Now that's a bad parking job

Hello, Hello, Hello.  Cat and I are back from the cruise, and Yes, it was the Mariner of the Seas cruise where a bunch of people got sick.  We did not get sick.  We did get drunk, overfed, rubbed down and wrapped in seaweed though.  (THAT was a new experience for me too).  We cleaned up okay, and I even put my formal night dinner pic up on my profile, just to show that I WAS sober and charming at some point along the way.  I saw our friends from the Doubloon down at St. Thomas again and if you ever get a chance to go snorkeling with them DO IT.  They haven’t posted the pics from that trip to their website yet, but I will be sure to link it in when it is posted.  In St. Maarten the 12 Metre Challenge was awesome and once again Cat and I got to crew an America’s Cup yacht in a race.  All in all a week of taking in easy and recharging.  Of course all sorts of “real life” was waiting when I got back, but it was worth the trade.

Someone asked me in person if I was going to post a blog about our 9/11 response (That is 2001, in case you are part of the 30% who couldn’t name that in the recent poll. Morons.) in light of the 5th anniversary coming up and all.  The answer is yes, that I’m working on it, but I’m trying to figure out what stories to include and how to put them.  I did find the video thing I had made and I put it up on youtube a while back.  I forget who asked me for a copy of that, so there ya go.  A “Job well done” to our British friends for kicking ass and making sure that it wasn’t the bad guys who reminded us of the meaning of “Never Forget” this week too!  So, we can’t bring liquids on planes anymore, I can deal with that.  Maybe we can uncover a plot to use small children who cry constantly and kick the seat in front of them for the whole flight as WMDs and air travel will be perfect.  (I kid of course.)

I promised to post a specific call last time, and so I shall.  It happened a month or almost two ago now.  At the time, we were in the middle of a nasty heat and humidity wave (called summer in Northern Virginia).  Temps were in the mid-90’s I believe and so was the humidity.  Basically, you walked around all day feeling like you had huge, hot, dog breathing on your neck everywhere you went.  If you had to be outside, you didn’t want to move, and just sitting around made you sweat like a whore on a slow Saturday night.  Of course, around here, that sort of heat and humidity means afternoon thunderstorms and lots of them too.  “Gulley Washers” was the term I’d heard for them, spotty, hard, fast rains that blow around trees and lawn furniture, drop all sorts of rain, and then disappear in about 20 minutes.  Sometimes they’d cut the heat and humidity, but not that evening.  One thing they did do, was erase any memory of how to operate a vehicle from the good citizens of our county.  You can actually tell where the squall line is by listening to the dispatched for the auto accidents some nights, and that’s what happened here.

The dispatch wasn’t a surprise when it came then, but during the short response, things started to sound interesting.  Cat was working, and I had Wayne, Tess and an EMT named Jon with me (as opposed to MedicJon).  Jon had been doing “good call voodoo dances” trying to gin up something before this, and it sounded like it worked.  The first description was for a head on, then it was three cars, then we heard that there was one car under another one, and that there were people entrapped also, there were injured people walking around as well.  

As we are rushing down the road with the engine, I am talking on the headset to the folks in the back.  “Don’t forget your vests”, “watch for other cars” followed by the game plan.  The multiple reports gave the dispatch credibility and it sounded like it was going to be serious.  I knew going in that if someone was trapped a) everyone would focus on them and b) there was going to be very little we could do until they were out.  I didn’t want to miss everyone else on this one.  We had a lot of people coming, Us, our engine, a Squad, a BLS unit and a Battalion Chief on dispatch, and en route the Rescue Chief marks up as on the way.  I knew the first thing we needed was going to be information:  “When we get there, I want the two of you to make a quick pass through the scene and get me a count of how many people we have.  Just ALS and BLS is fine, don’t do the whole ‘Red, Yellow, Green’ thing.”  (We use START Triage here for Mass Casualty calls, and while effective, it would be a bit of overkill on this one.  I just wanted to know how many injured, how bad, and where so I could call for more help, or send people home as needed.)  I told them to get the count and come back to me in person with the numbers so I could request anything else that was needed from command.  So, before we get there, we have a plan.  (Fuster Cluck avoidance 101)

Arriving on scene, I can tell we are going to be busy.  My best guess as to what happened was that two cars traveling in opposite directions hit head-on, and then a third rear-ended the one going north.  This third car was sitting with its entire hood up under the trunk of the car it struck.  There was a cluster of people standing outside the vehicles by a guard rail, and at least one of them had a busted nose that was bleeding like a busted nose. (Clever that).  There were people visible in the front of the north-bound car, and it was clear they weren’t getting out.  The back end, while busted up and on top of another car, was far and away the ‘good’ end of the vehicle.  The front of the car was smashed way back into the engine compartment and there was no appreciable distance between the driver’s front tire and the driver’s door.  (Never good).  The south-bound car was also smashed and sitting off to the side where it ended up. Wayne pulled us past the accident and into a relatively safe position and it was time to go to work.

