Car 512, Where are you?

Sorry for missing a week on my posting, life has been a bit hectic.  Cat and I have been overhauling the house in preparation for our annual Mardi Gras Party on the 11th, she’s been studying for her registry upgrade test, and preparing for hand surgery tomorrow.  I’ve been out of town some, up in New Hampshire for work.  As a result I’ve slacked off here.  I will get a post up here on Thursday afternoon/evening as I will be off and spending the day holding sparkly things in front of a highly medicated MedicCat.  I hope this means my email box will not be shelled with the “HEY, Where’s your Post?” emails for a day.  Grin.  Thanks guys for keeping me focused here.  For those of you in the DC area: “Sorry for the clip show, have no fear; we’ve got stories for years...”

Signal 14

Fortunately, it does not happen often, but in our system we have a radio code known as a “Signal 14”.  For those of you more familiar with the Police side of things, this is our version of “Signal 13”, or 10-13 code.  Where Signal 13 is the call for Officer in Distress, Signal 14 means that Fire or Rescue personnel are in trouble.  And like an Officer in Distress call, a Signal 14 brings absolutely everyone.  It is reassuring to see, but it is not something you want to use lightly, and if you can, you want to avoid seeing it displayed.  I’ve only said those words once over the air, and we were deep in it when I did.

The call was several years ago, and I was running as a BLS preceptor at the time.  The crew I was with that night consisted of my preceptee Nancy, a then-new EMT, Rob W also an EMT and Rob L a firefighter who was driving so I could precept Nancy.  Now, Nancy is a nice girl, and decent EMT who stands about 5 foot nothing and has a slight build.  She was pretty close to turned over, but was having some confidence issues, and was getting some more street time to work that out.  Rob W is an all around good guy, and family man.  He had more angst over doing the right thing all the time than anyone I’ve ever known.  While of medium stature, he was also a Marine Corps reservist, where he held the rank of Major.  (He later became a Lt. Col, a statement of his character.)  That’s the thing about interacting with a volunteer organization; you never know what the person you are talking to does in “real life”.  Rob L is a career fireman as well as a volunteer, and in pretty good shape himself.  All of these come into play, and in retrospect, we had a pretty good combination that night.  Ironic, since we did not usually run as a crew.

Early in the night, we get a call to assist a career medic in the area south of us for a possible overdose.  En route we hear that the patient has taken PCP, and the family is worried.  At that point, I had never run a PCP patient, but had heard plenty of stories about the amped-up, super strong, raging wild patent tearing up houses, and taking on teams of Police.  My dad was a cop for over 20 years and one of his best stories is of a guy on PCP.  So, this is what is running through my head as we head down for the call.  

The career unit was there well ahead of us, and we grab our bags and head into the house.  Inside, we see the medic crew talking to the patient, who is seated on the sofa and is clearly high.  Like I said, this was the first time I’d seen this before, and for those who haven’t seen it, it is really not like you might expect from the stories.  The PCP patients that I have seen seem to be running in super slow motion, and they like sparkly things.  For example, I once saw a guy who had wrecked his van while on PCP come out to face the three or four police cars that had arrived when we did.  He came out, and slowly stared from one car’s lights to the next with this look of wonder on his face.  (He then SLOWLY took this silly martial arts stance out of a movie and was sacked by about four cops who, unfortunately for this guy, moved at full speed.)  This guy was behaving exactly like that.  He was answering simple questions, but only after you were sure he didn’t hear you.  I also noticed that he liked to look towards movement.  The family was very concerned, and knew it was PCP because “this is how he acted last time he was on PCP.”  Now, I’m trying not to chuckle, and I’m trying REALLY hard not to mess with the guy by rolling a new quarter on the floor or something, but in the back of my mind I know we should be glad he’s calm and try not to stir him up.  
The medic that day was running with a crew of two, one of whom I know had been a cop before becoming a career medic.  We had good rapport and the assessment went smoothly.  As I recall, the guy was basically okay, or at least had vitals that you’d expect for PCP.  We decide to walk him to the medic unit, and the guys ask us if we can spare someone for manpower, just in case.  I was all for that, and while Nancy was precepting, and could have used the experience, I sent Rob W, the Marine.  They weren’t planning to do much but get to the hospital as I recall, so things were pretty low key.  The patient’s family was going to follow the unit to the hospital, and everyone was going without lights and sirens…no need to get the patient fired up over something.  

