

The cast and Crew

Okay, so if I’m going to do this regularly, there are some people I should introduce…you are gonna see their names plenty.  As I said in the last post, Good Drivers and Good EMT’s are everything.  I’m truly fortunate to have an outstanding regular crew, and others that come play with us from time to time.  

I’m Chris (no kidding huh) I’ve been in EMS for about 7 yrs now, and just typing that I can hardly believe it.  I never thought I’d do this, but that is another story, for another day.  I lead the crew, and basically am just here out of a twisted sense of a good time.

Cat is Catherine, she’s my wife and the other medic on the crew.  Her day job is also as a Medic, so she’s either addicted or stubborn on that front.  I’m getting her set up here as a poster, so I’m SURE you’ll hear from her.  Running with my wife is a lot of fun, I recommend it to most people. there are stories for another day there too.  She is a much better technician than I am, and if you absolutely, positively gotta have a line, she’s the one to call.  She’s upgrading her NREMT-I to P and plans to go to RN from there.  She has a twin who only comes on the unit for early am runs for BS calls, but we won’t talk about her. (grin)

Wayne – He’s my driver, I know Jon drove for me on the last posting, but that’s because Wayne was out of town.  Wayne is an EMT and Firefighter, and possibly the best driver I’ve ever known.  He knows where we are going on almost every call prior to my cracking the map open, and has mastered the fine art of hauling ass without killing us in the back.  He works on fire equipment for a living, plays poker and pool, and I’ve seen entire 12 packs of beer quiver when he passes.  I’ve been in the mess a couple times, and he is always there.  He’s dependable in a way that you only read about, and I’m glad he chose to drive for me.

Jen – She’s our rookie, though she’s fast outgrowing that moniker.  She recently graduated from college and wants to be a forensic anthropologist (see BONES on TV for more on that field) when she grows up.  She came for a ride-alone on new year’s eve, and we caught some interesting calls.  She came back to ride again and got hooked.  Next thing she new, she had her EMT certification and for months was the biggest Code Magnet I’d ever seen.  She’s smart and focused, and knows her stuff better than she thinks.  She swears that she’s awful with patients, but is too new to know that everyone feels that way a month out of class.  I have a soft spot for her because she puts up with a LOT of trash from everyone, though Wayne and I are the biggest source.  Besides, she is just like me when I joined, only a lot cuter.

Okay, so that is my team.  I’m lucky – I got to pick them by hand.  I’ll put them up against any situation hands down.  I also get to run with a pretty solid engine crew most nights, but I’ll introduce them later.

My money is on the Semi...

Okay, so it was a while between the first posting and this one, (not holding up to keeping up so far) but that lack of time should be resolving….

Christmas came a little early for my crew’s rookie this week.  She’s been begging, cajoling, pleading for a “good trauma” for several weeks now, with little to show for it.  Her hopes were particularly high this week as the area became inundated with rain for the 24 hrs prior to our shift.  She practically floated into the back of our unit when the tones went off for an auto accident in our second due.  The follow-up information stated we were on the way to a sedan vs. semi, multiple injuries reported.  As we headed down the road, the first-in engine marks up with one entrapped and unconscious, two others injured but out of the vehicle, and adds additional ALS transport pieces to the call. The Squad from the neighboring station pulled in ahead of us at an intersection, and we join them in the rush through the downpour to the scene.  We are lucky tonight, and have a total of 3 ALS providers and our rookie, an EMT with certs, onboard.  I get on the radio, to let command know that we are “heavy” with providers, but advise them to continue the additional units (My first lucky call).  In the back, Jen and Cat hang two “thousand bags” and gear up.  

Arriving on scene, there is a 4-door small sedan, with the driver side CRUNCHED  (We later figure 12” intrusion at the driver door) and an intact Semi.  The two closest Engines are on scene, have shut down the road, and started patient (pt) care.  I geared up, and headed for the car with the UNC pt, and had Cat and Jen go check on a pair of patients laid out on the grass next to the road.  In the car, a young, maybe early 20’s female sat, moaning, but unconscious, head in the hands of a firefighter who had somehow snaked his way into the back seat.  The engine crew had gotten oxygen on the girl, and even exposed most of her right there in the seat.  There was one lady there, obviously running the patient care so far, finishing up an initial assessment.  The driver was clearly pinned by the collapsed metal from the front of the car against her legs.  Somehow the door was open, which helped, but there was no way she was going to get pulled without cutting the car. Her moans told me she was breathing, there was a fair bit of blood on her head, but not much else seen during the 5’ assessment.  I leaned in over the girl doing the assessment and asked for an update.  I really wanted to know if she was reacting to anything, or had been conscious at all yet.  I didn’t see any deformities from the outside, but the car damage was impressive.  I was told that she had not reacted at all, outside of the moaning, and had been unc since the accident.  She also had multiple deformities to her right arm.  The squad was setting up for the cut, so I knew I had to get out of their way.  The girl doing the assessment was clearly very competent (a phlebotomist by profession, and daughter of a local rescue chief, I’d find out later) and much smaller than me, so after making sure she was okay in the car, I covered both her and the pt with a blanket as the squad started rolling off the windshield.  Okay, so she is BAD.  She needs a helicopter to the level 1 trauma center that is about 40 miles away, but, oh yeah, it’s POURING out with a 100’ ceiling – Looks like we are going for a ride tonight.

