Archive for the ‘Trauma’ Category

Sep
0


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Strike Out 2/2

Strike Out 2/2

We’re driving in the middle of the city after having just stopped at Starbucks to grab some caffeinated motivation for the day ahead of us. It was a long night yesterday as I was on the SWAT standby for an hour past my regular off-duty time. After the anti-climactic end to the situation I was able to go home and almost got enough sleep to make it through the next day. The hot coffee in my hand is helping to fortify my resolve as the morning commuters are exiting the freeway and the busy urban downtown area starts to come to life.

My coffee-inspired day dreams are interrupted by the computer on the console as it gets toned out and a call location drops almost on top of the icon representing our ambulance. The dispatcher comes up and tells us we have a patient with a laceration at the city police department on the second floor in the interrogation rooms. I’m actually looking right at the city police department building as the disembodied voice of the dispatcher is giving me the call information.

We pull up to the front doors as I load the gurney with all of my equipment and bid farewell to my warm coffee. I know we’ll be up on the second floor and the interrogation rooms are quite a ways on the other side of the building. Coming back to the rig for a Band-Aid could take a long time so it’s best to just take everything with us on the first trip.

A detective is waiting for us and proves to be a decent escort through the maze of the police intake and booking area as we make our way back to the interrogation rooms. The detectives aren’t really saying much but I can read their body language enough to know that something bad happened.

The detective opens the door to the little room and I’m faced with a complete blood bath. The tiny room looks like a set piece for the TV show Dexter with blood spatter covering the walls, desk, and floor. There’s a man sitting at the table with his hands cuffed to a metal ring on the desktop. Under his hands there is a fresh pool of blood.

I turn to the detective. “What the hell happened?” This is obviously the kind of high profile situation where Internal Affairs will get involved because someone messed up really badly. That explains why the officers were being so quiet and not telling me anything. The less I know about the facts the better it is for everyone when the investigation finally gets going.

The detective has a quiet voice as he fills me in. “So, did you hear about the hostage situation last night? Well, this is the perp from that scene. We had him in the room all night waiting for the morning shift detectives to come on duty. He asked for a soda. Someone gave him a can of Coke. He drank it, tore it in half, and cut his wrists with the sharp edges. We found him like this an hour later.”

“Wow!” That’s all I can say. I mean really, this is such a jacked up situation on so many levels I just don’t know where to start. The officers know how bad this is and they really don’t need the Paramedic to point out the sequence of stupidity that led to this bloody outcome. Whatever, I’m not here to judge, I’m just here to clean up the mess, as usual. But seriously, paper cups might be a good idea.

The man at the table hasn’t moved since I entered the bloody room but I can tell it’s the same man I talked to last night through the bars of the police cruiser. “Hey, are you okay?” Fine, it’s a stupid question but I have to start somewhere.

“Fuck you!” Seriously, are we going to play this game again?

Last night I could walk away from this guy based on the fact that he wasn’t visibly injured and refused all assessment. Today I can’t do it. I’ve got to check his wounds, bandage up what I find, and get him over to the hospital for medical clearance. He will eventually return here and be put on suicide watch.

I’m in the interrogation room and my partner, Anna, is handing me supplies to clean him up a little so I can see how bad the cuts are. As it turns out he missed the artery and all of the blood is just slow trickle stuff from the veins. He’s going to need some sutures and he’ll have some very impressive scars in a month or so when it all heals. Regardless of his medical outcome he just accomplished his third strike last night. He’ll be seeing the inside of a prison for the rest of his life, whether or not he manages to end his life a little early.

Three Strikes Laws are statutes enacted by state governments in the United States which mandates state courts to impose life sentences on persons convicted of three or more serious criminal offenses. In most jurisdictions, only crimes at the felony level qualify as serious offenses and typically the defendant is given the possibility of parole with their life sentence. These statutes became very popular in the 1990s. Twenty-four states have some form of habitual offender laws.

The name comes from baseball, where a batter is permitted two strikes before striking out on the third.

The three strikes law significantly increases the prison sentences of persons convicted of a felony who have been previously convicted of two or more violent crimes or serious felonies, and limits the ability of these offenders to receive a punishment other than a life sentence. Violent and serious felonies are specifically listed in state laws. Violent offenses include murder, robbery of a residence in which a deadly or dangerous weapon is used, rape and other sex offenses; serious offenses include the same offenses defined as violent offenses, but also include other crimes such as burglary of a residence and assault with intent to commit a robbery or murder.


