Unethical Decision Making

I was having a conversation with my partner today, telling “war” stories to one another when the topic of fatality MVAs came up. We are both in our 20s and have only a few years experience under us—we’re too young to have seen the really bad days of traffic accidents. We were reminded of an accident that we were both on, Spring Break a couple of years ago. For my medic partner and me (an EMT at the time) it was our second fatality of the day.

We were dispatched onto the beach at 11 pm for a rollover accident with injuries. There was a fog over the beach and a heavy March chill. The accident itself was a mile or so down of the beach access and we made our bearing on the lights of the fire units near the surf line.

As we approached, we could see a battered, black Toyota pickup in the surf, being rocked by waves. The rear doors of the fire department’s rescue unit was open and we could see 2 patient’s on the bench seat, and a third on the deck on a back board. We parked, positioning our scene lights on the pickup some 100 feet away in the surf. The firemen were crashing around in the surf, working on pulling another patient onto a backboard. With each wave, the pickup would shift a little more and the tide was coming in. Each wave was lapping against the tires of our ambulance.

Six firefighters, with a backboard and patient slung between them, were fast walking up the ambulance as we opened up the rear doors of the unit. The patient was lifeless, arms limp and dangling off of the board, gray in the face and soaking wet. We hoisted him up onto the gurney, expecting to get to work on him, but when he was slid forward, head resting near the airway seat and under the fluorescent lights, it was easy to see.

“He’s got brain matter showing. Get him out of my ambulance,” my partner told the firemen. He was pulseless and apneic, a clear DBA now that we could properly assess him.

***

The other three—the patient’s brother and their girlfriends—we took to the hospital as mandatory trauma system entries (death of a same vehicle occupant). It turns out that all four of them were crammed into the front seats of the pickup and as the truck rolled, the patient had his head roll out the open passenger side window. The driver and the two girls were relatively uninjured in the accident and alcohol appeared to be a factor. Two ambulances took all three to the area trauma hospital.

The State Police arrived at the hospital to investigate the accident. We had to hang around the hospital to do the criminal blood draws, so we got to see this all go down. The trooper made his way from patient to patient, starting with the two women. The questions the trooper asked were all the same, “what happened?” “How much have you had to drink?” “Were you wearing your seatbelts?”

Finally, he makes his way to the driver’s room. The trooper had enough of the details before even starting his questions. He knew that the passenger had died--he’d seen the body on scene. And he knew the driver and passenger were family. The driver didn’t know. When he was asking questions about his brother on scene, we deflected. “There are lots of ambulances here, another crew is with him.” “We taking care of you right now, there are others taking care of your brother.” But we knew.

So when the trooper walked into the driver’s room and the patient saw him, the first question he asked the trooper was, “how’s my brother?”

Without a pause, the trooper answers. “Your brother’s fine, he’s at another hospital. I have some questions for you.”

***

Our partner and I, plus the nurses in the ED all had the same knee-jerk reaction. What the hell was this trooper doing? He was outright lying to this man. His brother was dead and the trooper knew it, but he was being told he was okay and at another hospital.

Unethical, right? The trooper thought he was going to get better answer out of the driver if he though that his brother was okay. But does that justify such a horrendous lie? I don’t think so, and neither did my partner or the nurses. And as my partner and I talked about it today, we were reminded again about how upset we were two years ago about this.

But it does beg the question, is it unethical to deflect those tough questions on the scene? Is it okay to tell a family member that there loved ones, who we know to be DBAs, that they are being looked after by other crewmembers?

New Years Eve, 2005

It was a Saturday evening and I had only been working in the company full time for 6 months. I was partnered with a new paramedic because I was “a strong EMT,” as my boss put it, “someone who can keep an eye on her.” She was green, but so was I, and in that way we kind of balanced each other.

Around midnight, we were dispatched to a person fallen through the roof of a downtown highrise. The buildings occupied a whole city block; an old hotel, an office building, and the old city hall. Five and six story buildings, separate, but all interconnected in strange ways. There were abandoned, condemned, and used mainly by squatters and vagrants.

We pulled up to the block, police were on scene already, so were the fire guys, both the paid and volunteer boys. My partner and I grabbed our kit and a flashlight and climbed up the front steps of the reported building. We climbed up dust covered stairs, old newspapers and trash scattered about, ascending towards the roof. I pictured walking into a room and looking up, seeing a pair of legs dangling from a hold in the ceiling.

We were met by a cop on the third floor, telling us he’d met with the reporting party and that an 18 year old had fallen into some kind of pit on the roof. We hustle up the roof access, looking across rooftops towards where a teenager is waving us over. He’s on the next building over, with a roof one story lower than we’re already on. My partner and I, followed by the fireman, make our way over to the roof edge, then clamber down to the next building using the pipes and ductwork.

We followed the teen to the edge of this building, where a ten foot wide, narrow pit separated this roof from the next. He told us he and his friend were screwing around on the roof when his friend tripped into the pit. Shining our light down, we could see another teen looking up from four stories below. He was propped in the corner of the pit, sitting in stagnant water up to his waist. He was awake and alert, but said he could move his legs.