Jon and Tess hop out of the unit and set about executing the triage for the call.  I walk back and try to take in the ‘big picture’ and sort out what might of happened and what our challenges here could be.  I tag up with the Engine boss, Rick, face-to-face and tell him I’ll have a count and a prioritization to him in a minute.  He’s good with that, and is setting about calling in the situation to the incoming units, securing the cars, checking hazards and setting up for the extrication that we are obviously going to need.  I stick my head into the window of the north-bound car to get an eyes-on on the folks trapped.  There is a 30-40 year old man in the driver’s seat and a 9-10 year old girl passenger.  They are conscious (a real plus) and talking to me.  They are also staying pretty calm, which is surprising, possibly concerning too, but I’ll take it.  He says his legs and chest hurt.  I can see that his legs are clearly pinned under the dash of the car and it looks that while he was wearing a belt, he may have hit the wheel too.  There is blood coming from a laceration to his head, too, but nothing too serious at first blush.  “Okay, you are ALS, probably a fly-out, but lets see whats going on first”, I think to myself.  I know I COULD call for medivac right then and there, but I also know that he’s going to be a while getting out, so there is not much advantage in starting that yet.  The girl says her arm hurts, and lifts it up to show me.  She has a classic “silver fork fracture” to her right wrist.  She’s doing well considering and I have her place it in a way that will support it until I can get her some help.  She’s been in a doozy of a wreck, but was belted, oriented and other than the wrist, in apparently good shape.  “ALS, but can go to the local hospital if need be” I think after the quick check.

About this time, the count is coming back.  I’m trying to recall the first count, but as I recall, the other cars had about 3-4 BLS injuries, all from the same car I think.  During this time, the BLS unit arrived as had the Squad.  The squad was setting up for the cut, and I had pointed the BLS crew to the group huddled by the rail.  I find the Engine IO, who had command, and tell him that I’m going to need another Medic unit and I give him the count.  He asks about the helicopter and I tell him to hold off for a minute, but it looks likely.  He’s getting ready to radio that in, and I’m headed back to direct the EMS activity when I hear someone else calling in patient numbers on the radio.  It seems the BLS lead has done the same thing (Triage and count) and is making a call directly to communications.  I later learn that the combination of radio calls, combined with the slightly different numbers gave the impression of considerable confusion to the Battalion and Rescue Chiefs as well as the additional medic that would be sent to help.  I didn’t focus much on it at the time, but have Jon get into gear so he can climb in and help with the girl in the front car.  Firemen are setting up to hold C-spine, shore-up the car etc as well, and things are moving.  I check in on the trapped driver who is holding up okay, and have the BLS unit sorting through the group of BLS injuries and start treating.  Wayne and Jon are tasked with getting the girl out of the car and ready to go.  She does not need to be cut out, but the car is very close to the guardrail and that is going to give them a bit of a challenge.  I have not put on all of my bunker gear yet, and am trying to coordinate things without lingering in the “hot” zone around the crushed car.  A police officer asks if I can ‘characterize’ the patient.  “Sucks to be him” I think to myself, but I know what he’s asking.  “Right now, he’s serious, but not life threatening.”  The patient count is starting to drop, as some of the people initially identified as BLS are choosing to refuse care for minor scrapes.  The driver’s door has been pulled back, though not entirely removed yet and I can tell from where I was standing that he was going to be in bad shape.  I can see his lower left leg now, and the shinbone that is clearly protruding from his skin.  Any hope that maybe he was uninjured under the dash was gone.  “Okay, get me that helicopter” I tell Rick, and wonder about my ‘characterization’.  I don’t think we’ll be ready for them when they arrive if they leave now, but with the storms in the area, I’m not sure if we will get one at all.  I’m really looking to find out if I’m going to have to drive to the trauma center more than anything else.  The skies are dark and cloudy, and I hear the rumble of thunder in the distance.

