A bird on the table, and two in the air

Thanksgiving at the firehouse this year was very nice, and the guys who hosted us at the station did an outstanding job with a turkey and all of the trimmings.  All week, I had been planning my post to talk about holidays at the firehouse.  That all changed about 130 in the morning…

Cat had just gone to sleep, and I was just barely holding my own in the poker game when the plextron in the hall went off.  “Box 12-07, for a shooting…” As I fold a miserable hand and start for the door, I can’t keep myself from thinking, “Someone must have had too much family time.”  The pager on my hip starts shaking as I walk over to the unit, and I see that the call taker has noted that there is a lot of screaming on the line, maybe this one will be real.  Cat joins Wayne and I in the unit, as we hear the dispatcher adding the engine to our call.  With us and the BLS unit on the initial dispatch, that makes three units.  That sort of complement is usually reserved for codes and unconscious calls.  The callback information clears up the added piece.  It seems that there are now two people shot at the scene, and the shooter is still there.  We’ll be staging for police, and it is looks like we are in for a call.  

As we are on the way, Wayne and I discuss where to stage.  We want to be close so we can get in quick when the police say things are clear, but this call is not in the best neighborhood, and shooters tend to run.  Letting safety win over, we pull over at a convenience store just outside of the neighborhood and call in our location to the other units.  Not long after, the Basic unit and the engine join us in the wait.  Several police cars race by, flashing blue lights bouncing off the buildings as they go.  “So much for no more calls tonight” – a message appears on our computer from the basic unit teasing us for our optimism on a prior call.  “Double shooting, I’ll get up for that” is my reply.  After a few minutes, the call comes in that the scene is secure, and the PD are requesting us to continue in.  

The townhouse was not hard to find, it’s the one with all the police cars out front, and officers in the front yard.  Entering with my crew, I notice a guy on the floor of the front room in handcuffs, the shooter I suppose, but he’s unhurt, and all the yelling is in the back.  There are a lot of people in the house, kinda typical for this neighborhood, multiple families sharing a house, lots of people, a little space, and the smell of alcohol…no surprises so far.  In the back room, we quickly see what the commotion is about.  Laying on the floor on his right side is a Hispanic male in his 30’s, with three holes in his torso clearly visible.  “Big Bullets” I think, noticing that the wounds are as big around as my pinky finger, and I’m not a small guy.  The other thing I notice right away on him is that he is the classic image of a shock patient:  Grey, clammy, tired looking.  That he is conscious is a plus, but I’m immediately thinking he could crash on us at any time, maybe before we get out of the house.  He’s holding hands with a lady, I assume his wife, who has a similar hole in her left hip, right at the pelvis.  She looks a little better, but more upset, in obvious pain.  “Chris, What do you need?”, Matt, the fire captain on my crew, veteran of 19 years and a guy who has been there and done that more than once asks.  (For reference, he’s the fire captain in the Medics 1, Reaper 0 post, and DTXMatt12 on this site)  The guy is easy, he’s getting flown…provided he makes it that long.  I see that there is a hole at his left lung, midclavicular line, about the 9th intercostal space, and a matching one in the back, same area.  Looks in and out, but I know better than to assume that.  Either way, that lung is in trouble, possibly the heart is damaged, most likely from the cavitations caused by a big heavy bullet sending shock waves through him as it passed.  The one in his belly is concerning too, lots of vascular organs behind that one, and the aorta passes right behind that one, Not Good.  The girl could possibly be handled by the local facility, but I’m thinking likely pelvic fracture, plenty of internal bleeding there, and I don’t see where the bullet went, the femoral artery is back there somewhere, and that would be bad too.  I decide on the scene that she’s going to the trauma center too.  “They are both flying, get me the big chopper for both of them, or two little ones, whatever works.” I tell Matt.  Looking over at the patients, Matt then asks, “Want another Medic?” Good question.  We have the basic, and Cat and I CAN split, each take a patient one per unit and go with it.  But the guy looks real bad, he could be a handful, and the basic crew has EMT I know who is solid but excitable, and two others who seem to be a preceptee and a driver who may or may not be a lead EMT.   I ask Cat what she thinks, and she confirms what I’m thinking.  She wants another Medic dispatched, and does not want to split up care.  “Okay, get 52 here” I say to Matt.  I know they are in quarters, and they are the next closest ALS unit, about 8-10 min away.  