The firemen were at our side now, and we began discussing options; setting up the ladder truck and an elaborate rope rescue sounded like the most fun. But as we examined the pit, we could see the walls were lined by the windows from the hotel we had just come up. Telling the kid to hold tight, we headed back inside.

More firemen had brought up our back board and had found the hotel room closest to the pit. The small, square window in the kitchen opened into the narrow trench between these buildings, and we could see the teen at the far end. The pit stunk, full of standing rain water, trash, and the carcasses of dead birds. All of us—the firemen, cops, and my partner and I—looked at each other, asking the question who’s going out there? And while it made the most sense for the firemen with their water proof boots and bunker pants, it was my partner and I, along with two cops, who rolled up and pant legs and waded into the knee deep fetid water.

Our backboard we floated towards the teen between us as we slogged the 30 feet towards him. The water was cold and most likely very, very unhygienic. The teen, Jay, was shivering when we got to him, with back pain, and the inability to move his legs.

We had already activated the trauma system for limb paralysis, and now we were trying to be as gentle as possible as we packaged him. My partner and I talked the cops through floating the board under the teen as we picked him up, then we strapped him in well enough to half float, half carry him out to the tiny hotel room. We passed him through to the firemen still waiting in the hotel room, and continued packaging Jay in the dark.

The evening was just starting to warm up, though.

We were still packaging Jay when we were dispatched to shots fired, possible GSW in the next town over. Our other units were busy taking other calls all over the county and we had a trauma system, paralysis patient to take care of. With cops lighting our way down the creaking grand staircase of this old hotel, we hustled to our ambulance and loaded Jay inside.

He was hypothermic, having been unable to get himself out of the water for over an hour, he had no sensation or motion in his legs, and he was lethargic. I was working on base line vitals while my partner was working on IVs, when we were dispatched to our 2nd pending 911 call, a bar fight downtown with injuries. “Screw it,” my partner told me, “lets go.”

We were only 12 blocks from the hospital and it was time for just quick patient turnovers and turnarounds. Rescue was already responding to the shooting, and now the fire guys who were giving us a hand with Jay were on their way to the bar fight a few blocks away.

I’m sure that when my partner and I rolled into the ER, we looked quite comical—both of us were leaving a trail of dirty, wet boot prints, our pant legs were still rolled up to our knees, and we were making that slurp-slurp sound with each step we took.
I had taken my uniform sweatshirt off and was only in a white t-shirt with a backwards-turned company cap. I know I looked like a fool.

We tried to be as quick as we could with the turnover, letting the staff know about the pending calls and to expect more patients. Our turnaround I was proud of, phenomenally fast considering. We rolled down our pants legs and set out he door. As it turns out though, the GSW was an unable to locate and the bar fight was some guy that pissed off the wrong person and took a punch to the face. He was fine, of course—only some hurt pride. Jay, as it turns out, wasn’t paralyzed. Just really, really cold and weak.

My boots however, didn’t fare so well. They weren’t water proof and became water logged. And oh my god, the smell. Even after soaking in a tub of disinfectant and bleach for 8 hours, the smell still wouldn’t go away. My boots didn’t survive the night of New Years Eve, 2005.

Decimation and Shock

A plane crashed into a beachfront home 4 blocks from my house this morning.

I was in the shower, getting ready for work when I felt something shake the house. Initially, I thought that Boomer had knocked something over upstairs—we have thin floors and walls and little things often sound very big. But Meghan began knocking on the bathroom door when I turned the shower off and I knew something wasn’t right.

“Was there an earthquake?” she asks.

“No, I don’t think so.”

“Well, I heard a loud bang, the house shook, and then I heard a lot of sirens.”

“Probably just a bad car wreck, then, “ I reply. We’re only a couple blocks from the highway, and right behind the Gearhart fire station. “Let me get dressed and I’ll turn the radio on.”

Half dressed in my uniform, hair still wet, and plodding out of the bathroom in my crocs, I turn my portable radio on.

“… 3148 responding to Gearhart.”

“48 from Command, come straight in to the scene. We’re gonna need your elevated stream.”

I’m a little disappointed at hearing this, I’m missing another fire because of work. “Just a big fire,” I tell my wife. “Probably some type of construction accident.” We’ve had those before, explosions, BLEVEs, and the rare natural gas leak gone boom. I tell her it’s no big deal, to go back to bed.

But I dress a little quicker now, I’m thinking I’ll swing by the fire station on the way into work and see how things are going. I’m half listening to the radio as I button up my uniform shirt. I start to hear third alarm units going on the air, engine and ladder companies coming in from the other side of the county.

Then I hear it—

“…Medcomm, Medic 4. Fire reports three burn patients. Requesting a second ambulance.”

Shit. I’m at high speed now, grabbing my boots, cell phone, work vest, and ball hat. I kiss my wife quickly and tell her I’m going to head up to the scene and lend a hand until the second unit arrives.

I drive two blocks west and park on Marion, out of the way of incoming fire and police vehicles. Three blocks down, I see flames shooting above the trees, grey-brown smoke rolling upwards, and what remains of a house, laying on its foundation.

