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.