Sep
0


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Strike Out 1/2

Strike Out 1/2

strike

1 -  to try to hit or attack something

2 – Baseball; a pitched ball judged good but missed or not swung at, three of which cause a batter to be out

3 – Collective refusal by employees to work under the conditions set by the employer, a work stoppage

4 – to be unsuccessful in trying to do something

 

out

1 – to a finish or conclusion; the game played out

2 – a means of escape; The window was my only out

3 – used in two-way radio communication to indicate that a transmission is complete and no reply is expected

As the car passes the officer he recognizes the driver as a known felon. They’ve been briefed on this guy – armed and dangerous, two strikes down in a three strike state, gang affiliations with narcotic distribution. The plates on the car come back as stolen and the officer calls for backup before attempting a felony traffic stop. The man in the car knows that he’s been made so he speeds up, trying to outrun the officers. Every officer in this part of the city starts to converge on his location. When he finds himself boxed in he exits the car and starts shooting at the officers in their cars as he runs down the quiet neighborhood street. Seeing another officer blocking his escape route, he realizes that he’s trapped. He makes an abrupt turn and runs up to the nearest house. One kick to the front door and he makes entry into someone’s home. The officers hear screams as he takes a few hostages and yells threats through an open window. The officers surround the house but pull back as they initiate a SWAT call-out for a hostage situation.

The Bear Cat rolls past me and slowly drives up the street to park in front of the house where the suspect has barricaded himself. The six SWAT officers in the armored truck are positioned to report on any changes in the house and they will be used as a rapid reaction force if the suspect does something stupid like killing a hostage. Their job is to hold the scene at a forward position and react as needed to buy the rest of the team some time to formulate a plan.

From my vantage point in the incident command center I can see the SWAT commander setting up his game plan: floor plan of the house on a white board, arrows showing expected direction of attack, frequent radio communication and the occasional cell phone call. The SWAT snipers, dressed in woodland camouflage, begin the long and solitary walk to disappear into the neighborhood, with Remington-700 Police Sniper Rifles slung on their backs and a M4 duty weapons slung in the front. They quickly vanish from sight, undoubtedly taking up overwatch positions from rooftops a few streets away.

The SWAT Medic that is embedded with the team comes up to my rig and we make a game plan on various extrication scenarios and transport options. We’ll work under force protection protocols and enter the warm zone if necessary to initiate prompt treatment and extrication of wounded. If the suspect decides to force the officers into shooting him I’ll go in afterwards and make a field pronouncement. If he’s really stupid and starts shooting the hostages I’ll handle the initial triage and treatment while my partner calls for the appropriate number of units for transport. I’ll utilize the SWAT members to help extricate victims to the curb for the responding units to transport to the hospital.

The police helicopter finally shows up and starts doing lazy orbits of the house from 800 feet in the air. The pilot has the FLIR (forward looking infrared) turned on the house so he can see any movement. It’s sharp enough to pick up a hand on a window and discern our uniforms with the patches on the shoulders or the characteristic lack of heat signature where the ballistic vest insulates the torso. Unfortunately it’s not sharp enough to pinpoint heat signatures in the house. By now the snipers are in their overwatch position and I hear their quiet radio transmissions as they report on activities in the house as seen in their magnified scopes atop the rifles.

The rest of the SWAT officers start showing up to the command center that was hastily carved out of this quiet street in the middle of the hood. Their duffle bags of gear have been laid out like dominoes on the sidewalk. Officers who drove their personal vehicles into the hood stroll up to the duffle bags and begin their transformation from average citizen to door kicking SWAT officers. Black uniforms, heavy ballistic body armor, communication ear buds placed under headphones, and finally weapons loaded and made ready. The SWAT commander walks around to the troops showing a picture of the suspect as they prepare for the final showdown.

Whoomp! Whoomp! Whoomp! The continued noise of the forty-millimeter grenade launcher has been rhythmically pounding the house with tear gas for the last ten minutes. They systematically hit the house room by room – filling the interior with gas – until they have the suspect and hostages pushed to a back bedroom where there is no escape. I count 35 gas grenades before it finally goes silent.

The SWAT officers – who have collectively just heard a dispatch on the radio – turn in unison to walk down the street towards the house for the final assault. The K9 officer falls in with them and someone grabs a Halligan tool for door breaching. I’m going over scenarios in my head for possible outcomes in the next few minutes. I may end up with more patients than I can handle, with trauma that I can’t fix here on the streets. I could end up with wounded SWAT officers or a dead suspect or a random bystander shot in the mix. Maybe an officer twists his ankle on entry or gets a dog bite while going through back yards or a sniper falls off of a roof. Hell, anything could happen, I’ll just have to wait here and deal with the consequences as they come.

The tear gas grenades have been quiet for fifteen minutes now and the bulk of the SWAT officers turned the corner towards the house ten minutes ago – it’s been quiet since then. Out of the darkness from the direction of the house comes a lone patrol car backing slowly towards my rig. The officer steps out and walks up to my window. “Hey, we’ve got the suspect here, can you check him out real quick before we take him downtown?” Really, just like that and it’s over?

I walk around the back of the police cruiser to the back window which is rolled down. I can see a man in his mid-30s, hands cuffed behind his back, calmly siting in the back seat. I can talk to him through the bars on the back window. “Hey, are you hurt?”

