She was just 17, if you know what mean...

Wow time keeps slipping by me, but thanks to everyone who keeps checking in here, swinging by the myspace page, sending email and prodding me in the street to “Update that blog”.  I’m coming up on one year doing this and I’m still surprised anyone reads it.
I have a couple things I’m working on offline, but I just can’t get right.  May be that they are the ones closest to me so that is taking some time.  Anyway, this week’s duty made the choice of story easy.  Cat and Wayne were with me, as always, and we had a new guy getting some time on a medic with us, Brian.  Tess has been given the opportunity to go to the ER in Baghdad as a paramedic for a year, and has said her goodbyes for now.  May God keep her safe as she heads off to help others in an area of the world not known for that.

We had just marked clear of the ER from a bogus sickness call and had not even made it out of the parking lot when the MDT terminal jingled and the screen was filled with a dispatch.  Wayne heard the sound and looks over as I tell him we are headed for an auto accident down between the gates to Quantico.  He gives me a nod and pulls up to the light in front of the hospital.  The dispatch has not even hit the radio yet, and I’m acknowledging that we are responding.  I know Wayne will wait on the light in the intersection then hit the sirens and away we’ll go.  In the mean time, we are waiting to hear more information.  That information comes as an update to the MDT as the dispatch just starts going over the radio.  “Two cars, head on….ejection” I say.  Wayne doesn’t look over this time, but I see him slapping on the lights, and feel the unit accelerating…so much for waiting on the lights to turn green in the intersection.  Cat and Brian are in the back, and our headsets aren’t working, so I turn and yell back to them.  I get them up to date and get things going  “…Hang two 1000 bags and get your vests”.  The trip is a fairly long one for us, and I know we are probably 8-10 minutes out from the dispatch.  There is a medic that is based closer but they are already on a run, so too is the closest engine.  There is a Battalion Chief that should get there fast, and apparently a Utility is in the area.  I check the computer and it looks like we are going to be the first in EMS piece, and the updates that keep popping up on my screen say we are going to be deep in it.  Possibly one ejected, reports of people in the roadway, 2 ALS patients, 3 BLS patients…all before the first unit is on scene.  (Yeah, a patient count by severity before a unit on scene…must be a bystander with some experience there).  The first pieces get there and we hear confirmation of one entrapped, all lanes closed.  The Batt Chief is asking for more EMS pieces, (only us and a basic on the initial dispatch) and it sounds like they are going to be coming from a ways off.  He has communications call onto the Marine Corps base for their units.  Good plan, they should get there shortly after we do.  We are closing on the scene now, and it sounds like it is busy there.  I radio ahead to command, “We are 30 seconds out, where do you want us Chief?”  He directs us to get behind the utility as we crest the ridge and get our first look at the scene.  

There was a green car of some sort off the road and against a tree line.  On the driver’s side, there were several bystanders, and while I couldn’t see into the vehicle, I can tell something bad is inside.  Laid out along the northbound lanes are patients, four of them.  They all have lacerations that I see from the unit, and a couple have someone with them.  At this point, we (the EMS providers) are still outnumbered by patients.  I hop out of the unit and head over to size up what we are facing.  Quantico’s engine is just arriving, and their Medic has to be close.  I walk through the people laid out on the pavement.  As I told someone later, I’m reminded of scenes from the 80’s hit squads in South America.  They are all laying perpendicular to the road direction, about two arm’s length apart, and bleeding from various places.  I notice two things, 1) None of the bleeding is really bad and 2) they all look at me when I go by.  That makes them conscious/alert and the lack of severe bleeds or obvious deformities is a ‘good’ sign.  I move past them to the car, here things change.  