I grab my stethoscope and head off at a dead sprint up the road. All of town is out here to see what’s going on: couples in pajamas, or early risers out walking their dogs. Police haven’t even set up a perimeter yet. I jog up to the command officer as firefighters are pulling lines around me. The ladder from 3148 is up and they’re getting ready to flow water on the flaming pile of debris.

“Joey, where do you need me?” He points another half block up where the Medic unit is parked. I see three people lying on the ground, covered up to the necks with blankets, with bystanders all around them. I see one of our company EMTs. “Who’s in charge?”

It’s one of our new paramedics that he points to, and she looks a little overwhelmed. “Michelle, what can I do to help you?” Right away she starts giving instructions. She plans on taking the first two patients—children—and the next arriving Medic unit can take the mother. She needs my help to get them packaged and loaded, but first she wants me to find out if the Air Ambulance was activated from Portland.

I phone dispatch, letting them know I’m on scene, and then check on the air unit. The dispatcher, a little ruffled sounding, copies that I’m on scene, but tells me she doesn’t know if the chopper's in the air. I let Michelle know and we begin to load our first patient, a young boy. His hair is singed, his legs are blistered, and his feet are cut. He tells me he had to jump from the roof.

He looked like the pictures from the text book: covered with soot, with blackened hair, and lips that were just starting to puff. But he was amazingly calm. He followed our directions, said please when he asked us for something and followed that with thank you. He was concerned about his family and my heart was going out to him. I sat with him while the cot was readied. I introduced myself, talked to him a little bit, tried to offer a comforting, older brother kind of smile. And when we loaded him into the unit and I told him that Michelle would take care of him, he almost cried. “You’re not coming with me?”

“No, I can’t. There’s others I need to help. But Michelle will take good care of you, I promise.”

Behind me, and all around me, more fire units are arriving on scene. An additional ladder company from further south, additional engines from north county. Additional chief units are also arriving and they start coordinating defensive operations. The primary house is destroyed, collapsed to its foundation, with heavy fire rolling from the debris pile. The fire has partially engulfed the neighboring homes, and the chiefs set to work on the exposure protection.

Above all of this though, I hear a father yelling, “there’s still three kids inside!” He’s standing over Michelle and I and the young boy. He’s crying, tearing at his hair, hysterical, and I feel for him. He was staying in another house, further down the block when the explosion occurred. He has no idea what’s going on, he’s only concerned about his family.

The scene is a mess. Neighbors had been the ones to render first aid to the three patients, getting them to lie down then covering them with cool blankets and bath towels. The neighbors stayed with each patient until they were loaded into each of the ambulances.

Our second Medic unit arrived, as well as the OppsChief. The MCI protocol was activated, in some ways because he was expecting three more patients. I helped to get Michelle loaded with the second child, then gave them the best directions to get themselves out of the scene that was quickly bogging down with fire apparatus. The second medic unit had their patient loaded and was pulling around now, too. The OppsChief wanted me to stay on scene with him, at least until a third unit arrived to provide standby coverage.

Scene tape was going up now as the Sherrifs worked to control and move the crowds back. The OppsChief and I turned our backs to them and walked towards the command post. I took the time now to really study the scene. Something big had happened here, enough to literally blow the house apart. Glass had been blown into and across the street. The roof of the garage, still completely intact, had been blown up, then landed upright. Walls had been blown out, and debris piled the center of the house. The back side of the house was obscured by smoke and steam.

I watched the firefighters work hoselines through the debris pile. The ladder pipe was raining down a gentle fog. Steam was billowing out through the burned out home next door. I listed to the radio chatter as additional companies arrived and received assignments or were told to stage. Trauma Intervention Counselors were requested to the scene for the family members. I was watching all of this, wishing I was in my fire turnouts, not by white button down, when I heard the OppsChief ask, “so the plane came in from the west?”

I interrupt. “Wait, what plane?”

The command officer looks at me, dumbfounded like I should already know this. “A plane crashed right into the house.”

Holy shit. I was shocked and in disbelief. A plane? I couldn’t figure out how this was possible. It had come in from the west, over the beach, and that didn’t make any sense. This was the only house hit in the impact, and that didn’t make any sense either.

Bystanders had reported seeing the plane come in very low, strike a tree, then crash into the house. A secondary explosion, the one the shook my house, occurred just moments after the initial impact. Upon really inspecting the scene, a plane door was leaning against a tree in the front yard.

Oh my god. Three kids are dead, and three more are critical because a plane crashed into their house.

The house was decimated like nothing I’d ever seen before. And as I looked around at the firemen on scene, really looked at them, I could see the same look of shock, horror, frustration, and sadness that I knew was on my face. Three kids dead in an instant from a plane that had crashed into their house.

*****

I still had to go into work and the OppsChief cleared me from the scene as the third medic unit arrived. I went home, hugged and kissed my wife, cuddled my dog for a few minutes, then grabbed my day bag and headed out the door. It was going to be a busy morning.

My first assignment coming on shift was to transport one of the burn patients from the trauma hospital to the air station, and transfer them to an air ambulance crew for her trip to the burn center.