Matt goes off to make that happen, and that is one less thing to worry about.  He’s done this a lot, he’ll pick an LZ and get things moving.  “I’m going to get another pumper to set up an LZ, we’ll hang out here an help.”  Good man, good call.  Okay, the calvery is coming, time to see if we can save these people.  Cat takes the lady and starts her assessment and treatment, I go to the man and do the same.  There is still a LOT of noise in the room, plenty of people wailing about the shooting.  The basic crew is getting into the room, and they are starting their thing too.  I look to Wayne, “He’s gotta go, and right now.  I want a reeves and a cot right here.  She goes second.”  He grabs some help on the way out, and things are moving.  I talk to the guy, get his name, No allergies, no meds, no history.  Great.  I’m moving and talking, and I’m glad he’s got a clean medical slate, because I honestly was only half listening.  I got what I really needed in the fact that he was talking, was making sense, and had no allergies.  The allergies question always seems like a strange thing to ask first thing to a trauma patient, but if they go unconscious, you never get to ask again.  A tip I learned early in my career, and I use it every time.  I’m getting him on the monitor, and getting the B/P cuff put on.  No surprise, sinus tach in the 130s.  Fast and narrow, his shallow, rapid breaths finish the perfect picture of a shocky patient.  The cot and reeves were fast, and we get him up and strapped in.  They’ve brought two reeves stretchers which was good thinking and over the din I get the attention of Matt and Cat.  “Okay, for the rest of this call, THIS is patient 1.  That is Patient 2. Got it?” Quick nods from both.  I notice that we are starting to get a couple of people calling shots on the scene, not an uncommon occurrence on high stress calls, but a bad sign.  “We are NOT going to Cluster F this” I think to myself.  My crew and Matt’s unit have a great rapport, and we are still clicking.  “Okay, as soon as I’m out, get the other cot in here and get her out.  When 52 gets here, that is their patient, get Cat back to me.”  Matt nods and I know that it will be taken care of, noise, commotion and all.  As we start out of the room I ask Cat if she is okay, and I get a “Yeah, but when 52 gets here, they will get patient 2, and I’ll meet you in the unit.” We are on the same page, and the last thing I notice is that she has completed a trauma assessment, and is almost done bandaging the wound.  