The car is mangled, the front end is toast, and the driver’s side is not any better.  The driver’s door is almost ripped off, the windows don’t exist.  The driver is female and she has been knocked back in her chair so hard that she almost exited the vehicle out the driver’s side REAR window.  A bystander in motorcycle gear is holding her head and I can see that her face is grossly deformed.  My initial assessment is that she has fractured her left orbit and temporal region of her head.  She already has a golfball sized hematoma right at the middle of her forehead.  Her right leg is folded under her hips, but her leg looks intact.  She is clearly unconscious and is bleeding from her face and probably her airway from the sounds I’m hearing from her.  The patient is clearly going to need to be cut out, but all we really need is the door ripped the rest of the way.  I yell for someone’s attention and give them the circular finger in the air…time for a helicopter.  The guy holding her head is doing a good job with C-spine stabilization, and I ask him if he is good to go for a bit as I quickly make sure the rest of the car is empty.  off.  He assures he me he is ok, and I turn to get Cat’s attention.  She was back at the road starting to work with one of the guys there.  I wave her off of that and have her come over right away.  “Hey, this one can’t wait, she’s ours, let the next units finish sorting things out.”  (Ok, not PC, but it does get Cat and our guys moving.)  Cat nods as she comes around the car and starts working on the driver.  I ask if she’s cool for a minute, that I want to check in on command and make sure we have a handle on the big picture.  She nods and gets to it.

I jog back to the buggy where command is and make sure he knows we are going to need a chopper.  The officer off of Quantico’s engine is there and assuming Operations.  I give him my quick count and tell him we are focusing on the driver first.  The Medic from Quantico arrives as I’m walking back and one of those guys is clearly getting a good scene assessment going.  I tag up with him and we agree that he is going to coordinate the incoming units and sort the patients on the road, we are going to finish with the driver.  Cool, Okay, the big scene is handled and I can go get back to Cat.  The Tower is pulling in and I grab the officer as he gets out, “Hey, the driver in the car over there is bad, I need her out yesterday.”  I get a serious nod and they start pulling equipment.  

I get to the car with our cot in tow.  Wayne has retrieved the backboard and straps, and Cat has done her initial workup.  She has had no reaction from the patient, and has organized the mix group of rescuers and bystanders into a plan of action to pull the driver out.  (She rocks).  The door is quickly cut free and we are in business.  Cat tells me that we are going to intubate quickly, and I agree.  Wayne says he already has the kit open in the unit.  We get her on the board and quickly strapped down.  It is not a pretty job, but it will work.  As everyone is moving her free, I lean in to Cat, “Does she have a pulse?” “Yeah.” She says.  I look again and I’m not so sure.  “Check again”, I’m asking softly so as to not set off the bystanders that are helping.  “Got a carotid, but no radial” Cat updates.  (BP low probably around 70 that means…makes sense).  We carry her to the waiting cot and head off to the unit.  Her arms are flopping free at first and Brian does a good job helping get her contained.  She’s out cold, but still breathing….I can hear it…not good.  As we are rushing to the unit, I notice the looks that we are getting from people we pass.  They are having the same thoughts I am, and I’m not sure that she’s going to make it long enough to make it onto the chopper.  I have yet to see her respond to anything, and while she is moving air, her airway is clearly in jeopardy.  At least now we are going to be somewhere where we can attack her problems and see if we can’t keep her alive long enough to get to the Trauma Center.

The door slam shut and we get to it.  Wayne asks for trauma shears and starts to strip our patient.  Cat is setting up suction and the ET kit and Brian is getting out a Bag-Valve-Mask (BVM) so we can breathe for her.  Cat asks for a 7.0 tube while she starts to suck the blood from the patient’s throat.  I get the ET tube and stylet set up, lay it across the patient’s neck and ask Cat how it looks, “We’ll see” is the response.  From Cat, that’s bad.  Brian is good to go with the BVM and we are starting to get some pure oxygen into her.  Everyone has a task to work on so I give the girl a quick once over and set up for IV access on her left side.  I see that she is going to have a fracture on her right ankle, and Wayne is doing good exposing her.  She has decent veins, and I reach from my 16 gauge (one of the big ones), as I talk Brian through getting her on the ECG.  Cat is going for the intubation as I am ready to go for the IV.  “Well, that’s an artery” I hear behind me.  I turn back and Wayne is standing over that fracture, and it is shooting blood back on him and the back door area.  “Let’s STOP that” I say as I reach back and grab the wound, applying direct pressure to the bleed.  Wayne reaches for a trauma dressing to get things controlled.  Damn, I really don’t have time for this I’m thinking.  I’m now stuck holding an arterial bleed on an otherwise minor fracture, knowing that Cat is likely to need a hand on the ET and that I really need to start some IV fluids going.  I have Brian come around to the back to help Wayne, and they are quickly on the bandaging.  A fireman from Quantico I’ve never seen sticks his head in the side of the unit.  “Bad luck for you buddy, get in here and do whatever she tells you.” I say to him and point at Cat.  Cat is having a tough time getting the tube.  The patient’s breathing is agonal, and she is gasping like a fish out of water with each breath.  I wish we had RSI for the millionth time.  The gasping combined with the internal bleeding is making it about impossible for Cat to keep a visualization of her vocal cords.  At least now she’ll have a set of hands to help out with.   I pull up the patient’s arm and notice that I can’t hold her wrist, it too has an open fracture.  Sigh.  The IV slips in, and I get a great flash.  Just then her arm twists in mine and pulls the IV right through the other side of her vein. Shit, the line’s blown….Hey, she’s moving…no she’s posturing…SHIT.  I notice that only her left side is moving, which is odd, but I just file that away for the moment.