Now because of the way we approached the house, we had to go down a street to turn around, while the medic unit had a straight shot out to towards the hospital.  As a result, while we were following them to the hospital, they got a considerable jump on us, and were out of sight ahead of us on the way.  Rob L, Nancy and I were joking in the unit about the reaction of the patient, and comparing notes on other calls when we hear the medic unit call out over the radio.  They are calling dispatch asking them to send a Police officer to assist.  They have pulled over at an intersection a couple miles up the road, and the patient is unruly in the back.  Now, I’m sitting in the back of the unit, letting Nancy lead from the front, but that was enough for me to assert control.  “Rob, get there, light them up!”  Rob did not need to be told twice, and in all truth was already moving when I said it.  The lights come on, the siren wails and feel the unit accelerating hard.  Our guy is in the back there, and it’s only him and the one medic.  It didn’t take long to get there at all.  

Pulling up I see the medic unit pulled to the side of the road, the back doors are open and there is another car pulled in behind it.  Inside, there are a lot of people, none of whom are the Police.  Running to the unit, I see that the family had been following right behind, and the patient’s mother and two brother’s had hopped out to ‘help’.  Mom was outside behind the unit wailing.  Inside, Rob W, the medic, the patient and the two brothers were all in ball trying to restrain the patient to the cot.  It looked like the family was helping the medic, and as we entered, I saw that was the case.  I told Nancy to go up front.  She was pretty small, and I didn’t want to have to keep track of her in any melee.  Frankly, there wasn’t much she could do but get bounced from wall to wall in the back, so, I wanted her safe.  

Now, the struggle in the back was pretty unusual.  There wasn’t any swinging or punching exactly, but there was this slow motion wrestling.  Apparently the patient had tried to get up and exit the unit while they were headed up the road.  This would have been bad for the patient, and we lose points for letting a patient wander in traffic at all, never mind doing the 40 mph exit from the back of a moving unit.  The goal here was to get the patient secured back in the cot.  Well, he was fighting this with persistent, but slow resistance.  So, while we were moving much faster than him, he was exhibiting the incredible strength that I’d heard of before.  At one point I had myself and another guy losing a battle against a single arm on him and we had both position and leverage in our favor.  The guy just slowly pushed us back and off the cot.  Of course we just let go, repositioned and started over because he was in PCP slow-mo.  
So, now that both crews, minus Nancy are in the back, and a PD unit is coming, we start telling the family, “we got it, please go back to your car. Thanks for the help” etc.  We don’t want one of them getting hurt accidentally and adding patients to the situation.  This is all well and good, but then the family members decide that things are going badly.  Specifically, mom starts up with “Don’t let them hurt him.”  I hear this and can already see where this is headed.  At this point, I have to paint in one more fact that was not relevant from my point of view until exactly this moment.  The patient and family all happened to be black, and of course, as fate would have it, both my crew and the medic crew were all white.  That fact didn’t even occur to me until one of the brothers made a comment to that effect.  I don’t recall exactly what he said, but it was not helpful or complimentary.

I call back to mom that we are NOT hurting the patient, just trying to keep him in the cot so he won’t walk into traffic.  Well, that didn’t seem to be a convincing argument, because now the brothers start trying to pull us back off the patient.  So, when the Police Officer arrives, he has mom outside inciting things from outside the back of the unit, and one patient, two brothers, two medics, two EMTs and a firefighter wrestling inside.  It was Real Cozy in the back there for a bit.  Amazingly, it STILL had not come to blows, just pulling and pushing trying to gain control.  There was plenty of yelling going on too.  

The officer quickly gets involved, and gets the two brothers out of the unit by explaining that they can stay and go to jail, or get out.  He closes the doors behind him and it’s just us and the patient.  The patient has managed to get from the cot to the bench seat and the cop and the medics are trying to gain control of him there.  The good thing is that since he is against the wall of the unit, and the bench, things are a bit more controlled.  I’m actually standing away from the action, but inside the unit on the opposite side of the cot towards the back.  Frankly, the patient was covered and there was little I could do to help outside occasionally helping with an arm here or there.  I’m a bit worried about the family outside though.  I can’t see them well now that the doors are close, and through the back window, I see them moving around in their car.  That could be bad, so I’m trying to keep watch in that direction too.  When the car door opens, the interior light comes on, and I see someone getting out of the passenger seat and headed for the unit.  I call out a warning and try to see who is coming and where they are headed, but I can’t tell.  I don’t think anyone heard me over the struggle, or if they did, there was little they could do.  They are getting the upper hand on the patient finally, the cop and the Police trained medic getting him into some holds to keep control, but aren’t quite there yet.  