“Fuck you!” Not exactly the response I was looking for but okay I guess it’s something.

“Did you get taken down hard or is the tear gas hurting your eyes?” It’s not the first medical assessment I’ve done through the bars of the back of a police cruiser.

“I said FUCK YOU!” Maybe I’m just asking the wrong questions.

“Are you saying that you don’t want any help from the Paramedics and you just want me to go away?” I think they call that a leading question.

“No, I don’t want anything from you. FUCK YOU!” Okay then. Somewhat of a limited vocabulary but he’s made his wishes quite clear.

I stand up from the window and address the officer who has been standing by waiting for me to complete my medical assessment. “He’s all yours.”

 

 

Jun
0


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Field of Honor 2/2

Field of Honor 2/2

To the fire lieutenant as we’re loading up the ambulance, “Can you please call PD and have the poor steed put out of its misery?”

He laughs as he’s closing the rear doors to the ambulance, “I was thinking a mechanic might be more appropriate.”

I tell my partner we can start transporting and since it’s a fairly non-emergent call I’m chatting with my patient as I double check all of his vitals.

“Seriously, Segway polo? When did you start playing that?” I’m still having a hard time not laughing at the whole spectacle of the last few minutes. All of the participants were pale skinned, greasy haired, tech workers, looking like they just escaped from the cubicle jungle for a few hours of sunshine. Or possibly their employer kicks them out at lunch to prevent the workforce from succumbing to a vitamin D deficiency. My patient is a little older and has the look of a middle management office worker who was trying to keep up with the younger guys and inadvertently took a spill.

Segway polo is similar to horse polo, except that instead of playing on horseback, each player rides a Segway PT on the field. The rules have been adapted from bicycle polo and horse polo.

“We’ve been playing for maybe a year now. There’s a company that sponsors the event and they deliver the Segways to the park every Friday. We’ve had a pretty solid group of guys for a while now so we’re thinking of setting up a match against another company.”

I put the capnography nasal cannula on him to track his quality of breathing. Given his body style – tall and thin – I want to keep an eye out for the possibility of developing a tension pneumothorax. I can see that he is in a significant amount of pain by the waveform and the shallow tachypnea that I’m seeing on the monitor.

The Segway Polo world championship is the Woz Challenge Cup, sponsored by Steve Wozniak of Apple Computer. The first match was played in 2006 when the Silicon Valley Aftershocks played the New Zealand Pole Blacks in Auckland, New Zealand. The result was a 2-2 tie.

I start an IV and administer some Morphine to reduce the pain level a bit. After a few minutes I can see it’s working as the respiration waveform on the capnography monitor is starting to elongate to a normal shape. My patient eases back into the gurney in a more relaxed position as I turn the lights out and move to the chair behind his head so I can tap away at my computer to document the strange events of the last few minutes.

The spectacle of the Segway Polo players sticks in my head not so much as an oddity yet more as a somewhat sad evolution of a noble and practical sport – the sport of kings has beed usurped by the nerds. At one time the elite military horsemen of kingdoms would compete against each other to hone skills for warcraft. Now, with the advances in technology making personal conveyance machines more practical and the global economic woes making horse ownership less practical, the original sport is in rapid decline as the anachronistic adaptation gains traction.

The whole episode makes me think of other areas of warcraft that have evolved over the centuries. At one time a skilled archer would put countless hours into honing his skills with the bow in the hopes of defending his homeland from invasion and putting dinner on the table. Today any random gang-banger sticks a Glock out the window of a moving car and indiscriminately takes a life with the pull of a trigger finger.

Ultimately, the whole episode makes me just a little sad – not so much for this individual episode of life gone wrong – yet more so for the social commentary that can be extrapolated from my overall observations of the evolution of our society.

My patient did in fact have separated cartilage in two ribs and a hair-line fracture on one rib. He was sent home a few hours later with instructions to limit physical activity for a few weeks and a prescription for pain medication.

His trusty steed, the Segway, made a full recovery after a tune up by the mechanic. 

 

 

Apr
0


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Field of Honor 1/2

Field of Honor 1/2

field of hon·or

1 – a scene of a duel

2 – a region where a battle is being, or has been, fought

3 – the scene of the final battle between the kings of the earth at the end of the world

Polo strategy on hitting: Get your hand high for a long shot. Hit through the ball. Keep your arm straight until it passes forward and above the shoulder. Give yourself space hitting the ball – not too close to the horse. Take your time on the ball. Ride your horse before your hit the ball. Set your horse up for the shot.

Jamie Le Hardy – Polo Champion

He lays in the field of battle next to his trusty steed, writhing in pain and struggling to breathe; diaphragm spasming to the point that the lungs can’t function. Other combatants stand around him swaying in the awkward forward and backwards rocking motion that is unique to their mode of transportation. His polo mallet lays nestled in the grass next to him after causing the accident. His steed lies nearly lifeless just a few feet further away.

