Rude Awakening

rude

1 : Relatively undeveloped; primitive: a rude and savage land

2 : Exhibiting a marked lack of skill or precision in work: rude crafts

3 : Lacking education or knowledge; unlearned

4 : Ill-mannered; discourteous: rude behavior

5 : Abruptly and unpleasantly forceful: received a rude shock

Awak•en•ing

1 : The act of awaking, or ceasing to sleep

2 : Rousing from sleep, in a natural or a figurative sense; rousing into activity; exciting

3 : to cause to be aware of

William Shakespeare –The Tempest

Is human life just a dream, from which we never really awake, as some great thinkers claim?

We arrive at the same time as the BRT which is taking an angled position across the street to block the intersection with their rig. This provides a degree of protection from traffic. We saw the patient laying in the crosswalk, flat on his back, not moving as we drove into the intersection. He looked like a GSW victim; bloody, laid out, no movement.

Jake, our ride-along EMT student, is excited as it’s the kind of bloody mess of a call that he was hoping to get today. EMT students are required to ride in an ambulance as part of their course completion. The majority of them are here to get their certificate so they can apply to fire departments. Maybe half will go on to be working EMTs, less than a quarter of them will become Paramedics. Along the way a few will get picked up by fire departments. It’s not uncommon in this area for 3000 people to apply for a 15-person academy in a fire department so the odds are definitely against them.

Throughout the morning Jake maintains a constant monologue about the fire departments he wants to apply to, where he wants to work, and the exciting things he did in the fire academy that he went to last year. We listen to him while suppressing smirks at his naiveté. Jake quickly became disinterested in the mundane calls of the day; the old lady with weakness for three days, the Crohn’s disease patient with abdominal pain, the pregnant woman with abnormal discharge who is worried about her baby. All of them could have taken a cab to the ED, or made an appointment with their primary care physician, but that’s not what happens in this county. They call 911 because they feel entitled to immediate transport and evaluation at the ED. Anyone who doesn’t think we already have universal health care should spend a day with us and see the reality that we see every day.

My partner Brent and I exit the rig with Jake in tow and approach the patient as the fire medic is approaching from the other side. The patient seems to be a man in his thirties. I kneel down to listen for breath sounds while I’m feeling for a radial pulse; both are present but weak. The fire medic rubs up and down the patient’s sternum with his knuckles to see if he is responsive to painful stimulus; no reaction.

We start cutting off bloody clothing as one of the fire fighters is holding c-spine to prevent further injury to the neck and spine. Brent goes back to the rig to get the back board and straps. Jake is cutting up one of the pant legs. He’s never done this before and he takes slow deliberate cuts with the trauma shears. The fire medic and I strip the rest of the patient’s clothing in the time it takes Jake to do one leg.

Now that we have him stripped the injuries are obvious. Bilateral deformity to the knees, facial and head trauma in the front with matching trauma to the back of the head. The fire captain comes up after talking to some witnesses in the crowd that is growing on the sidewalk.

“Okay, per witnesses, this guy was crossing in the crosswalk when a car traveling at a high rate of speed did a hit and run. They said he went airborne and landed in the crosswalk.”

Looking down at the blood covering the white lines on the pavement I’m confused. “I don’t get it Cap, how did he get hit from the side and end up further down the same crosswalk?”

“No, he was in the other crosswalk, went airborne, and landed in this crosswalk.” Damn, that’s big air!

I stand up to see the street better; two lanes each way with a turn lane in-between. It’s at least 100 feet from crosswalk to crosswalk. That gives me an idea of the speed of the car and level of trauma that was inflicted on this guy. Given the wound pattern it appears he turned to face the car as most people do, and the bumper broke both legs. He folded face first into the hood causing the facial trauma, then was launched across the street landing on his back and causing the trauma to the back of the head on the concrete.

We get him secured to the back board and loaded into the rig. Throughout the process he hasn’t moved or reacted to anything we did — he’s completely out. We’re conscious of the time spent on scene — as this is a code-3 trauma activation we want to hold our scene time to under 10 minutes.

The fire medic looks up at me from outside the rig. “You want a rider?” I tell him yes; I have Jake in the back with me but he really can’t do much to help. I can use another medic with me. He jumps in and I tell Brent to get us out of here.