Both children had been taken to the same hospital and both were in relatively the same condition. They both had extensive first and second degree burns, both had been sedated and intubated in the ER (to protect their airways and provide for their comfort). My patient, whom I’d seen at the scene, looked far worse than when I’d last seen her. Blisters had formed all over her face, and her skin was starting to swell. Patches on her arms were sloughing off and we had to be careful as we moved her. She was transferred to my gurney, then quickly transported to the air station where the helicopter crew was waiting for us.

We turned the patient over, then returned to the ER where the nurses there told us what a fantastic job that our crews did. All the typical high-fiving and back slapping that goes on after a “good call.” But I can’t get the image of the kids’ faces out of my mind. I just can’t believe how destroyed this family is now, how such a freak accident has decimated their lives. All I want to do right now is go home and hug my wife.

*****

This was written the evening following these events (8/4/08), however I could not post this until today. Numerous news stations covered the accident and a report can be found here.

Shaky Hands, A Follow Up

The ER doctor at Providence pulled me aside today after I'd dropped
off a fall patient. He wanted to tell me what a good job I had done
with Wendy. "You saved her life," he told me.

They had trouble placing the chest tube and had to make a second
attempt at it. By the time the tube was placed though, all the air in
her chest cavity had already vented out the needle. "Without the
decompression, she would have died in the ER," he told me.

I have never felt better about being a paramedic.

Shaky Hands, Part 3

Shaky Hands, Part 1
Shaky Hands, Part 2

For the next two seconds, I internally panic. I honestly think the only thing that didn't stop me in my tracks was that we were wheeling Wendy out to the ambulance. I second guess myself. Maybe she didn't have a pneumo. Maybe my needle placement was wrong. Maybe I should have been more aggressive up front. I debated whether or not I should intubate her. RSI would take too long. We're two miles from the hospital. Finally, I think back to the paperwork the med-aid handed me and that Wendy was very clearly a DNR patient. What will I do if she arrests? Will it be because of something I did or didn't do?

My internal conflict is over by the time we reached the back doors of the unit. I outlin my hasty plan to my partner. "Set me up a BVM. I'm gonna take one more listen to her left side, then I'll assist her on the way in. We don't have the time to intubate her. Let's just get going."

I put my ears on as my partner whips out the BVM. Terese, one of our Basics that's working an extra shift with me, moves swiftly in the ambulance, securing the equipment for travel and setting up the BVM. I listen to Wendy, no improvement in her lung sounds, but as I watch her breath, her work of breathing seems to have eased some.

"Wendy?" I ask. "Does your breathing feel any easier?" She looked up at me, desperation and fear in her eyes, and shakes her head no. She still can't talk, but at least now she's responding again to my questions. My tension eases, ever so slightly.

My partner is up front now. She places the ambulance in drive then flips on the lights and we start transporting. My hands are still shaking and now that I'm sitting in the airway seat, my legs have started to shake, too. Another nervous response of mine, both my knees are pumping up and down rapidly as I bounce my heels off the deck of the ambulance. I'm trying to take deep breaths, to be calm and cool, but it's not working well.

I have the BVM over Wendy's nose and mouth, her eyes are pleading up at me to help her. He jaw is so narrow and slight that I can't make a proper seal. Even in my attempt to assist her breathing, I can't seem to do it right. I'm forced to supplement her rapid breaths with puffs from the bag. I try to coach her, "breath in with me on three. 1, 2, 3... 1, 2, 3..." God I wish I could do more, I think. My hands are busy, so I tell my partner to give a report to the hospital when we're only 60 seconds out. The ER staff doesn't like it, but I can't effect how close the care centers are to the hospitals.

Terese unloads the cot by herself while I try to hold the bag in place over Wendy's face. We roll her through the ambulance bay doors and into the ER bay. The ER doc doesn't look happy to see us. The ER is full and they've had to clear a bed in a rush for my patient. The doc is smirking at us as we roll in, a tired, haggard and almost hateful smile. I can see it in her face, why the hell did you bring me this?

I should have taken another deep breath before starting my report, but the words just started tumbling out of my mouth. I couldn't even make sense of what I was saying and the nurses had to stop me a few times to clarify a point or ask me a question. I was ashamed as I take pride in having good turn over reports. The RT has arrived now and has taken over bagging the patient. Wendy is more alert now, tracking movement and responding to stimuli. Her work of breathing has improved considerably, but she still can't talk. I leave her side, slowly being pushed to the back of the bay as nurses and techs step in to assume care. The ER doc, standing at the back of the bay turns to me. "Why did you decompress her?"

Away from the patient's side, away from the immediacy of her care, I'm able to take a deep breath and calm myself. The doctor can see the stress in my face, the sweat on my brow, and gives me a knowing smile as I start over from the beginning. Eventually, I get to where I can answer her question, "I decompressed her because she could no longer breath adequately, her lungs sounds on the left had disappeared, she became lethargic, and subcutaneous emphysema developed all in less than 10 minutes. I did it because she needed it and I thought it was the right thing do to."

The doctor looked at me for a few long moments, then gave a knowing and reassuring smile. "Okay," she said then continued with her assessment. The doctor would later tell me that she now faced her own dilemma: whether to place a chest tube in this elderly woman with a DNR and send her to specialized care in Portland, or keep her under observation at Providence's own ICU where she would receive a lower standard of care, but be closer to home and adhere more closely to her DNR.