The origins of Polo date back to the 5th century BC in Persia where elite calvary units of the king’s guard used the game as simulated horseback battle.

As I walk up to the players on the polo field they canter away in their awkward little leaning motions to give me more room to inspect my new patient. We arrived with the fire fighters so our little entourage is trudging across the field while we carry bags and push a gurney to the crumpled man in the middle of the “field of honor.”

As with any injury of this nature one of my first concerns are the integrity of the neck and the neuro-function of the extremities. I run my patient through the battery of simple neurological tests while one of the other polo players recounts the events leading up to the injury.

Sultan Qutb-ud-din Aibak, the Turkish Emperor of North India, ruled as an emperor for only four years, from 1206 to 1210. He died accidentally in 1210 playing polo.

“Jim was shuffling the ball towards the goal and one of the defenders started to crowd him. It was totally legal and everything, he was just defending. So Jim went to score and took a big wind up with the mallet. When he took the shot his mallet got caught in the undercarriage of his mount and he got thrown. He didn’t pass out or anything but it looked like he couldn’t breathe so we called you guys.”

After all the neuro tests come back with no issues I sit Jim up and assess for any obvious abrasions, bruising, or swelling that would indicate a problem. Nothing really looks out of place until I encircle his rib cage with my hands and have him take a big breath. Jim practically jumps out of his skin with painful sensations shooting from his flank to the middle of his back. A closer inspection shows that the ribs are stable enough but it’s very likely that he separated some of the cartilage where the ribs connect to the spine. It’s not a critical injury but it’s worthy of some x-rays and sign-off by a doctor. Once I listen to his lungs I’m satisfied that the injury is probably localized to the ribs and not involving a collapsed lung – I’m ready to transport. I’m just worried about his poor steed laying in the grass, barely moving, with pitiful whimpering noises coming in small gasps.

To the fire lieutenant as we’re loading up the ambulance, “Can you please call PD and have the poor steed put out of his misery.”

Military officers imported the game of polo to Britain in the 1860s. The establishment of polo clubs throughout England and western Europe followed after the formal codification of rules.

 

 

Feb
0


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Flight of Fancy Postscript

Flight of Fancy Postscript

post·script

1 – a note, paragraph, etc. added to the end of a letter or at the end of a book, speech, etc. as an afterthought or to give supplementary information

Three days after leaving my mostly urban county by helicopter the young man in question was extubated and regained consciousness with no lasting deficits. The trauma surgeons in my county trauma center made the right call in sending him to the specialists at University Hospital. And, as much as I may have some misgivings about the use of an air ambulance in an urban setting, I believe it was the right choice of transportation.

Most forward thinkers in the pre-hospital setting are fairly skeptical of the use of helicopters for all but the extended transport times in rural settings. A flight time of twenty minutes can easily be extended to over an hour when all factors are taken into consideration; travel time to the scene, landing and unloading, assessment and loading the patient, landing and unloading the patient at the hospital. In many cases where the benefit may be minimal the right answer is to drive the patient and get to definitive care faster.

In this case I believe the use of the helicopter was warranted given the time of day and general unstable nature of the patient. In the midst of morning rush hour the normal drive time of 48 minutes would be extended to nearly two hours even with the use of Code-3 lights and siren. The geographical choke points of bridges and waterways create near gridlock traffic situations where an ambulance literally has no place to push the traffic out of the way.

It’s easy to get jaded in a busy urban environment like this. My initial impression of this escapade was that of skeptical acquiescence. The decisions about where and how this patient is transported are very far beyond my control once the doctors put things into motion. It’s also easy to lose a little bit of feeling or caring for someone who intentionally put themself in danger to satisfy the cravings of an addiction. Violence and trips to the ED are unfortunate byproducts of the environment for people who engage in this lifestyle. Just as a Paramedic may have very little sympathy for an injured drunk driver – we may have the same lack of compassion for someone who intentionally drives into the hood at four in the morning to score drugs. As a byproduct of their misadventure lives are put at risk while driving Code-3 and flying helicopters in a very busy airspace. That is a risk we will take when an innocent life is on the line yet it’s hard to justify when we are put in that position by someone’s poor choice of lifestyle.

Yet my impression of this patient changed a few days later when an officer involved in this case told me that the patient had bounty hunter credentials on him at the time of the shooting. Was he actually trying to clean up the streets rather than contributing to the problems in the hood? I don’t know, I will likely never know, but it does serve to remind me that it is not our job to judge people. We are here to fix who we can, keep them alive as long as we can, and deliver them to definitive care with all haste. That’s what it is to be a Paramedic.