The side door to the unit flies open suddenly.  Standing in the doorway is one of the brothers and he’s clearly pissed.  I start moving in that direction as he reaches in, and around the cop, who is bent over the patient.  To this day I clearly remember what happened next.  The brother’s hand comes in and around the cop’s hip…right to his gun.  He latches on and starts to pull.  The cop pushes down once on the patient, grabs a hold on the brother’s hand, spins and basically dives out the door into the dark down the ditch on the side of the road.  Now things have slowed down for me. I spin around and reach for the radio.  I don’t know who got that gun, but if it is not the cop, we are in a world of hurt.  There are six people in an ambulance and SOMEONE outside the open door has a gun.  Fish in a barrel does not quite summarize how screwed we may be at that moment.  

Grabbing the radio, I say those magic words. “Medic 52, Ambulance 12-8 are Signal 14, repeat Signal 14, gun involved.”  As I’m talking, Rob W has converted from EMT to Marine and thrown himself out the back door and to the aid of the police officer.  I hear the medics saying they can at least contain the patient finally and are yelling to help the cop.  The other brother comes from the car, and I believe is being met by Rob L outside.  Now I’m desperate to know that the call has been heard and that the cavalry is coming.  I know that ultimately the arrival (or not) of the rest of the police is going to be the difference here.  I can’t hear the radio at all over all the yelling and I go out the side of the unit and up to the cab.  I’m pretty focused on making sure help is coming, and only peripherally notice the wrestling that is going on in the ditch.  

I try to open the passenger door and it won’t budge.  Nancy has locked herself in, and is now so freaked that she can’t work the lock.  I yell to the window, “Did they HEAR me?” “What?” is her response.  Okay, when this is over, I’m going to kill her.   “Did the call get out, did they say they are coming?”  She looks sheet-white and says, “I don’t know, they said, ‘All units hold your traffic.’.”  Excellent!  By protocol, when someone calls Signal 14, they seize the channel, and everyone else is ordered to maintain radio silence until the signal is lifted.  If they issued that order, they got the call.  We are only about 2 miles from the Police Station, and I already hear sirens.  

Looking to the ditch, I see the first brother on the ground, holding his face and being held by someone (I can remember who was who now.)  The cop was in the process of Pepper Spraying the other as I recall.  Inside, the medics have the patient pinned.  As I see the blue lights of the first unit coming from the next hill, I rush over to cut off mom, who is racing around the car to jump on the back of the police officer.  “Ma’am, go BACK to your car.”  I yell as I square in her way.  She’s yelling about hurting her sons and at that point I get angry for the first time in the call.  I tell her that her son’s are in trouble only because she didn’t shut up and go to her car when she was told to before.  Now, that may not have been the textbook answer, but at this point the text was out the window.  The first unit comes on scene and the cops quickly secure the brothers in the ditch.  Other units follow quickly, on the order of ten or so and the situation resolves as fast as it escalated.  At some point Nancy figures out how to work a door and gets out to help.  

In the end, the brother’s we treat the brothers on the scene for Pepper Spray and release them to the cops who bestow them with chrome bracelets, room, board and a court date for assaulting a police officer.  The patient is secured to the cot and taken by the medic to the hospital with police on board.  Mom barely escapes getting locked up herself when she starts yelling at the cops.  I’m mildly amused when I hear the officer explaining that it was most likely her stirring things up that got her son’s arrested.  After that call, we go out of service, and fill out individual police reports back at the station.  We all carefully write what we know, and don’t compare notes while we do it.  

A couple months later we all get the news we knew was coming.  We get our subpoenas for the court date.  It seems the brother who grabbed for the gun had been under house arrest (you know, tracking anklet etc) at the time of this call.  It seems that a few months prior to our little party he had assaulted a Police Officer.  So, he was fighting the second conviction saying he was “Acting in defense of another” namely the patient.  It was a short court date.  I did have to testify, and the defense attorney asked something like, “Isn’t it possible that the defendant intended just to get the officer off of his brother and just happened to grab the gun?”  Now, I paused, thinking the prosecutor would object to my being asked what the guy was thinking, but he was taking a note and didn’t jump in.   So I thought briefly about offering that he might have intended to get a ham sandwich out of the cop’s pocket for all I knew, but answered along the lines of, “I don’t know what he intended, I’m not Ms. Cleo, but I know he grabbed the handle of the officer’s weapon, held on, and pulled him from the ambulance with it.”  At which point he winced and basically gave up on that line.  The others there were not all called in and things closed up quickly.  It did not go well for the brother.  

Months later I learned that things had been pretty close outside the unit.  According to the story, later verified by a bashful Rob W, when Rob left out the back of the unit, he found the officer and the brother locked arm in arm in the ditch.  They were struggling over the gun, still in the holster and the final possession of the weapon was not clear.  Rob, reverting to Marine, dove into the fray from the top of the ditch and landed between the cop and the brother.  On his way down, he brought his forearm across the bridge of the brother’s nose breaking it rather cleanly according to reports.  This seemed to have been the decisive act, as he let go of the gun handle and covered his face, allowing the officer to gain the upper hand and move to secure him and the other brother, then arriving from the car.  By all accounts, up until that moment, the fish in the barrel outcome was still very much a possibility.  Needless to say, Rob is always welcome on my unit, and his first beer is on me any time he wants to get out socially.  That’s the thing about a volunteer organization, you never know what that EMT does in “real” life.  