About this time, I get a tap on my shoulder and turn around to see one of our Chiefs, Dave, standing there.  “Why is Tess in that car like that?” he asks and I see him pointing.  Tess is leaning in over the girl and doing an assessment.  While she is wearing her vest, she doesn’t have her bunker gear on and I know that is the issue as soon as I see it.  Oops.  Lost track of her assignment, and should have reminded her.  Jon, meanwhile, is fully geared-up but can’t get into where the girl is because of the limited room, and the people already there.  I jog over, pull Tess out, yell to get Jon in there and have Tess go suit up.  Problem solved, and back to work.  Time to suit up myself too, the Rescue Chief, Ed, is arriving on scene, as is the other medic unit and it’s going to be hand’s on time fast.  

I point the incoming medic unit over to the little girl, and try to recall Wayne, Tess and Jon so we can get set to take care of our patient, the driver.  His door is coming off I have them get the cot and backboard ready to roll so we can move fast when we get access.  I brief Ed on everything that is going on, and he tells me that he is on it, “Go be medic” he tells me.  I give him a smile, nod and head over to the car feeling like a kid who just heard the bell for recess sound, just as everything is clear and I’m waved into the car.

This whole time the driver has been with the firemen holding his head, talking to him and covering that cut to his head.  Getting back in, I see that my patient is still oriented and talking to me, there is blood on his chest, but it looks like it came from a considerable laceration to his head.  I’m glad the chopper is coming now and I know I’ll have to move fast not to leave them waiting.  All of that occurs to be before I work my way back down to his legs.  I see that he clearly has an open fracture to his lower left leg, just below the knee, and the bone was visible from 5 paces.  His right leg is not clearly visible from under the dash, but looks like it is in bad shape too.  His pulses are good, he’s got clear lungs, is fully oriented and remembers everything.  The squad guys, who came from the neighboring department, did a really good job of clearing things out of driver’s door area, but I have a problem.  The rear of the car is still elevated on the hood of the other car, and this guy is supporting his weight on the one good bone in his lower left leg.  I can’t move him in either direction without pivoting him around that leg.  Thing is, his shin is protruding a couple of inches out of his leg, just below the knee; if I turn him on it, I will de-bone him like a chicken leg at a bar-b-que.  I have the board ready to go next to him, and he’s collared and ready to go, but I just can’t work out the logistics.  I take a step back and look at things again.  Dave is behind me and is pretty straight to the point, I think he sees what I do. “Can you get him out?”  he asks.  “Don’t think so, that leg is going to come off if I turn him.” I respond.  “Want to just take the roof off and pull him out the back?”  is the offer he makes.  I tell him that I think we have to do it.  I know the squad guys are hot in all their gear, but it has to be done.  I’m feeling their pain as I say it, but I feel a bit better when Dave says, “Hey, we always get fancy, and it’s always the simple ways that work.  Shoulda done that in the first place.”  With that, he picks up the tools and starts cutting posts.  “Hey, someone wanna help the Chief cut your car?” I hear from behind me, I think it was Wayne goading the guys on.  

In no time, the roof is off and it’s time to try again.  We are going to lay back the patient’s seat (while supporting him), and slip a backboard down behind him.  Then it’s the simple matter of sliding him up the board and into place as we move him backwards over the trunk.  Not all that uncommon a move for an extrication, and one I’ve done before.  Oh yeah, but in this case the trunk rises about 5-6 feet above the ground, and to get him on the board, we will have to lift him until his head is about 8 or so feet up before we can lay him backwards.  One more challenge in the heat.  So, bottom line is, we do it.  It takes a bunch of people and we are all covered in sweat when it is over, but with people standing on the back seat, and someone on the trunk, and two people doing nothing but supporting and stabilizing his mangled legs, me on the ground lifting one side, and someone else in the passenger seat, the job gets done, c-spine precautions and all.  To his credit, he dealt with it really well, you KNOW that hurt.
Okay, I hear two things now:  Chopper is on the ground at the LZ, and the thunder is closing as the rain starts.  The extrication took a total of about 20 minutes, so we really had to move.  Thing was, his legs came out in a slightly crossed position, and he had obvious bilateral open fractures to the lower legs (Bone visible on the left, and a tell-tale opening and deformity on the right, almost certainly an open Tib-Fib combo), and a likely femur fracture as well so I’m not really looking to move them much.  It just means that we are going to have to work around it.  It adds a minute or two in securing him to the board and loading him, but we do it.