 

 

Feb
0


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Flight of Fancy

Flight of Fancy

flight

1 – a swift passage or movement

2 – the motion of an object in or through a medium

3 – the action or process of flying through the air; a bullet in flight

 

fan·cy

1 – not plain; ornamented or complicated

2 – requiring skill to perform; intricate

3 – the power to conceive and represent decorative and novel imagery

 

flight of fancy

1 – an idea which shows a lot of imagination but which is not practical

The back doors to the helicopter swing open to expose a passenger compartment where a flight RN sits in a jump seat and kicks a metal sled, loaded with medical bags, towards me. The sled slides free of the helicopter and we ease it onto our gurney and strap it down with seat belts. Pushing the gurney across the mostly empty tarmac of the airport my partner and I load it into the ambulance as the two flight RNs jump in the back. I take a seat in the front to help my partner navigate to the trauma center.

The morning rush hour traffic has the freeways reduced to parking lot status and the side roads are only marginally better yet it’s our best bet so it takes both of our attention on a constant vigil – on the lookout for the motorists who forget what to do when sirens come up behind them.

We pull into the Big City trauma hospital and I jump out to back my partner into the closest parking spot next to the door. As I stand behind a backing rig, annoying beeping sound assaulting my ears, the ER attending doc approaches me. We have had a cordial familiarity over the years.

“Why’d they send you guys? The patient is on a vent and five drips!” He knows I can’t transport a patient like this as we don’t have a drip machine or vents and I’m not authorized to transport someone who is likely on medications that are outside of my scope of practice.

“It’s okay,” I smile, “I brought a flight crew of RNs with me.” He looks a little surprised as two crimson jump-suited RNs fling open the back doors to my rig and jump out.

The flight crew is getting a history on the patient who’s laying in the trauma bay as my partner and I hang back – we’re pretty much sherpas on this call – we’ll leave all of the patient care to them. While they get up to speed on the patient my partner and I talk to a few of the trauma RNs and police officers that we know.

“So what’s a clean-cut white boy like this this doing in the hood at four in the morning?” It’s somewhat of a rhetorical question and I can’t even ask the question with a straight face. The most obvious answer is that it was a drug deal gone bad. At least that’s what everyone involved is thinking until proven otherwise.

The officer looks tired; I’m thinking he got held over to stay with the victim in case he wakes up and has anything to say. The kid has two chest tubes in him, he’s on a vent with a breathing tube, he’s got milky white paralytics slowly dripping into his veins; he’s not going to wake up for a long time – if he ever does. “We’re not sure what was going on. We just found him in the driver’s seat of a car that had a slow speed crash into a line of parked cars. When we checked on him we saw the GSW to the chest and called you guys.”

I’m in the back with the flight crew as we traverse the urban streets back to the airport. My partner is in the front alone and the siren and air horn are singing a duet in an effort to clear the way.

The kid’s blood pressure just bottomed out to 70/46 and his end tidal carbon dioxide level just spiked to 76. The flight crew are scrambling to reduce the paralytics and increase the vaso-constriction – yet not so much that he bleeds out faster. The bullet created a perforation to the esophagus and a tear in the aorta that’s creating a slow leak of blood into the thoracic cavity. The blood from this leak is constantly being suctioned by the two chest tubes attached to active suction. Drugs are pushed into IV tubing, IV pumps are re-set with new values – it’s a delicate balance between sustainable vitals and faster bleed out. The only thing that will fix this kid is the specialized thoracic microvascular surgery found at the university hospital. Even the attending trauma surgeons at our world class trauma center decided to pass on the surgery. This kid is well beyond critical.

When the paralytics were decreased his level of mentation starts to increase along with his blood pressure. He starts to choke on the tube – we call it bucking the tube. His eyes look as though they’re coming into focus. One of the flight crew pulls a preload of sedative out of his jumpsuit, makes a quick calculation in his head, wastes some of the sedative so that it’s proportioned to the patient’s weight, and injects it into an IV port. Ten seconds later the patient is back in his comatose state and his blood pressure is at a good level for the next phase of transport. Another unit of whole blood is pulled from the biohazard cooler and added to the many lines of tubing that are keeping this kid alive.

Driving across the tarmac we pass the parked airplanes and helicopters. It’s still early in the morning and there’s not a lot of action on this lazy midweek day in the quiet corner of the airport. We see the crimson helicopter with the pilot doing a pre-flight walk around as he opens the back doors to accept our patient.

After loading the patient into the helicopter one of the RNs is thanking us for the ride. “Hey, do me a favor, stick around until we get in the air. You know, just in case he codes… Thanks.”

BIG CITY, USA — It’s been an especially violent week in Big City. Police are investigating a string of shootings in different parts of the city, believed to be unrelated.

Unfortunately, gun violence is nothing new in Big City, but there has been an increase over the last couple of days and officers are doing everything they can to keep up. Big City police are stretched thin as they investigate five separate shootings in just 12 hours.

“It’s been a busy week. I think we had at least three homicides last week and then one… I know at least one working today,” said Big City Officer Jason Smith.

One shooting happened Thursday morning at First and Union streets as a high school student was riding his bike to school. He was shot by someone who was also on a bike. Crime technicians were delayed two hours getting to the scene.

“There were two other callouts this morning so that’s where we’re at,” said Smith.