A fine adieu

At the beginning of each year, our department swears in our newest officers and realigns our staffing by reassigning our people among our three stations and six duty crews.  On the plus side, this lets us refill any staffing holes created by attrition and allows people to try new stations and areas.  On the down side, it means that the teams you’ve been running with often get shuffled in the process.  That is what happened this year for us.  MedicCat, Wayne and I are still on the same unit, Jen has moved on to be precepted by a BLS lead and EMS Lt Kelly.  We have gained Tess, an ALS provider to be precepted to lead status.  Tess has experience as a Medic in North Carolina, and is a fluent Spanish speaker, both of which will come in handy this year.  Unfortunately, DTXMatt is now running on the crew before mine, and at a different station.  While it means I can play poker with him without breaking for my calls, it does mean the end of a very good, solid two year run with an excellent fire crew and a good friend.  We’ve run one duty with our new fire crew, and I can already tell things will fall in just fine over time, just need a couple runs to “find our groove”.  I’m sure the good people of our area will provide us plenty of opportunity to hone ourselves.  Our last duty as a crew was last week, and while I’ve gone as many as 10 months without a trauma that needed a helicopter, and we already had more than our share for the year, a quiet last night just would not be our style.

Cat wasn’t with us that night, she was at her ‘day’ job as a Paramedic in a city north of us, so we started the night with three.  Jen could only stay a few hours before she had to leave to be prepared for her new ‘big girl job’ at the coroner’s office.  Of course, the whole time she was there, she was aching for a call.  And just as certain, none came.  We warned her that if she left, the calls would come, but I suppose that she’ll just have to chalk that one up as the last truism she learned on our crew.  That left just Wayne and I for the balance of the night.  We’d gotten dinner in, and were taking it easy when the dispatch came.  The first thing that caught our attention was the number of tones that dropped.  That many units usually means something potentially significant, but not always.  The dispatcher told us we were going out for an auto accident just into our second due and that most of the units from our other stations were coming with us.  Then she told us why:  “Vehicle overturned, with entrapment….and Fire”.  She was obviously reading the information for the first time as she announced it, and her voice got more and more excited with each addition.  She barely got the words out, and Wayne and I were out the door, and moving to the Station and the Unit.  (We are living in trailers out back during renovations).  “Get your jacket on and grab your helmet before we roll, we may be first in on this” I yell to Wayne as we get to the unit.  I toss up the rollup behind my door and snare my bunker jacket and helmet as I climb into my seat.  Wayne is in gear and in the unit, starting the engine and climbing behind the wheel.  As soon as I switch the radio to the assigned channel, and signal that we are responding, I hear follow up information.  The engine revs and we launch from the station.  Wayne is stoked.  So am I honestly, and the addition does not do much to calm us.  “Multiple calls for this….patient is reported unconscious, multiple vehicles involved”.  Well, that’s the perfect combo.  Multiple Calls, so several people dialed 911…means it is almost certainly SOMETHING, and it also must be impressive if they all noticed.  Overturned, trapped, unconscious and on fire, if there was ever a description of “Up Shit’s Creek”, that’s it.  Wayne’s hauling freight now, and the light traffic is actually helping for once.  These are the calls when the response is like they show in the movies, things flicker by, but you don’t really notice it, not exactly a blur, but effect of the flashing lights reflecting off the cars and signs you pass have that effect.  “Okay, easy, We gotta get him out fast, but it’s just a trauma run….easy.”  The voice in my head starts talking me down.  I love that voice, it brings focus, stills the adrenaline…some.  As we are getting close, I hear the engine and the squad mark on scene….Overturned –yes, trapped –yes, Unconscious –yes, on fire –no.  Well, that’s something.

We arrive on the scene in the parking lot of a small car rental company just of the road, and I see the engine crew already assessing the overturned car.  It looks like it skid for quite a while, hit a curb, ripped the hell out of a bush that was out front and landed, upside down on its hood, after slamming into a masonry sign.  I note that Police are on scene, and the officer has a “Check that out” look on his face.  “What happened to multiple…oh, there.”  I notice another car, with significant damage to one side and the roof off to one side.  It looks empty from the unit, but who knows.  

