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.