One of those earlier calls took police to Lake Street near 23rd, just a few miles away. That’s where a man with a gunshot wound was found inside a crashed car.

“It has been busy. We’re doing the best we can with what we got and we handle each case. And ultimately our goal is to solve every case we get,” said Smith.

Three shootings happened on Thursday and two happened Wednesday night. It’s violence that doesn’t go unnoticed.

“It’s been a little intense here in Big City for the past couple nights,” said Jose Martinez.

Martinez works with youth at the Sojourner Center for Human Rights.

“We work directly with those young people who are involved to try to figure out what’s happening here and how we can create lasting peace,” said Martinez.

He says it will be the community coming together to create lasting change.

“What’s happening here doesn’t have to be and there’s a better way to solve our problems,” said Martinez.

He also says a bullet never solved any problem.

 

 

Oct
2


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Ghost Rider

Ghost Rider

ghost

1 : any faint shadowy semblance; an unsubstantial image; a phantom; a glimmering; as, not a ghost of a chance; the ghost of an idea

2 : the disembodied soul; the soul or spirit of a deceased person; a spirit appearing after death; an apparition; a specter

3 : to die; to expire

rid·er

1 : someone who rides on an animal such as a horse, or on a vehicle such as a bicycle or motorcycle

2 : a supplementary clause or amendment added to a legislative bill, insurance policy, or legal document

As a rule, the more bizarre a thing is the less mysterious it proves to be. It is your commonplace, featureless crimes which are really puzzling, just as a commonplace face is the most difficult to identify.

Sir Arthur Conan Doyle – Sherlock Holmes – “The Red Headed League”

I walk into the small eight-by-eight foot room with a single empty desk pushed up against the wall. Two men with guns strapped to their waists follow me in and sit down in the Spartan chairs to either side of the desk. Obviously the chair left for me is the “hot seat.” I don’t see a spotlight shining on the chair but there’s no mistaking the fact that this is an interrogation room and the men with the guns and badges have some questions for me today.

“Let the record show that Detective Jones and Detective Brown are present with Paramedic KC. Today is one, one, eleven at 1500. Paramedic KC, do you recognize this man?” He slides a picture across the table to me – actually it’s a mug shot with lines showing height behind a perturbed looking man facing the camera.

“Yes sir. He was my patient three weeks ago.” I’m starting to wonder if this is the time when I should ask for a lawyer. At least they didn’t read me my Mirada rights. I wonder if that’s a good thing or a bad thing. Either way it’s obvious that the conversation is being recorded by the way that they are verbally describing the occupants of this very uncomfortable room.

“Can you sign here please? This acknowledges that you recognize the person in the photograph and that he was your patient on the date written below.” OH CRAP! This is starting to sound serious…

“So, the man in that picture passed away three days ago and we’re looking into the cause as a possible homicide. Can you describe the circumstances in which you met this man and what transpired during the time you were with him?”

— 

Medic-40, copy Code-3 for the man who fell of his bicycle three days ago.” The radio crackles to life interrupting the enjoyment of my afternoon quad-espresso over ice.

“Medic-40 copy, we’re en-route.” Kevin flicks the lights on and chirps the siren to enter traffic headed in the direction of the call. Seriously? Code-3 for a three day old bike accident?

As we pull up to the Church’s Chicken I see a man sitting on a bench by the door with three firefighters standing around him. The guy has to be 450 pounds and from the rig I can see that he’s interacting so he’s probably okay. “Let’s leave the gurney in the rig and see if this guy can walk.”

“Exactly what I was just thinking.” Kevin and I are on the same page. Lifting a man that size on a gurney is a group effort and anything to avoid injuring ourselves is a good thing. Classic, a fat man sitting in front of Church’s, who would have thought…?

As I’m getting out of the rig the man stands up with the firefighters and starts to lumber towards us. Awesome, he walks!

Once he’s situated on the gurney, in the back of the rig with me, I start asking questions as Kevin starts entering information into the computer. It’s not exactly a stat call so we have time to sit here and do an assessment prior to rolling to the ED.

“Okay, so I understand you fell off of your bicycle three days ago. Why are you calling us today?” I’m taking a blood pressure and getting him hooked up to the monitor while I ask questions.

“Cuz it just kep gettin’ worser so I has to get checked out.” He’s pleasant enough and almost seems apologetic for having to call us. It’s a normal occurrence for us; people with no insurance put off going to the clinic as long as they can and then call 911 to get treated in the Emergency Department.

“What got worse?”

“All this swelling in my face. This ain’t normal for me.” I wiggle past him to the foot of the gurney so I can see his face straight on. Sure enough – now that I look at him straight on I see that his face isn’t symmetrical – his jaw and cheek are swollen on the right side.