I now had paperwork to complete, demographic information to collect, and an ambulance to put back in service. But I was awash with emotions and couldn't focus too well. I was still anxious and nervous about whether I'd done the right thing, I was tired physically and emotionally exhausted, and I was excited and enthusiastic--I'd never done a needle decompression before and now I had a story to tell.

During the next 30 minutes while my partner and I attended to our tasks, I would poke my head into Wendy's ER bay. She was on a nasal cannula now with oxygen sats at 100%. Her heart rate and respirations were down. Her work of breathing had greatly improved. But best of all, her look of fear and desperation had disappeared. She was anxious, I could tell, but she knew she was being taken care of.

My partner and I returned to quarters after collecting my paperwork. I wrote my chart and had dinner while we waited for the night car to start its shift. I felt that I had done good work. My partner told me how impressed she was with me, that she knew I was one of the few medics in the company that would have decompressed her. She felt like we truly made a difference in the patient's outcome. With the shakiness gone, the anxiety and adrenaline subsided, I had to agree. "We did good work," I told her, shaky hands or not.

Wendy went to Portland with Medic 7 roughly 4 hours after arriving in the ER. She was diagnosed with a tension pneumothorax and subcutaneous emphysema extending along her entire left side and up into the left side of her neck. Her outcome, beyond that of being stable when she left Providence hospital, is unknown.

Shaky Hands, Part 2

Shaky Hands, Part 1

I like to think that I'm a good paramedic. Now, that's not to say that I'm cocky or overconfident. But I have had fellow paramedics, coworkers, and firemen tell me that I do a good job, that I always remain cool and calm, and that I always seem to know what to do. Sheepishly, I'll say thank you as I blush a little and turn away. I know that a lot of what they're seeing is the show that I'm putting up for everyone else's benefit. "Act like you know what you're doing, even if you don't," my Basic instructor always told me.

Having spent time in the field as a Basic and an Intermediate before becoming a Medic, I knew how scenes were supposed to go. I knew how to form a treatment protocol into a treatment plan in the field. I knew the operations side of things--how to run the equipment, talk on the radio, and give reports. I knew how to conduct patient interviews, how to interact with the firemen, doctors and nurses. I like to think that I had a pretty good handle on things when I was done with medic school and had a brand new patch on my shoulder.

My very first call as a medic straightened me right out.

I've been a medic for less than a year. If I take a shift off and have a long weekend, I come back to work nervous about how I'm going to do. There are still lots of skills that I've never performed and lots more than I've only done once or twice. There's plenty of calls that I've never had, lots of treatment protocols that I've never used in real life. And every time one of those calls comes up, my hands shake a little.

Wendy is now on my gurney now, barely breathing, barely conscious, and unable to speak. My heart rate, blood pressure, and respirations are up as my adrenaline starts to kick in. Using one hand to dig out a 14 gauge catheter from the house bag, I grab my portable radio with the other.

"Fire dispatch, medic 4." No response.

I'm feeling for the landmarks on Wendy's left chest, thinking back to the text book. Second intercostal space, mid-clavicular line. I notice that my hand is shaking as I press my fingers into the void space. I'm also thinking holy shit, I've never done this before.

"Fire dispatch, medic 4." I need a fire EMT to ride into the hospital in case she becomes apneic or arrests. As it is, I'm already thinking I'll be assisting her or RSI-ing her on the way in. Fire Comm can't hear me though, my partner and I are on our own.

I open the orange catheter pouch as the med-aid asks me what I'm about to do. My hands are still shaking as I bring the needle to the patient's chest. I start to rattle off a text book answer and she gets wide eyed as she realizes I'm about to stab this little old lady. My partner has been feverishly working to get the patient strapped to the gurney, on high-flow oxygen, and on the heart monitor.

I apply slight pressure to the needle and I'm in... and that's it. That's not right I'm thinking. That's not how the book said it would go. There was no pop, or hiss, or woosh of air. No sigh of great relief from the patient. There was no hitting the rib and sliding over like you're taught. There was no muscle mass to strain against, the needle just went right in, almost on its own before I could stop it. With the catheter sticking there, like a little flag planted in her chest, I prop it up with gauze, hastily repack the house kit and start fast walking Wendy to the ambulance. The problem is, she's not getting any better.

Oh fuck has now become oh holy fuck, now what?

to be continued...

Shaky Hands, Part 1

"Medic 4, code 3, Sandy Beaches Retirement for a fall."

Damn it, I'm thinking. I was deeply involved with Guitar Hero: On Tour at this point and did not want to be disturbed. This had better be important. It was my second fall patient at a care home this shift. I pull my ballcap on, slide on my eye protection and head out to the unit. My partner is waiting and puts us in route, "medic 4 responding."

We're two minutes away, not even worth the code 3 trip. We pull into the round-about drive at the front door and let the ambulance idle as we grab our equipment. I stuff the narcs pouch into my vest pocket, thinking I'd rather have it with me than to have to send my partner back out for it. We grag the house bag, toss it on the cot and roll inside.