As we’re rolling towards the freeway I’m setting up my intubation kit while the fire medic is working on an IV and Jake is trying to take a blood pressure. He’s never taken a blood pressure in a moving ambulance with road and siren noise — it’s an acquired skill and he’s got to start somewhere. There’s blood in the mouth, I suction it away and insert my laryngoscope. Visualizing the vocal cords, I pass the tube into his trachea. I inflate the cuff, which secures the tube in the trachea, and attach a bag to squeeze some air in to confirm placement.

The patient, still a John Doe (JD) to us, suddenly starts moving all extremities at once and shaking his head. He’s trying to scream but there’s a tube in his throat so all that comes out is air with a fine mist of blood. I’m trying to hold his bloody head steady with one hand while holding the tube with the other hand to stop it from getting dislodged. Jake and the fire medic have their hands full holding arms and legs. It’s not a seizure — the movements are purposeful, yet unorganized. It’s the flight or fight response of an injured brain manifesting in a combative outburst. JD doesn’t mean to be combative —heck JD isn’t home right now — it’s just the autonomic part of his brain trying to do something, anything, to protect from further damage.

It takes all three of us to subdue him. I’m holding the head and tube, trying to preserve some semblance of c-spine precautions and stop the tube from being dislodged. Jake is holding his legs which are kicking even with bilateral fractures at the knees. The fire medic is using leather restraints to secure JD’s hands to the backboard.

As we’re pulling into the ED I decide to remove the tube. If JD’s moving enough air to be combative then he can breathe on his own — the ED may well re-tube him but that’s up to them. I might have sedated him but that’s contra-indicated for traumatic head injuries, not to mention I couldn’t reach the drugs while all three of us were holding him down.

We roll him into the trauma room where a team of 15 nurses and doctors is already waiting for us. It’s a teaching hospital — one of the best — so a brand new resident gets my attention and says, “You can talk to me.” I’m sure they teach the “baby docs” to say that every time. It always kind of makes me chuckle.

I give the baby doc a full report on my treatment and JD’s condition. All the while JD is screaming and flopping bloody appendages around as they pull him off the board and baby doc orders the RSI kit (rapid sequence intubation – sedate him, paralyze him, and tube him). That’s one that’s not in our protocols but it’s the only way to handle JD right now.

As I walk out to the ambulance bay I encounter a dirty look from Brent as he’s scrubbing the cabinets of the rig to get the blood off. “Sorry dude, we tried to keep it clean.” I’ll do my paperwork fast so I can get back and help with the decontamination of the rig.

While doing my paperwork I’m explaining to Jake the pathophysiology of coup-countercoup traumatic brain injuries. He’s using some wipes to to try to get the blood out of his white polo shirt. He’s not as talkative as before; the constant diatribe of his accomplishments have dwindled to a morose silence. I don’t think he’ll be one to work as an EMT or go on to be a Paramedic. The reality of our mundane calls interspersed with the insane call isn’t for everyone. I suspect he’ll continue testing for the Fire Department and given the odds that may not work out the way he expects.

I finish my paperwork and head back to the rig to help with the decontamination.

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~ by KC on August 3, 2010.

4 Responses to “Rude Awakening”

  1. Excellent story KC. Did the guy recover?

    • Hi Mike, this is one of the things that took me a while to get used to in Para-medicine; I don’t always find out the outcome of the patients I take to the emergency department. For the next week I was in a different part of the county and I didn’t make it back to that ED and wasn’t able to do a follow up on that patient. I assume he didn’t have a good outcome but I really have no idea if he recovered or not. My inclination is that he didn’t. But I really have no idea. It’s a strange concept to come to terms with; I do the best I can for a patient and turn them over to the proper facility and hope for the best. In reality I’m off to the next call and seldom look back. I like to do follow up if I’m given a chance and happen to be in the same city the next day, and the same nurses/MD’s are on shift, but that’s not always possible. I’ve had to come to peace with the fact that I did the best I could at the time and got the patient to the appropriate facility to deal with their problem. It’s an interesting exercise in compartmentalization of responsibility.

  2. cool story

    • Thanks ‘Fox, I do what I can. I tell what I see and that makes me feel better. Sometimes it’s good, sometimes it’s bad, but that’s life. I just happen to be there when IT happens.

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