The squad starts doing their thing, and I trot over to Cat, to get a status on the two guys in the grass.  There is a LOT of help here, the firemen from a couple of engines seem to have come over here, and Cat is calling the shots to the people getting supplies, backboards and such.  I also glance at my rookie, Jen, who appears to have been completing a textbook trauma assessment and started care.  Cat tells me that these two are ALS, but conscious, talking and confused.  She identifies the patient she is over as the worse of the two, and is concerned about some blood in his ear, that she can’t find a cut for.  I find command on the scene, tell him the order of priorities:  My crew will take the driver, and she’s the worst, the pt with Cat is next, then Jen’s.  I have my driver get the cot and a backboard, and get ready for our pt to be cut out.  About this time, the two additional ALS units get on the scene one right after the other.  I point the first one over to Cat, and send the other over to Jen.  (Finally, I can regroup my team, and focus on one set of problems).  I tell the ladies to give report, hand off care, and get back to the car, get ready to roll.

My driver, a Medic himself, has called the local hospital to tell them that we are going to pass them and go to the trauma center with our pt.  The doc is okay with that if her B/P is over 100 systolic, but wants us to come there for stabilization if not.  (Yeah, the local hospital is a community one, good for medical pts, but not trauma at all.  I hope for her sake she’s kept a pressure until our unit.).  The roof of her car is peeled back, and the squad and fire crews pull her over to our waiting cot and backboard. (She’s already got the collar on.)  She’s quickly strapped down and brought into the unit.  (Tape was no good for her head….everything was SOAKED.)  The team climbs in and gets to work.  

I gotta say, everyone took a position and did their thing.  Cat had called airway early on, and went up to look at getting a tube.  Jon (my driver that night) set up on pt right, and got going with an IV.  (Lucky him he got the side with the Z-shaped arm).  We’ve got Jen into our routine, she sets up for the B/P we gotta have for destination determination and starts putting on the ECG.  I have to wait on the B/P on her left arm for my IV, so I redo the trauma assessment to make sure we have it all.  We’ve picked up the firefighter who was running care in the car, and she gets to splinting the (Open, we now see) fracture to the R humerus.  The B/P comes in over 100 (113/70s I think, but it was a couple days ago) thank God, we’re going for a ride.  I stick my IV in place and take inventory.  

The pt is still unc, with some possible movement with my IV, but that is all.  Cat is struggling to get her mouth open to secure an airway, and had to suction blood a couple times.  Her SPO2 is ok, like 97% on the mask, but her breathing starts to fail, and now we are bagging.  Her ribs feel okay, but her abdomen feels rigid, her Right arm is AFU, and she has some brusing starting on her left calf, but it feels intact.  Her ECG is irregular, but sinus.  Her pupils are equal and reactive, but slow and constricted.  A firefighter hops in to drive, and Jon asks if we REALLY need 3 medics (and 2 EMTs) in the back here.  I look the pt up and down and say “Yeah, I think we are going to need it.  I’m not sure she’s not gonna gork on the way”.  (Turns out I was both right and wrong).  As if on cue, the pt starts to move, which seems like a good thing, until we note that she is pointing her toes and extending her arms and wrists in a position that you never forget as a medic…she’s posturing.

The good news is that we are moving, and the driver is making good time, without tossing us around in the back.  (Good EMT’s and Good Drivers are everything).  We call the Trauma center and they tell us to RSI the pt.  That’s well and good, but our area doesn’t let us do that, and so we do not have a paralytic.  Cat’s day job has RSI protocol and is good with it, so that helps.  Following the directions from the RN on the phone, we do everything that Lidocaine and Versed allow, and try for the tube.  Unfortunately, her jaw stays clamped, and we have to go with a nasal airway.  The transport is spent keeping a close eye on her vitals, two people keeping a solid seal on the BVM, and assisting her respirations, working with her on that when we can.  Her resps were a Biot’s rhythm, more bad news. (She seemed to be Chayne-Stokes for a bit..either way, bad ju-ju).  She brady’d down to 50 at one point, but rebounded to 133, just her way of keeping us on our toes I suppose.  They did a nice job with the airway, SpO2 stayed at 99-100 the whole time.  
We get to the trauma center, give report and start clean-up.  Before we leave, we get to see her scan.  She has a cranial bleed as suspected, but her abdomen is clear.  She was also developing a left sided Hemopneumothorax, which earned her a chest tube.
That’s where the story ends, with “nice jobs” from the trauma team, and no idea of patient turn-out.  (Thank you Hillary HIPPA).  I’ll update if I ever learn more.