A staff member meets us, one of the med-aids. "She's been on the bathroom floor for maybe a half hour. She was calling for help up until we found her."

I nod, then enter the apartment. From the door, I can hear the patient's raspy, quick breathing. Well, that's doesn't sound good. I introduce myself to the patient as I carefully step around her, kneeling by her side. She tells me her name is Wendy and that she fell when she got up off the toilet. Her breathing is fast and shallow. She's writhing in pain, and winces every time she moves. There's no blood, no visible trauma, which I'm thinking is a good thing.

I ask her if she's having a hard time breathing. "Yes." I ask her about her pain, and she points to her left flank, locating just below the rib cage. "10/10," she rates it without hesitation. I lift up her sweater and exam: no paradoxical movement, no crepitus, no subcutaneous emphysema, but her lung sounds are diminished on the left.

A lot of things are running through my head at this point: how to package her, how to medicate her, the possibility of a pulmonary contusion, a developing pneumothorax, the need to needle decompress or intubate. I want to relieve her pain before we begin to move her and I need to balance my scene time with the amount of care I need to do.

I have no working room, the bathroom is cramped and I'm squeezed between the toilet and trash can. We have to get her into the living room and on our cot to work on her properly. She denies neck or back pain, or a loss of consciousness so we forgo immobilizing her. I send my partner down to the rig for our megamover, then quickly start an IV and give her 1mg dilaudid. She's talking less now, in shorter sentences, and now I'm thinking I should enter her into the trauma system.

My partner arrives with the megamover and we roll her onto her right side to position it. While she's up, I feel her back and note subcutaneous emphysema along her entire left back. Her lung sounds on her left are so distant they're non-existent. I must have had an oh shit look on my face, but I calmly inform my partner that she has sub-q emphysema and that it's time to go. We roll her onto the megamover and she doesn't even wince at the pain. Her eyes are drooping, she's not talking anymore, and her respirations are 40 plus.

Oh shit has turned into oh fuck.

to be continued...

Helmet Education--The Traumatic Way

I'm a pretty big proponent of bicycle helmets, and motorcycle helmets for that matter. I've taken enough bad spills off of a bike to know what a helmet can do for you. One wreck in particular split my bike helmet completely in half, I'm sure it saved me from a serious head injury that day. Nothing pisses me off more than to see some 8 or 10 year old riding their little BMX bike around without a helmet, or worse, with the helmet on but the chin strap not clipped.

Two weeks ago, my partner and I ran a vehicle versus bicycle on the main highway through town. The location was on a little bridge at the north wye, it was 35 mph (which meant most people went 40-45), and the bridge was narrow with high sidewalks on either side. Locals would crab or fish off of the bridge and there was always plenty of pedestrian traffic.

As we approached, traffic was stopped in all directions, always a bad sign. Worse, a group of bystanders were crouched in the middle of the highway, waving us in. From experience, it's always bad when the bicyclist is still lying in the roadway when you arrive. He was prone, a small amount of blood around his head from a laceration we could see from the unit. But he was moving, frantically, and wouldn't hold still.

There was road rash to his back and flanks. He'd landed on his messenger bag that was slung around him, protecting his front side. Obviously, he hadn't been wearing his helmet. The driver that hit him said he'd just turned into traffic, then the car hit him and he was thrown up onto the car before rolling to the ground. Bystanders verified the story, as did the giant dent and spidering of the windshield on the driver's car. The kid's bike was pretty bent up, too.

We rolled the kid onto the backboard and it was then I recognized him. He was a local, someone everyone in town knew. Maybe not by name, but by face at least. He had a slight developmental disability and was always seen riding his bike around town, though never with a helmet. Numerous times, I'd seen him dart into traffic without looking, acting like he owned the road. And most times, I was expecting him to get hit.

He was asking repetitive questions, had a positive loss of consciousness, and was uncooperative, whether from the DD or the head injury, we didn't know. We put him into the trauma system which meant a 20 minute drive to the trauma center. Packaging the patient was rough as he wouldn't cooperate, but we did it quickly, had him loaded, and were on our way. Vitals were taken, IVs were started, oxygen was applied, and an ECG was obtained. All was normal.

We were met by the trauma team, nurses and doctors done up in paper gowns. Other specialists had arrived from the golf course or from their on-call day at home, wearing jeans or khakis. It's always an interesting collection of doctors and specialists that come together at the arrival of a level 1 trauma. The patient was calm and cooperative by this point, and no other injuries were found other than the superficial ones.

The kid was held at the trauma hospital overnight for observation and presumably released the next day with the addition of a few stitches.

Funny thing is, I was driving into town yesterday, and here was the kid riding along on a new bike. This time though, he had on a bright, shiny new red helmet.

My Tolerance

I said it before a couple months back, I have zero tolerance for drunks. In the county I'm in, it doesn't take long for someone to get drunk and stupid and require emergency services.

I responded with fire a few nights ago for a vehicle into a power pole, with secondary reports of lines down and arcing. The first arriving captain gave a size up as a power pole down and blocking the roadway, one vehicle off the road. The Rescue unit I was on was directed to loop around to the backside of the scene to control traffic, and as the paramedic on the Rescue, I was told to come up and evaluate the patient.