“Yep, that’s swollen all right. So this all happened in the last three days?” He nods his head and it looks like it hurts him just to do that. “Okay, let me feel your jaw.” I put my hands on either side of his mandible and he opens and closes his mouth, wincing in pain as he does it. No clicking that I can feel and the jaw seems solid – probably not broken – but it’s hard to say with all the fat and swelling deforming the normal jaw lines. I pull out my flashlight and look inside his mouth and I’m met with a putrid smell and green/yellow puss on the right side. Yikes!

“Looks like you got a pretty bad infection in there.” The infected teeth and the vitals that I got are starting to add up to a pretty sick guy, quite possibly a lot worse than he looks.

“I got bad teeth, you know, don’t go to the dentist all that much. I think when I got hit they got knocked loose a little. Then I start spitting that yellow stuff today so I called you.” Fair enough, but hold up…

“You got hit? I thought you fell off of your bicycle.” I’m having a very hard time picturing this man on a bicycle. I’ve gone to calls for a lot of bicycle accidents and I can’t remember anyone being over 200 pounds, much less 450.

“Yeah, you know, when I hit the ground.” Okay have it your way. I check out the side of his face with my flashlight and don’t see any road rash or bruising – just inflamed swelling and a bit of redness.

Either way, the damage is done, and all I can do is treat what’s in front of me so I start transporting him to the ED while I look over his fat skin in hopes of finding a vein for an IV. His heart rate is in the 130s and respirations of 32 with an end tidal carbon dioxide of 23. The temporal thermometer comes back with a fever of 101.7. Everything is adding up to sepsis but it’s still a little early so he’s not going into shock yet. At the ED they’ll drop a few liters of fluid on him and start some IV antibiotics. They’ll take x-rays of the jaw to see if the infection has progressed to the bone – if so he’s in for some pretty painful surgery. I can get the process started now and see about taking the edge off of the pain.

I crack open an ice pack and have him hold it to his jaw as I thread a 22 gauge catheter into the only vein I can find – in his knuckle. It’s too small to get very much fluid on board during my short trip to the ED but I leave it wide open just to start the process as I break open the morphine vial.

He’s a big guy so I’m sure he can take as much morphine as I’d be allowed to give him so I’m surprised as we’re pulling up to the ED he tells me that his 10/10 jaw pain is now a 0/10. Awesome! At least I did something for him.

As we push him into the ED a triage nurse that I don’t recognize is taking my report. “Fell off his bike three days ago? You can take him to the lobby.” There’s a nursing strike right now and this woman has a thick southern accent – she probably just flew in to help staff the hospital and isn’t too familiar with how we do things in this county.

“Yeah, can’t do it. I started an IV and gave him fifteen of morphine. If he’s not septic yet he will be in a few hours.” Sorry if I’m inconveniencing you by actually treating patients…

“You did what? Oh fine! Give him Hall-6.”

My last memory of him is sitting in the corner of the ED as he thanked me and waved goodbye.

“So you never saw a bicycle at the Church’s Chicken?” Detective Brown has been taking notes while Detective Jones asks some follow-up questions.

“No, didn’t see any bicycle. He said it happened three days ago so it didn’t surprise me not to see one. I still can’t picture a man his size on a bicycle but that’s what he said.”

“Anyone standing around him when you arrived?”

“Just the firefighters.”

“Okay, KC, I think that’s about all the questions we have for you. We appreciate you coming in.” What, that’s it?

“Can I ask what happened? I mean, why a homicide investigation?”

“Well, we’re still trying to figure out what exactly happened. I can tell you that he was treated at the ED and ultimately transferred to University Hospital for surgery to clean up an infected jaw. He eventually died at that facility from the injury. There were no medical malpractice issues but the cause of the injury is suspect so we’re looking into it.”


Oct
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Necromancy Revisited 2/2

Walking through the door I fight the adrenaline-induced tunnel vision. As team lead it’s my job to keep the big picture in sight and not focus on the minutia. I have four EMTs following my lead as we make it into the lobby. My boots make sucking noises with each step I take on the blood-soaked carpet; spent bullet casings litter the ground. With the smoke still clearing from the room I can smell residual cordite from the weapons fire mixed with explosive residue. I almost trip over the body in front of me because of the low visibility.

A quick check for a pulse and a reposition of the airway tells me he’s non-viable – blast injury to the torso and GSW to the neck. I pull a black ribbon from my triage waist pack and hand it to the EMT behind me. “Black tag – keep moving.” My EMT ties the black ribbon to the wrist of the dead body behind me as I continue in to the room.

With the smoke clearing more I can see the extent of the room. Vinny’s men are holding down the corners where they have a visual to every angle; two of his men have fallen into ranks with my team and two others are securing the egress route at the front doors. Vinny gives me a head nod – letting me know it’s secure and giving my team the floor to do our jobs.

In a loud voice I address the room. “If you can walk I need you to exit the building now. EXIT NOW!”