Inside the unit, I have myself, Wayne, Tess, Jon and the lead from the BLS unit also named Chris (He ended up with refusals from all of the other folks, even the busted nose which was a bit surprising but I think the folks saw how bad the others were and declined).  Ed sticks his head in to see if I need a hand, notices all the people and tells me that he’ll be right outside if I need him.  Good man.  The doors close and everyone starts asking the patient questions.  My CF alarm sounds in my head and I stop everyone.  “One person will talk to my patient.”  I assign Jon to his head, taking care of oxygen, watching for airway and consciousness issues and documenting answers to my questions as well as getting history, meds and allergies for me.  Tess I assign IV duty.  He is in good shape, or was 0.4 seconds before impact, but has really deep veins that are very much not visible.  She’s the hospital tech and the best ‘stick’ so she draws that duty.  Chris and Wayne get the legs.  I assign them the job of bandaging all openings that were not there before the wreck and splitting/stabilizing in place everything from the pelvis down. (I had exposed him by cutting of his clothes outside).  I am doing vitals, specifically Blood Pressure and ECG, and secondary survey.  About this time I note the pool of blood forming on the floor.  “Where is that coming from?” I ask.  Jon shows me that the laceration to his head is an avulsion, a loose flap of skin, and now that he is laying down, it’s bleeding pretty profusely…More tasking for Jon, but he did well with it.

I find that his head is structurally intact, airway is clear, pupils are good, he’s fully conscious, arms and hands are good, ribs not tender…and I keep getting stopped with information flowing up from the guys on his legs.  They are doing well, and finding deformities and lacerations, and trying to keep me up on in, but we already know that his legs are busted and this is throwing off looking for things that will kill him.  “Okay, wait, I know his legs are busted, you know his legs are busted, Sir,” as I look at him “I’m sure you know this, but both of your legs are pretty badly broken.  I know they gotta hurt, and I’m hoping to be able to help with that.  These guys are doing a great job taking care of them, but I gotta check the rest of you so I don’t miss anything.”  I tell the guys that basically, if it isn’t pumping blood into the air, I don’t want to hear it until later.  About then the Battalion Chief sticks his head in the back.  “Hey, I know you are working here, and you do what you gotta do, but I just want you to know, the storms are really close and the chopper may not be able to lift off if they don’t get going soon.  I don’t want to rush you, just let you know.”  In my head I’m laughing, no pressure.  Oh, and Tess now reports she has missed her first IV attempt.  I tell her to look again, and finish the assessment.  I find his abdomen to be very rigid and tender on one side (Left I think now).  Damn, that’s the thing.  The head avulsion is bloody, the legs are going to take a lot of surgery to fix, but this possible internal issue in his abdomen can kill him right now.  

I take note that his ECG and vitals are about right for someone in his shape, tachy, but decent pressure etc.  I try for an IV on my end, and blow it too when he flinches a touch.  I tell Wayne to drive, and as much as I hate rolling without a line, we GOTTA go.  Tess and I are searching on opposite sides while we go to the Landing Zone and she gets hers.  It isn’t big, but it is in and I’m happy.  The flight medic and nurse hop in and get report.  It takes a while to list all the fractures and lacerations, but I make sure to point out the abdominal issue as well.  I note as we get to the LZ that I’m getting less lung sounds in his lower lobes, another sign of  possible internal bleeding and pass that on.  The flight medic give me a little “no shit” as he listens behind me.  We all move quick, once again racing the weather.  The crew is out in it longer than they probably should be, but they are glad they are here to help.  He gets moved to the chopper and off he goes as the rain gets a little heavier.  

We head back to the unit and start to the hospital to clean up, restock and write report.  I hear the ambulance get called back to the scene for that guy with the busted nose as we start to move.  All of our bags from the scene had been tossed in their unit, so I radio to tell them not to worry, we’ll meet them there and sort it out.  It was only after I unkey the mic that I realize that what I said was, “Go ahead and pick him up, we’re going to head back to [the hospital] and start hosing out the unit, we’ll meet you there.”  Hmm, ‘hosing out the unit’ is not normally heard on the air, but whatever.  Ed has been asking about the patient’s birthday for the police I think, and I didn’t get it.  I also advise him that he can tell the cop that he is in a life threatening condition now…Ed already had.

Okay, now the punch line:  So, we are at the hospital, Wayne and company did get the hose out and everything cleaning up etc.  The little girl was there and looked good but with the broken arm.  Ed meets us at the hospital to make sure everything is cool and has some news.  It seems that the patient’s girlfriend or wife (Forget which) works as a nurse too, but wasn’t with them because she was working…at the Trauma center we just flew him to.  And I thought I was under pressure with that call that night.