The accident occurred on a back road, at a wye intersection and from where the Rescue parked, I had to slog through a mud patch. Approaching the older model Ford pickup, I notice that he center punched the power pole and did a significant amount of damage to the front end of his truck. The pole was down, 50 yards behind him and sheered off at ground level. Power lines were drooping just 10 feet off of the ground over our heads. The driver was still in the pickup as I approached and my captain is telling me he doesn't want to go to the hospital, but he wants me to evaluate him anyways.

No problem I'm thinking. I'll ask a few quick questions, then cancel the ambulance crew so they can get back to bed. I approach the vehicle and first I notice the strong smell of alcohol coming from the cab of the truck.

"What happened, sir?" I ask.

"I hit a power pole."

"I see that. Are you hurt?"

"No." He responds.

"Does you neck hurt?"

He shakes his head no.

"How about your back?"

Again he responds, "no."

Finally the question "how much have you had to drink tonight?"

"Nothing." Not the unexpected response given the circumstances.

"Well sir," I respond back, "I can smell the alcohol. So you've either been drinking or there is an open container in your truck. Now, I'll ask you again, how much have you had to drink tonight?"

"A couple of beers." He was still lying, but not as blatantly. It seems every drunk I've ever been on has only been "a couple of beers."

At this point, my tolerance for this particular drunk has reached zero and I ask the question, "now sir, why did you lie to me just then?"

"Why wouldn't I?" he shoots right back.

Our conversation continues and he refuses transport, but at this time the ambulance crew has arrived, so I let the paramedic have a go at convincing him to be transported. The interview continues with more questions and I ask the driver, "I see where your truck is at and where the power pole is at. How fast do you think you were going?"

Without hesitation he answers "sixty." Never mind that the speed limit on this road is 30 and that he was defiantly going much faster than 60. The truck had center punched the pole and sheered it off at the ground. The truck was going fast enough that there was no secondary impact of the pole into the cab of the truck, no other damage at all in fact.

I'm keeping an eye on the driver during this conversation and it's now that he exits his truck to take a look at the damage. He looks around at the scene and his truck and the only thing he can say is, "my truck. Look what I did to my truck."

As politely as I can, I remind the driver how lucky he is that he didn't seriously injure himself or someone else. He didn't get it though, he was focused on his jacked up truck. I got the impression from the police officers that he was a repeat offender for this sort of thing, and given his behavior, I could believe it.

We cleared the scene as the officers were giving the driver a field sobriety test, of which he could hardly even keep upright to pass. Again, I had proven to myself that my zero tolerance for drunks was well deserved.

My Relief

I live in a small town, part of a small county. I know most of the firemen and EMTs in the county by first name. I'm familiar with dozens of frequent patients, care center staff members, and nurses. Because of the closeness of it all, I've also run calls on family members and friends.

I've run on my uncle when he had a massive heart attack, I took my brother to Portland for an appendicitis, I've been on friends of my wife and parents, and just last shift, I transported my sister in law.

I was on the phone with my mom last shift while my mom and dad were driving back from Portland over highway 26. We had to cut our conversation short because cell phone reception tends to cut in and out over the pass. About 10 minutes after hanging up, my partner and I are dispatched to an MVA on highway 26 at milepost 26, a very common milepost for accidents. Now, it took a moment or two, but then I realized that milepost 26 would be right where my parents would have been.

Code 3 out to accident, I couldn't shake the terrible feeling in the pit of my stomach that I would be seeing my parent's crumpled car off the side of the road. I thought about terrible scenarios like having to intubate my own mother. I prayed the entire drive out that the size-up we'd get from fire would be a positive on. One vehicle, two injuries is all that we heard.

We rounded the last corner approaching the scene, numerous fire and police cars parked along the shoulder, next to a steep embankment. We slowed to park and I saw my parent's car parked on the shoulder between a state police cruiser and a rescue truck, but it didn't look damaged. Still, I was fearing the worst. The firemen had two patients c-spined on the shoulder of the road, but I couldn't see the patients because the firemen were crowding around them. I placed us on scene, then exited the ambulance and approached the commanding officer.

He began giving my a brief report as I surveyed the scene. There were skid marks on the highway, crossing both lanes. I saw flashlights a hundred feet down the embankment where a car had landed. Then I start looking over towards the patients and I see a familiar white haired head suddenly look up, a stethoscope draped around his neck. There was my dad, a First Responder with Seaside, directing patient care. The relief that I immediately felt took over completely and for a few moments, I wasn't even listening to the firefighter. But I recovered quickly and went to work on the patients.

Looking over to the second patient, there was my mom, no medical training whatsoever but wearing a pair of medical gloves and holding c-spine on the second patient. Relief again as I walked over, touched mom gently on the shoulder to let her know I was there, then continued to work. We transported both patients, minor injuries that had self extricated from the vehicle, back to Providence Seaside.

I talked to my dad the next day and he told me they came across the accident just minutes after it occurred, before police or fire had arrived. He always carries a small jump kit in his car and he grabbed it and went to work assessing patients. He said when he turned, my mom had a pair of gloves on and was asking how she could help. Right then, I couldn't have been more proud of my mom and dad, or more relieved that they were okay.