I hop out and trot over with the bags to get a better size-up.  I know better than to approach the car too closely, and frankly, the damn thing looks like a see-saw, upside down and down at the hood, and I’m not going for that ride.  I crouch into a catcher’s stance and peer into the driver’s window from about 5 feet away.  There is a Hispanic male, looks mid-30’s who has dropped partially to the roof of his car….no seatbelt, great.  He’s grey, and he is NOT moving.  I can’t see his chest, so I have no idea if he’s breathing, but his face is kinda pointed to the closed glass of the driver’s window, and it is totally slack.  It looks like a guy in an aquarium peeking out at the world…after being in the tank way too long.  We’ll, that’s not good.  I walk over to the Cop and ask if he was going to have the call.  He said no, but asked what I thought.  “I gotta tell you, I’m not sure he’s alive.”  He tells me that when he got there, the guy had his hand over his mouth, but doesn’t now…well, that’s something.  I ask a fireman from the engine if the other car is clear, and they say it is.  That’s when I notice that it appears to have been hit hard enough to move it at least one parking spot over, and possibly over a median in the parking lot. Aint that some stuff?

Wayne heads over with the cot, backboard and straps, and we get ready for the patient.  The ambulance crew arrives and comes over to see what they can do.  I tell them to get two IV’s hung in the unit, and when the guy is out, I need him stripped naked and a quick, complete exam before we move.  The Squad guys are cribbing the back of the car to stabilize things and are working to get the patient out.  I see why we got the ‘on fire’ calls.  The air bags have deployed and all of the packing powder had filled the car with what looked like smoke.  Now that the back window has been punched, it is streaming out and clearing up.  The engine officer comes over and asks how we want to do this…we want a helicopter?  I explain that I’m not sure if he’s alive, but if he is, I’m thinking that a 100yd accident, roll over mid-air while hitting another car hard enough to knock it into another parking spot and over a median before smacking a brick and mortar sign, unrestrained and ending with a GCS of 3 and no movement five minutes later qualifies for a helicopter.  It came out more like, “Well, if he has a pulse, I’ll fly him.  If not, we’re done here.”  Now I know he knows it, but he had to ask.  I get a nod and he goes off to help with the extrication.  They are working on opening up the driver’s side window and are going to slide him out that way.  The Rescue Chief arrives on scene and comes over to see what’s up.  I’m glad to have another medic to help out.  

The engine officer comes back and tells me that he reached in and felt a carotid pulse.  Cool.  “Okay, get me that helicopter.”  We designate the strip mall down the hill behind us as the Landing Zone, and he gets on the radio.  Well, I got a copter, and I got a patient, if only he wasn’t still stuck in the car.  About that time, I see two firemen sliding up to the window and yelling for the backboard.  The backboard is slid in through the driver’s back window and under the patient.  The firemen then slide him onto the board, and the board back out of the car.  They get him pulled out pretty quick, and do an admirable job of protecting his neck as they do it.  Looking back, the whole job was pretty fast considering the things they did, and I got a patient intact and in short order.  Kudos to the Squad.  

Okay, my turn.  After I see that he has an open airway and is breathing, we get the board up to the cot, and get to work.  There is plenty of help here.  The patient is being strapped to the board, exposed and assessed all at once.  Things look good when he starts gasping and swallowing air like a fish out of water.  I don’t know if you’ve ever seen this, but it’s never pretty.  He is wide eyed, and trying to sit up with each breath.  As he inhales his mouth opens wide like a fish and he swallows air in big gulps.  It looks scary the first time you see it, it sounds bad, and it’s a bad sign.  I’ve only ever seen it in people with severe “Dain Bramage”.  He does this a few times, then drops back.  He’s still breathing, but he’s out again.  As the EMT’s are working, I notice a few hands have the slight shake that says they are pretty ampped up, and that gasping didn’t help.  “Smooth is fast, go easy and get it right, you’ll be surprised how fast you’re moving” I say as calmly as possible to the team.  That’s something I say to myself all the time when I feel myself getting overly stoked.  No sense in rushing and screwing up.  In a few short moments, he’s exposed and I’m struck with two things:  It looks like nothing is obviously broken, and he smells like a still.  I guess the alcohol explains the lack of broken bones – he was drunk and probably just bounced around flaccidly in the car.  Chief was pushing to get to the unit, and we get him secured quickly and move inside.  The basic crew comes in with us to help.