Just then John, the guy off the Tower, and a former ALS certified provider sticks his head in.  I start to have him switch with the Quantico guy and help Cat, but he has to do something else outside.  I must have looked stressed.  “Hey…Breath” he says and gives me a smile.  My first thought was an indignant, “I’m not panicked yet”, but I take the mental pause, give John a wink and say, “I’m on it, I just need SOMETHING to go right here.”  John grins and is gone.  “Sorry, you’re stuck here” I say to the Quantico guy.  He’s cool with it.  Okay, change of tact.  Wayne just about has the ankle bleed under control.  I tape my blown IV attempt, wave Cat off the ET attempt and we all rotate one position around the patient.  Cat sets up for an IV on the patient’s right side, and I take over airway.  The ET is out until the flight crew shows up with RSI, but I’m a BIG believer that a lot of butt can be kicked with a solid BLS airway.  I clamp a solid seal on the BVM mask and start to sync my squeezes of the bag to her gasps.  I’m getting good compliance as long as I work with her natural efforts and I’m happy for the moment.  Cat finds nothing but lacerations on the patient’s right arm up through the A/C area where she was going for the IV, so she moves up to the bicept.  That IV goes smoothly and we suddenly have something for access and a decent handle on an airway…for now.  Cat moves to the patient’s left for more of the same.  We have a driver hop up front and we are on the way to the Landing Zone.

Being at the head I can see the entire patient and everything going on.  Since we have one IV going (an 18 gauge) I ask Cat to try with the 16 for this one.  Wayne’s bandage job seems to be doing the trick and that bleeding is controlled.  I have him double check to make sure he has a pulse in the foot…we don’t want things TOO tight.  He assures me he does and all is well.  I’m impressed with the considerable pool of blood I see between the patient’s legs and dripping on the floor…wow, they had their hands full.  There is another pool that formed from the wrist fracture, but it wasn’t arterial.  Brian gets on that and Cat quickly has the second IV in place in her left bicept.  The ECG is showing the ugly tachy rhythm that I have seen in several traumas it seems, and is running along in the 130’s to 150’s.  (She’s lost/losing blood, and her heart is racing to keep pressure up…it’s compensation, and the next step is BAD, the heart slows and down she goes).  The hematoma on her head is huge now, and Cat’s secondary assessment says that she may not have the orbital fracture on the left side, but she’s sure there is a right sided jaw fracture and dislocation to the left.  The patient’s eyes are constricted and bloodshot, more bad news…her ribs are intact, but she’s exhibiting see-saw respirations, her abdomen is becoming rigid…she’s bleeding inside too.  (The B/P machine on the lifepack gave some high BP number, but didn’t get the pulse right so we disregarded that number.)  Her pelvis was stable, and all her long bones seemed ok.  She had open left wrist and right ankle fractures, and that controlled arterial bleed.  She’s still in deep weeds, but we are suddenly ahead in the sense that we have done what we need for the flight and have a minute left to restrap her to the board and get everything secured.  Wayne raises the flight crew on the radio and we tell them to come with the RSI kit.