My second biggest fear in this job is running a call on family member or friend (my first biggest fear is not being able to find the address). I live in such a small place that there is no paramedic back-up, no one to take over when I find myself caring for a loved one. It's a difficult thing and one of the things that makes working in a small system so unique.

What I Get for Taking Vacation

It's been a hell of a week. I took a shift off on Tuesday to spend a few days away with my wife celebrating our 4th anniversary. I paid for it though, before and after.

The shift before my anni-vacation, my partner and I ran 5 calls before noon. One of which required cardioversion for SVT after two unsuccessful rounds of adenosine. In the middle of all this, dispatch is paging us that there are return medivans waiting at providence ER. We made three round trips to Portland that shift.

I had to paralyze and intubate a stroke patient while nervously waiting for additional personnel from rescue. We took him to Portland on a vent.

Upon returning from my anni-vacation, I had a first ever experience as a patient went from a 3rd degree block to cardiac arrest in front of me. I was setting up an oxygen mask and not looking at teh patient when a fireman said "I think he just went out on you!"

"No he didn't." I replied as I double checked the monitor leads (one of them had fallen off). It was then the patient went from pale to purple in 10 seconds. Fuck I thought.

"Code 99." My partner calls into the radio. Immediately this is followed by the FTO sitting at post "Medcom from Medic 3, does 1 need our assistance?"

In the middle of applying defib pads, setting up for the intubation, and IV, I grab the handset. "Negative 3, fire is already on scene." I don't need another medic to drive 15 minutes from post to 'assist' me on a code when I'll be off scene in less than 10. (I have a problem with second ambulances responding as "back up," something I'll rant about later.)

That shift was rounded out with a transfer for gall stones at midnight. Something I truly considered a valuable use of my emergency medical skills.

Today, it continued with a trauma system entry from the memory ward at one of the local adult care facility. The patient fell outside and was in the rain for 10-20 minutes before the caretakers found him. He had a huge hematoma on the back of his head and was supposedly altered from his normal state of dementia. Turns out he had a subdural bleed as was a trauma transfer 30 minutes after arriving at the hospital.

And this afternoon, I took my second vent transfer of the week, an acute MI with complications. I just took a vacation, but really, I need another one.

My First Lesson

As a new paramedic, I feel pretty fortunate. My company has a tendency to put new medics into the field with little field training time and this is apparent in the quality of the paramedics that work for us. I had a month of FTO time before I was put on my own, which was more than most and very welcomed. I finished my field internship in July of last year, which means that from July until when I tested in August, then received my certifications in September, I hadn't practiced as a medic. I needed the field time with a senior medic to re familiarize myself with the skill set. I started in October as the senior tech on the ambulance; we staff an ALS transported ambulance with one paramedic (the senior tech) and an EMT-Basic (the junior tech).

My first call as a paramedic was a gunshot wound to the chest. Now, I live in a small community with virtually no violent crime and virtually no firearm related accidents. As an EMT, when you hear of a gunshot wound you immediately get pumped up; you're thinking about blood, guts, and carnage, which is what our EMT training was all about. As the paramedic, the guy ultimately responsible for the patient and your crew, I was thinking about our safety and trying to put together a treatment plan.

But I was nervous. This was my first call and up until this point, the only gunshot wound I'd ever been to was a through-and-through to someone's leg. I'd never dealt with anything this potentially life threatening on my own before and I was a little scared.

The first arriving sheriff's deputy advised us by radio that this was a confirmed GSW to the chest, but that it was a hunting accident and safe for us to approach the scene. The patient was in the back of an SUV, having been brought down from the woods by friends, and was not in good shape when I approached him. He was hurt, but he was conscious.

So I started communicating my plan right away to my partner, the firemen, and the sheriff's deputies. I then went back to the ambulance to give a preliminary radio report to the hospital and activate the trauma team. It was at this time that I learned possibly my most important lesson (so far) about being a paramedic. When I returned to the patient to see the progress made in moving him from the SUV to the ambulance, nothing had been done. So I communicated by plan again, which at this point was simply get him on a backboard and into my ambulance.

Still nothing happened; the firemen seemed to have their own idea about what to do. So I communicated my plan again, punctuated by a "now!" It was no that the fire chief turned to me, told me to calm down, and that they were working on it. Now, if there is one sure fire way to piss me off, it's to tell me to "calm down," and the sheriff's deputy saw it. He turned to me and said, "I know. I'll take care of it." And he did. Within the next two minutes, the patient was on the board, in the ambulance, and we were transporting.

It was a short trip, less than 10 minutes, and I had my hands full starting IVs, getting him onto the heart monitor, oxygen, and checking for other injuries. We arrived at the hospital, turned over the patient to the trauma team, and then I went to go have a conversation with the fire chief. He started immediately apologizing and said "I thought your partner was the paramedic." In other words, he thought my EMT partner was the one in charge and had told his firemen to listen to my partner, not me.

So now, whatever call I'm on, I always start with, "hello, my name's Jeramy and I'll be the paramedic taking care of you." And you know what, I've never had a problem of mistaken patient care responsibility since.