As we climb in the Chief tells me to handle the airway, he’s good on the rest.  I’m good with that on principle, but the patientn is with it often enough that I’m not going to be able to snorkle him…not without RSI, and he’s got a clear airway, and is breathing on his own, so I’m thinking get him some big oxygen and post an EMT on there to yell if something comes up.  So, that’s what I do.  I get a non-rebreather mask off the shelf and get the oxygen flowing.  I get the mask on him, and work with the guy holding C-spine to get the strap around his head (Some guy, mentioned elsewhere on this site gave his opinion about NOT getting the mask on right).  All the while, I’m watching his breathing.  He’s moving good air, and regularly so that’s all good.  I take a quick listen to his lungs and I have clear sounds, and it’s equal on both sides.  The patient has a really short neck, and was in a strange position coming out of the car, so they had a hard time with the collar on the scene.  They were working with it when the Chief told them to move and the collar needs to be put on right.  They had it on a bit crooked, but they also kept holding him manually, so he’s still in good position.  I get that cleaned up and things are looking better now.  Okay, Airway, Breathing, check, check.  I call out to get a Pulse Ox on him so I can get a feel for how well he’s getting that oxygen into his blood, tell the guys to keep an eye on his breathing and let me know if anything changes and take a look at how things are going below the neck.  My mental clock is ticking, and I know our ride is on the way, we need to be moving soon.

There are PLENTY of folks in the unit now.  Chief and I, the two from the ambulance, and the chief has asked two guys from the engine to come in.  It’s quite the party.  I see a secondary assessment going on, there is a BP cuff on his right arm, and chief is passing out “to do’s” to the folks.  A quick check, and I see we still need IV access and ECG monitoring, I feel like we are slipping behind just a bit, so I slide over to the CPR seat, grab an IV line and get ready to go.  Chief goes to the other side and is prepping to get access over there.  I have the BP cuff on my arm, so I reach over and hit the button on the LifePak to get a pressure.  I’m thinking it could be low, so I’m not going to mess with the arm much while it’s going.  I take the chance to reassess.  The EMT at the head asks if he should drop an oral airway, and I tell him to do it, but do NOT drop a nasal one – potential head injury and all.  I get someone else going on the ECG.  Chief tells me that he’s going to go with a smaller IV access to ‘make sure we get one’ and let’s me get ‘the big one’, fine, no problem.  I look down and the cuff is not inflated.  What the ???? Then I see it.  The cuff on the patient is not the one from the LifePak…doh!  Okay, fix that, get a pressure..and it’s high.  I don’t remember exactly, but high, like head injury high.  His pulse rate is down a bit too for someone in a wreck, I want to say 70’s…not low enough to be a threat, but low for an accident.  The symptoms for the intracranial pressure are classic Cushing’s Triad well, that and…”Hey, he’s not breathing” I hear.  “Bag him now!” both the Chief and I say.  The EMT’s spring into action, and he starts gasping again.  “Okay, work with him.  When his breathing slows, bag him.  It’s going to come and go…okay?” I ask.  They got it and I see them getting a good seal, good chest rise, nice.  The Chief’s line is in, and I get mine on the second attempt.  He had great veins, but he gave a good twitch just as I pushed in, pulling me through the vein.  Just as I’m thinking he is reacting to pain, I notice his hands….he’s not reacting, he’s posturing a bit..damn.

Okay, time to see where we are.  Airway is good, the guys are bagging when they need to, getting good chest rise, and a sat of 100%, the IV’s are in and cut back...he doesn’t need more pressure, ECG is regular if a touch slow considering, lung sounds okay, somehow no deformities anywhere, and he tenses when you press his belly.  Time to get to the LZ.  I yelled up for Wayne to roll to the LZ, only a few hundred yards away, and tell everyone, “Okay, we’re on this.  We got this covered, it’s cool.”  I sense the crew relax a notch and that’s good too.  I’m not keen on the slight posturing going on, and I cut the lights to check pupils.  His eyes are slow, and the right one didn’t react to light at first…more bad news.  

We hit the LZ just as the helicopter finishes the size up pass, and heads in.  Timing doesn’t get much better than that.  A few of our guys hop off, and the flight team gets on.  Chief gives report and they get a tube after RSI’ing the patient.  We get things going, and firemen at the LZ help the flight crew load the patient.  One more for the trauma center.

About this time, I think of Jen, and the fact that she didn’t get any calls while she was here.  I meet Wayne behind the unit and as the chopper is loaded I call her cell phone.  It’s late and there is no answer.  I wait for the message to finish and over the rotor wash I yell into the phone.  “I think this is your voicemail…but I can’t hear over the helicopter!” and hold the phone up towards the rotors.  Grin…well, she’ll love that one.  Wayne laughs, and Matt come over and shares the joke.  About that time, my phone vibrates…I have a text message from Cat.  She got the dispatch page on her pager while at work, and wants to know what I’ve been up to.  I read the message, “So, is that another call for the blog?”  Yeah, I guess it is.