We get to the LZ just in time to see the chopper landing.  The flight crew hops in and gets a quick report.  They set up fast for the RSI intubation and pass on a complement on what we’ve been able to do so far.  The flight nurse has an issue with the intubation even with the paralytics and sedation, and says that the airway is covered in blood about as fast as we can suction it.  They rotate, and the flight medic gives it a try.  He is in quickly and while they work to secure the tube, I swap out an IV bag and get the patient onto their monitors.  I also manage to cut away some bracelets off the fractured wrist for transport. The four of us (Cat, the flight crew and I) are pretty busy for a few minutes getting things ready.   The crew agrees with our assessment of the patient (real bad) and passes on several complements on getting her set up.  Always nice to hear from the flight guys.  The patient is transferred to the chopper and just that fast, they are on their way.

As the guys come back with the now empty cot I see the puddle of blood that is left on the cot and turn to see a unit that is truly messed up.  I know I’ve gone through 3-4 pairs of gloves myself, Wayne has blood on his pants, I have it on my pants and shirt, and Cat has her share as well.  Brian had his bunkers on the whole time, so his uniform is spared, but the bunkers are in for a good washing.  We have a LONG cleanup coming.  The Cot is in bad shape and ultimately, back at the hospital, Cat and Brian end up all but taking it totally apart cleaning it….the mat was removed, the slings removed, the frame cleaned piece by piece, and everything hosed.  Somewhere in the mess inside was my watch which I had removed to save it from the blood….too late.  Between report writing, cleaning and restock, we get back on the road in only 2 short hours.  Cat ran home for new clothes for us and the rest of us went off to scrub Brian’s bunkers.  

Once again, I have no idea what happened to our girl.  I never got any more info.  In fact, I didn’t have her name the whole time, she had no id on her, and she clearly wasn’t talking.  Only after getting to the ER did I find out that the other folks from the car were in our local ER, and was able to ask them for her name.  We had thought that she was about 22-24 yrs old, and we found out she was 17.  So too, were the four others in her car, all in the ER.  One of the mothers of a patient was able to give me the name, and she came to a halt when she realized why I wouldn’t already know it….she had to be unconscious the entire time.  We don’t know the cause, but it appears that they had been horsing around in the car, lost control, hit an SUV head-on then swerved off the road into the trees. Again, just a guess, but it fits what was seen.  Another young life that is going to be drastically changed if not ended.  Between us on the scene, we think her odds were bad, maybe 75/25 against on survival, and in any case certainly has a lot of rehab ahead.  I’ll let you all know if I ever find out.

The Smelly Man

Recently I was reminded of a call through the winces and moans of another crew while we were at the hospital.  If the firehouse is where you bond with the other guys on your crew, then the ER and the report room is where you catch up with the rest of the EMS folks in your area.  Information on classes, gossip and “Whatcha just run” stories are exchanged as crews write reports, restock and clean units and equipment.  Often, the report room is the first line of defense for frayed nerves or emotional decompression after a tough call as well.  If nothing else, you know that everyone there, wherever they are from, are there because they just ran a call too, and they’ve been where you are, or will be someday.

I was in the report room, pulling times for my report from the computer, when an EMT from a neighboring department came in bemoaning the smell of feet that was going to be with her for a while.  I had not seen her in a while, but consider her a friend, and it wasn’t until after a hello hug that she clarified what had happened.  They had gone out to pick up a guy, from a local shelter I believe, for some benign reason or another and to hear the crew tell it, he had some of the most foul feet ever to be found on the ends of a live human.  Now I knew he was tall right away, and they quickly confirmed that he was.  Now, I’m not maligning tall people and saying they have rancid feet, this is just a deep understanding of Murphy’s role in EMS.  You see, tall people’s feet extend to, or over, the end of the cot.  This just makes sense.  So, when you are lifting them into or out of the unit, you will tend to have them brushing your chest as you do it.  And it is safe to say that for this particular EMT, that is a more likely risk than it is for say…me.  So, knowing the way Murphy owns us in EMS, clearly the more fetid the toe cheese, the more certain to be a foot-hanger as well.  So, she pulls him out of the back and gets herself a good dose of foot-jam smear on herself, insuring that that while the patient is gone, his essence remained.  She was anxious to get back to her station to change to say the least.  Now, you and I both know that Murphy’s follow-on is that this crew is about to run their butts off and won’t see the station for HOURS…and of course that is what happened to them.  I’ll admit, I heard them dispatched time and again that day, often right from the hospital and I chuckled.  I felt bad for her, but not bad enough to not enjoy the situation.