As we climb in the back of the unit, it’s just Wayne, a firefighter named Dan, and I.  Wayne get going on hanging two 1000cc IVs, and I have Dan get some big oxygen on my patient.  The first B/P comes back as I’m getting set to start covering some holes and it’s not good.  71/41.  “That’s not enough” I think.  I try to tape down an ‘occlusive’ over the first hole, but nothing is sticking.  The patient is just too diaphoretic.  The bandage is an adaptation itself.  I need something that is airtight, but the bandage in the pack is a gauzy material with a gel, and I don’t trust it to hold air tight.  It is packaged in plastic though, and I DO trust that to block air from going into the wound.  So I’m using the package and all as a bandage.  To get it to hold, I grab wider tape, and some alcohol pads.  I quickly wipe around the wound and try to get the alcohol to dry things some.  The wound is not bleeding much, at lest not externally, but that’s not all that uncommon.  About this time, the door opens and the engine driver is asking if we can spare Dan.  My first thought was “No.” and I say so.  “They are asking for him inside.” Is the response.  Now, I’m feeling guilty about splitting on Cat, and I don’t know what is going on inside, the other medic is a couple minutes out still, I could really use the hands, but well, we’ll make do.  “Okay, Dan go see what they need.”  Now it’s just me and Wayne, and the patient is getting antsy.  Wayne has the IV’s ready, and we hand off tasks.  I hold the ‘bandage’ where I want it and tell Wayne to tape down 3 sides with the tape I toss to him.  “When that’s done, do the same thing with this one” I say, pointing to the hole in the back of the patient’s lung.  As I’m getting out the IV needles and pulling some tape, Cat arrives.  She’s handed off patient 2 to the other unit and is here to help.  In the background, I’m hearing the radio chatter between the helicopters and the LZ engine, they are asking for an LZ brief, so they are close, we need to move.  The patient is laying on his left side, so we can treat his injuries, and Cat is on that side so she gets the lines going as I hold the patient’s arms.  We get a 16 gauge going on the left, and an 18 on the right, and get the fluid flowing.  In the meantime, Wayne bandaged two wounds with the occlusives and I have bandaged the third.  The engine driver pops his head in the midst of this and asks if we are okay.  I tell him we are, but we are going to need a driver to the LZ.  At first he says he’s not sure if there is one.  “There’s gotta be SOMEONE” I say as he heads out.  I think to myself, “I got two medic units, a basic unit, and an engine here.  I should be able to treat two patients and build a small barn before I go.”  Shortly thereafter, about the time the second IV is going in, I hear Matt yell back that he’s driving, and are we ready to go.  With the lines in and running, we start to the LZ.  I get get repeat vitals, and have Cat confirm lung sounds for me.  I had diminished movement on his left, which is to be expected, but just want to be careful.  The IV tape is not doing any better than the bandage tape was earlier, and we quickly wrap tape all the way around the patient’s arm to make sure it holds.  The fluid was running, and the second B/P was better – 106/80-something.  His wounds start to bleed under the bandages, and Cat and I quickly press against them to help stauch the flow.  “Okay, what are we missing?” I ask and Cat and I double check things.  The patient is conscious, and anxious, still looking pale, diaphoretic and sick.  The IV’s are in, the holes are bandaged, and his heart is hanging on, if fast.  There are no other injuries, good movement everywhere, and he’s maintaining his own airway.  His left lung is not moving as much air as his right, but his oxygen saturation is 99% under his mask.  I’m sure he’s bleeding badly internally, but with a quick transport, and the extra B/P, maybe they can get him to an operating table.  

No sooner do we come to a stop at the LZ than the flight crew hops on and gets to work.  We give report and help get the patient off of our equipment and onto theirs.  They note the left sided reduction in air movement, and look clearly concerned for the patient.  I rip off a copy of the report and the ECG tracing to give to the Flight Medic, and help get them moving.  They swap the patient over to their cot and hustle over to the helicopter, rotors running and ready to go.  Behind that one, there is another chopper waiting for patient two.  “Double Play” I think…been a while for that.  Cat tells me that they found the bullet in the left buttock of the other patient, and while she exposed, assessed, bandaged and got initial vitals, the lead from the basic was able to circle the location of the bullet on the patient.  

The second medic was close behind, and they were greeted by the crew of the other unit.  After we watched the chopper with our patient take off, we clear the LZ and head back to the hospital to resupply.  Our unit is a mess, I have a report to write, and there are cards to be played.  On the way back, we quickly compare notes to make sure we didn’t miss anything.  Wayne tells me that he saw some bullets and shell casings by the door, he’s estimating .357 or better in size, confirming my thoughts.  Cat agrees, based on what she felt under the skin of Patient 2.  We give the Doctor on duty the heads up that we flew the patients and a run down of their injuries.  He agrees with our decisions, and teases us about taking his good call from him.  I remind him that he has an open invite to join us anytime.  We’ll see if he does.

I didn’t hear back from the crew as to the patient condition, but the front page story in the local paper today is of the double shooting with one fatality over the holiday.  Seems our guy didn’t make it.  That didn’t come as a surprise to any of us, but at least we gave him a chance for as long as we could.