A Midwinter's Night Dream

So it has been almost forever since I’ve posted, I’m blaming the holidays, and a bout with the flu for that.  But I’ve recovered from the flu, and running all over Virginia seeing family and sharing laughs, so it is time get back here.  I’m still kicking myself for missing the call that DTXMATT wrote up, but there will be more, there always are.  But, just like sharing stories around the bay table, hearing one story reminds you of another, and hearing the scene security issues reminded me of a call that sticks with me even today.

The call came shortly after nightfall during a snowy mid-winter’s night.  The snow had accumulated a few heavy, wet inches on the roads and was still falling hard.  Those of you in the Virginia area know the type of snow I mean, the heavy stuff that crunches under your feet, and you have to shovel off of your car.  Great for Snowmen and snowballs, but packs rapidly into muddy ice on the roads, and only gets more and more slick when the salt doesn’t totally melt it free.  This becomes important, because it means that ‘response’ indicates that we are on the way, but full speed is more like 20-25 mph and the rumble of the on-spots can be felt once we turn off the main roads.  On-spots are an automated chain system that can be activated by the driver when the unit comes onto icy roads.  When activated, a disk with lengths of chain rotates down in front of the tires and lets the tires drive over the chain.  This allows us the benefits of chained tires, but removes the need to have the chains on all the time.  The restriction is that you are limited to only a few miles per hour when they are used, or you risk damaging the system.  All of this is important because these conditions result in it taking much longer to get to our calls, and equally affect each of the subsequent units as well.  

The initial dispatch was for a difficulty breathing in our second due, a bread-and-butter call.  We get sent with the basic unit from that due to assist.  We start the trek up to the call, and Wayne and I exchange comments on the light traffic, and poor examples of parking that are demonstrated every so often by a vehicle that slid to the side of the road.  We make good time for the conditions, and see the ambulance coming from the opposite direction as we approach.  Not far from the address, dispatch passes information that perks our ears, and puckers our backsides.  “Units responding to the difficulty breathing…we have lost contact with the caller.  The line is open, but the caller is not responding.”  Well, that’s bad.  Okay, sure, maybe she went potty, and left 911 hanging, but it’s not likely.  The tone in the dispatcher’s voice tells me that she doesn’t think so either.  

The address is an apartment, and following the unwritten rules of EMS, the patient is on the top floor.  We arrive with the basic unit, and boogie ourselves up the stairs hauling everything we think we may need, to include the drug box, up to the third floor.  (I know, waaah, 3rd floor is the top one).  Getting to the door, I test the knob.  Of course, it is locked.  POUND, POUND, POUND on the door – “Rescue!” I yell, fully hoping for an “In here” or some such.  Instead I’m met with a loud series of barks and growls and scratching at the door in front of me.  Now, I’m a dog lover, and have two myself, but I know that I’m not hearing the “Hey, someone’s here to pet me” bark, and the scratching is going on about head level on the door.  Great, a big, pissed off dog, and no response from inside.  Okay, I’m a big guy, 6 feet tall, and 250 lbs at the time with a size 12 ½ duty boot, and the door is not really an obstacle here, or not for long.  And Difficulty Breathing-turned-Open Line means someone checking out and NOW.  I need to be in there, and quick.  “Start an engine company and PD to this location, I need to force entry, and I have a large dog on the other side of the door” I say into the radio.  Damn!

Two thoughts battle for supremacy in my head: “The odds of resuscitation diminish ten percent every minute post cardiac arrest” and “If I bust through that door, and that dog hammers me, this call is over for that patient.”  I know the first responsibility of any Medic is the safety of self and crew, and I know the rest of the team there feels that too.  One of us goes down with that dog, and they become the only patient, until that situation is resolved.  

What we have here is a first class dilemma.  I promise you that it is much easier to talk smack in either direction before you get there, than it is to make that call standing by that door, hearing the dog, and KNOWING that there is someone slipping away on the other side just a sure as you know that they called YOU for help.  In the time since, I’ve come understand that I made the right call, and I even use it to teach new people, but it still stinks.  

As I stood there waiting, and banging on the door, the complex manager comes up to see what is going on.  I explain the situation, and he offers to run for the master key.  I encourage him to do that, and we start talking about how to handle our situation.  The bottom line is, once the fire crew, or the master key got there, we could get in, but that did not mean that a quiet entrance would deal with the dog.  The lead from the basic was then relatively new as a lead, and with a former military background, I could tell she was straining at the leash to get in there too.  We agreed that it sounded good, but would get one of us attacked and leave nobody for the patient…so we waited and planned.  The only protection we had was our bunker gear, so Wayne ran down to get a jacket.  (We run with full Structural Firefighting gear on our units).  