So, her plight that day reminded me of a call that our crew know simply as “Smelly man”.  I’m not sure I’ll be able to do justice to this guy in words, but if you’ve run EMS for any time, you have surely had your smelly patients, as have we.  However, given all those runs, understand that this guy is know at The Smelly Man and no other description is required.

It was a weekend duty and it was sunny and hot, a real mid-atlantic summer day where the temperature and the humidity raced each other into the 90’s every morning.  It had been that way for a few days in fact; typical for this area.  We get punched on a call for a sickness I think, maybe it went as an overdose, but it is us and the Engine from our second due.  Wayne, as always is there, and in the back I have Jen and Kelly is with me getting some medic precept time for class.  So, it was a fun group and a group of solid providers.  I was feeling good about the day.

We arrive on scene at a middle of the row townhouse and I notice a pretty good police presence right away.  This is not the best neighborhood, so that doesn’t key me up too much as we roll into the house.  There are kids in the front room and all the activity is clearly out the back.  The engine was in ahead of us and I’m getting looks that could best be described as “not good”.  It wasn’t the amped up, “uh oh” look, just a bad look I could not place…that started to concern me.  As I exited out the back door, I see several folks looking down at a Hispanic male, late 20’s I’d guess, marginally responsive laying on the cement slab at the back of the house.  There is this little shed thing attached to the back of the house, like many townhomes.  The shed is like 4’ x 4’ in size and opens to the outside patio area.  The door is open and it looks like this guy had been in there and flowed out when the door was opened.  I say ‘flowed’ because there was also a good flow of a noxious, foul liquidy stuff also flowing out of the doorway and over to where this guy is.  About this time it hits me.  There is a wall of stench that sucks the oxygen out of your lungs.  I recognize it as human waste, but there is more to it that I can’t place.  My eyes almost water and I notice the fire guys already starting to rotate from the patient to the rear of the yard for air.  The guy is kinda responding to questions, but is in a bad way, perhaps even worse than he looks is my thought.  I ask what happened and the story I get explains a lot.
     
This guy had been reported as missing to the police about 2-3 days prior, by his wife.  Turns out, he was living in the shed on a bender.  He’d been in this little hot box, drinking alcohol, drunk out of his mind and oh yeah, all he’d been eating was the Turtle Wax car wax they had stored in there.  The ooze was his two day baked urine and poo cocktail that he’d been sitting/laying in.  That was the smell: old, baked excrement, sweat and stale alcohol, box for 48-72 hrs and serve hot.  Oh man.  This was one of those times I did not want to be the medic on the call.  There was nobody else to fix this one and I just wanted to run.  It did occur to me that the lady crying just inside the door was the wife, and most likely the kids in the front room were his…nice.  At least they weren’t coming back here.  Okay, let’s just get through this and do what we can to help this nipple head.  I ask the fire guys to get the cot brought around back and they are more than happy to GO do anything.  The fire officer and I agree that we are NOT going through the house, but will take him out the back yard and around the side to the unit.  I don’t want to parade Dad past the kids like that, and he is literally dripping this ooze still and I’m not looking to leave that trail in there either.  At least I didn’t have to tell anyone to glove up on this one.  I try to get some information while the cot is coming and I’m trying to hold this guy up while I assess him.  Jen is starting to dry heave and is not going to make it.  Now the smell is repulsive, and the thing that is my personal puke-trigger is not a patient usually, but if another provider loses it, I’m in trouble.  Jen is turning green and it is going to be an issue I can tell.  

We get the cot around, pour him into it, and start to move.  On the way to the unit, the engine officer asks if we should decon him prior to loading him in the unit.  Damn Fine Idea I think to myself and agree.  I don’t want to delay his transport much as I know that the heat and alcohol alone are really bad, his level of consciousness is severely depressed and he is flat unresponsive at times and the last dude on the planet I want to have to code is this one.  (The thought of that intubation, even today, has me gagging).  I figure I can keep his head clear and on oxygen while they hose him and the time spent is going to be minimal.  I’m concerned that we are just going to create a big, wet, dripping, sloppy mess, but then I see that we have already achieved that so there is not much to lose.  (the Solution to Pollution is, after all, Dilution).  We stop just outside the ambulance, and right there in the street, in front of God and the neighbors he gets a shower from the water can off the engine.  Frankly, he could have used a few minutes under the inch and a half attack line, but I was glad for what we did.  I hoped that it would cut down the stench.  As we loaded him into the unit, I quickly learned that it was not to be.  Jen was in a really bad way and we had to send her up front for the ride.  She simply was not going to be able to stand it.  I pulled my Vick’s out of my gear pocket and spread a layer of it under my nose.  I’ve never had to do that before, and I was just hoping it worked.  We opened all the windows in the unit, turned on the blower, had Wayne and Jen open the front windows and run the fan full tilt up front to try to create a rear-ward airflow.  Jen tells me that it didn’t help, they were still feeling it up front.  

In the back Kelly and I are doing our best to do what little we can for this guy.  He’s covered in his slime, now dripping and somewhat diluted but still creating a challenge.  We towel him down some, and as I recall the little alcohol prep pads were not close to up to the job.  We ended up spraying the alcohol foam we carry on his arm for an IV site and on his chest to dry him enough for the ECG pads.  The whole time we are fighting dry heaves, at least I know I was.  I tried not to look at Kelly directly, just in case she was looking bad too.  She got her line, and his vitals were not remarkable I believe (don’t recall now, so must not have been THAT out of whack), but his heart rhythm was a bit irregular.  I think his sugar was elevated too, we didn’t give him any en route.  O2, IV, Monitor and transport…there wasn’t much else to do.  He was in a very lowered level of consciousness, but protecting his own airway.  He looked BAD, and not just from the slime he was covered in.  My gut was telling me that, smell aside, we were in a “You may die at anytime, and there is not a damn thing I can do to fend that off, just hang on to the hospital, and I hope you haven’t screwed yourself too bad” situation.  

Wayne takes off for the hospital and the breeze through the windows is welcome, but not enough.  We monitor the patient, keep taping to secure the line over a very wet and slippery patient and try to get as much fresh air as we can on the way.  I call in the report over the phone on the way and I try to give the hospital fair warning.  I get a chuckle and an Okay.  “Hear me now, believe me later” I think as we hang up.  Every couple of breaths or so I try to sniff up some of the Vicks..it helps, but only for that breath.  I hear you are supposed to lose a smell after four minutes or so…didn’t happen.  I picture this cartoonish image of the unit flying down the street, Jen hanging her head out the window like a dog getting wind, and a noxious green cloud pumping from the back and sides like we are on fire, plants wilting in our wake.

We get to the ER and Kelly and I bust out of the unit.  She dives out the back, and I shoot out the side.  We must have looked bad, because a couple of the techs and nurses sitting out side on break start laughing when they see us.  I’m sure the dry heaves didn’t help our cause much.  “Laugh it up, we’re bringing him to you.” I tell them as we recoop and start to pull him out.  They are still chuckling as the go to open the door for us.  Then we pass by them and head for the Trauma and Cardiac bays.  “Oh God….oh no” I hear one say as we pass.  Yeah, you were warned I think.  I find the charge nurse and tell her we are here,  I ask about stopping in the decon room, but she poo-poos that and sends us to a cardiac bay.  Your call lady.  We pour him over to their bed, and there are puddles waiting for us on our cot after.  The crew quickly heads out to start hosing down everything and I give report.  I see the nurse in charge here has the same dilemmas I did.  He’s bad and there is a lot that needs to be done, but he has got to be cleaned the rest of the way too.  She gets lots of help as he slips even deeper and is fully unconscious.  I give report, and go out for some fresh air on the way to the report room.

It took the better part of the day to get that smell out of my nose.  No matter how much you wash, change clothes whatever, you still smell it.  I think they did eventually decon him again in their room, I can’t imagine that they did not.  I do know that they quickly got him moved from the ER to the ICU…and that he coded in the hall on the way.  Had to figure that was possible, and it was a big concern of mine while he was with us.  His blood work was all screwed up, turns out you shouldn’t live on Turtle Wax.  He eventually made it, and so did we.  Jen works as an autopsy tech now and deals with dead people and decomps all day.  She confirmed, at the time of this writing that he is the worst smelling live person she’s ever encountered.  Some of the worst decomps beat him, but not all of them.  So, now I have a scale on which to base “Smells bad” and also one for the biggest alcohol bender.  I still carry that Vicks too, just in case.