A few long, long minutes later, I see red and blue lights dancing through the hallway window.  The engine and Police units were here.  The fire crew comes up the stairs with the ‘rabbit tool’ in hand, and in full gear.  The police are with them as they arrive.  We explain the issue and get a look from all of them that said, “And what exactly are WE going to do about the dog?”  To the fire crew’s credit, they started work on the door right away.  The door popped open briefly and we caught a glimpse of the Chow on the other side.  Big hairy bear of a dog and one I’ve heard has powerful jaw strength….wonderful.  The Officer on the engine grabbed the extra jacket and started back for the door.  

After a short three count he pushed back into the apartment, leading with the jacket like a matador’s cape.  A second firefighter followed him in similar fashion.  I went in on the second man’s hip, with MedicCat right behind me, and the Basic crew following her.  Our own EMS SWAT stack making entry.  The dog barked once or twice, then retreated in the face of the swinging jackets.  Unfortunately, he moved back right to the patient’s lap, turn and growled, guarding Momma.  Of course.  

The patient was a female, apparently chronically ill by her physique, sitting in a chair facing the front door.  She was head up, pale, and still holding the phone to her ear.  She was also apparently not breathing, and her eyes and mouth were open.  Shit.  Not a surprise, but damn, didn’t want that to be the case.  The two firemen-cum-Matador shooed the dog off of her with flourishes of jackets, and the dog hopped down and circled through the kitchenette area, around an island and back behind us, between us and the door.  Convinced those two had a system now, Cat and I rushed to the patient.  We each checked for a carotid pulse, and felt none, but as her head moved back from our touch we heard this agonal gasping sound escape her throat.  My head whipped towards Cat’s and I caught her doing the same to me.  She heard it.  “You hear that?” she asked.  “WE GOT SOMETHING” I announced to the group, “let’s GO!”  Now we are NOT working this code while fighting a dog, so we each grab an end of the patient and start for the door.  The dog/bull fight is still raging, and we advance and retreat a couple times towards the door under the cover of bunker jackets as the dog and the fireman do battle.  Finally, the firemen get the dog to retreat to a back room and slam shut the door.

What followed next was an ugly, full rush to the waiting unit.  The basic crew and fire guys grabbed gear and chased us and the patient down the three quick flights of stairs, out the door and the couple of yards to the unit.  Someone had run ahead and pulled out the cot, and wham, on she goes, and up into place.  Okay. Code.  No dogs, my house, the medic unit.  

Hoping that we heard some sort of breathing or breathing attempt we quickly get a look on the ECG….Asystole. Damn.  I was really hoping it was something better, but that is just not my luck.  The police are in the apartment and are checking for identification etc. and we pass word to look for medications if possible.  

We start transport quickly, knowing we have a longer transport time ahead due to the weather, and run our ACLS protocols by the numbers.  Everything proceeds smoothly, and sometime after MedicCat gets the IV on our dead patient, a secondary exam finds a subclavian subdermal med-port in her chest.  We note it to pass on to the hospital.  We aren’t going to be able to offer much else in terms of helpful history and hope the police get an ID to get some records.  The intubation goes well, and there is not too much resistance to ventilations.   We work the code into the ER, and they continue for a while before stopping efforts.  At some point the police arrive with a patient name, and the hospital could pull her records.  I don’t know exactly when her heart stopped, but even if it occurred at the moment we heard of it, I was only a few hundred yards away when it happened.  That though has visited me more than once since.

While writing my report, I noted that the call taker at dispatch stayed on the line the whole time.  They noted in the log the time they heard my first pounding on the door, they said that there were dogs in the background and that one sounded Big and angry.  (There HAD been a smaller dog in a pen on the other side of the room).  They also noted the time when they heard us making entry.  I don’t specifically recall, but I think the delay was like 9-11 minutes or so.  Seemed like forever…and at 10 percent a minute…  Anyway, I thought of something else later, that call taker must have still been on the line when Cat and I got to the patient, and heard the gurgle that I now think was just gasses escaping when we moved her head, and the hopeful “we got something, let’s GO”.  I’ve wondered since what this call was like for her, though I’ve never been able to ask.  

I think I heard at some point that she’d been a cancer patient, but don’t hold me to that.  It did occur to me that she died, eyes open and still on the phone, so it must have come fast.  That’s good for the patient, and probably means we would not have had a chance either way, but I’ll never know.  A family member, either son or husband arrived as we were leaving the hospital, and I remember learning that he came home to find a coffee table pushed aside, the dog in the bed room, and his family member gone.  He figured we’d been there, and asked the property manager or the police what happened.  I never did get to talk to him but I hope he knows we tried, but we just could not risk our crew with that dog.  Like I said, I’ve come to grips with this one intellectually, and would run it the same way again, but I’d rather not.