Nobody moves. Hell, nobody even says a word! I focus in on the six people sitting on sofas in the corner. I’m fighting with balancing the big picture and noticing the minute details – macro vs micro, the eternal battle of EMS. Micro wins out when I notice that everyone in front of me has their hands and feet duct taped – they’re incapable of walking out of here because they are bound hostages.

Six people with big round eyes are following my movements as I quickly scan them for injuries and I hear the muffled screams from under the duct tape. That tells me enough for now. Turning to the next EMT behind me; “Cut the tape on the feet, clear them, and get them out of here.” I want to quickly reduce the number of people in this room so that all I have left are wounded, and I want to keep the hands bound in case any of these hostages are tangos in disguise.

Moving on I see a man convulsing on the ground with a blood saturated shirt. While I reposition him to check his airway bright blood erupts from his mouth missing my leg by inches. Bright red blood – probably from a perforated lung – gives me an idea of where to look for the wounds. I rip his shirt off and see the entry wound to the right side of his chest. Feeling around his back I find an exit wound near the right scapula.

I turn to the next EMT behind me and hand him two occlusive dressings to seal the wounds, as well as a red ribbon from my triage pack. “Chest seal front and back; keep an eye on his airway. He’ll be one of the first out.” I move on in my clockwise lap of the room.

There’s a man laying supine on the ground, eyes open, not following me or reacting to me when I give him a knuckle rub to the sternum. There’s a mid-axillary GSW to the right flank with no exit wound. A quick listen at the neck with my stethoscope tells me he’s still moving air for now. Shrapnel is embedded in his torso with minor bleeding. I’m getting closer to the blast sight and this guy took more of the blast. Turning to the EMT behind me; “Compression dressing to the flank, he’s critical.” I hand him a red ribbon and move on.

Moving closer to the blast site I find a secretary wedged under her desk. Damn! She looks familiar! She’s screaming and tracking me with her eyes. Arterial spray is coming from her arm and her entire torso is covered with embedded shrapnel. I slide her out from under the desk and turn to the EMT behind me, “Tourniquet to the arm. She’s delayed,” and I hand him a yellow ribbon to tie around her wrist. She’s still screaming as I continue my clockwise lap.

Closer to the blast sight now I see the man laying on the floor screaming and clawing at the blood saturated carpet with his fingers. The source of his discomfort is fairly obvious as I almost trip over a leg that used to be attached to him. I pull a tourniquet to hand to the EMT behind me when I realize I’ve run out of help. Fuck! Micro wins out for a moment as I apply the tourniquet and tie a yellow ribbon to his wrist. Macro takes over again as I walk away from him. Sorry sir, some people are more critical than you are today.

Coming around to the front of the room I’m by myself as my team is caring for the people left in my wake with ribbons tied to their wrists. Two more bodies laying in front of me have further saturated the now ruined carpet. A quick check for vitals tells me there is nothing for me to do here. Judging by their military style clothing I’m thinking Vinny’s operators are very good at their job and left the tangos non-viable. With black ribbons tied to their wrists I walk off.

Finally, I’ve made a full circuit of the room and have a mental tally of the wounded and an extrication plan to get the most critical out first. Walking up to the man with the through and through GSW I see that my team has him ready to go. “Okay, he’s first out.” Looking to Vinny, “I need two SWAT for a cary out.” Vinny nods his head and points to two of his operators who rotate their M-4s to a back cary position and immediately jump in to help two of my EMTs roll the man on a combat cary tarp.

Just then I hear the call from across the room. “I need ALS over here.” It’s one of my EMT’s kneeling next to the unresponsive man with the mid-axillary GSW and blast injuries – he must have run into a problem that needs a paramedic. “I lost lung sounds on the right side,” he tells me as I kneel down and check his findings.

“Good pick-up. Grab a tarp, he’s next out.” I open my waist pack and pull out the enormous needle. Finding my landmarks I insert it to his chest, pull the needle while leaving the catheter in place, and re-check lung sounds. He’s breathing on both sides now that the collapsed lung has been vented with a pulp-fiction style stab in the chest.

As I stand up and look at Vinny, “Two more for a cary out.” Two camouflaged operators appear with two of my team and a tarp. As they’re working him I walk over to check on the man missing a leg.

One of my EMTs is with him and has check to make sure the tourniquet is doing its job. “Okay, this guy is next.” The first team of two EMTs and two SWAT head my way and roll the recent amputee onto the combat tarp. As they pick him up I check his shoe and see that it matches the one on the severed leg. I pick up the leg and put it on the tarp next to the patient. “Make sure the leg stays with him.”

As I make it over to the secretary under the desk I motion the second returning cary-out team to me and get her rolled onto the tarp. The two EMTs and two SWAT operators pick her up and I kneel down to look into her eyes. “I’m glad we got a chance to save you this year.”

We’re heading to the double doors guarded by Vinny’s men and she stops screaming and gives me a smile.

A man in a reflective vest steps out from a glass office. “END-EX, END-EX, secure all weapons!” End exercise.

Once again we have completed the yearly joint training exercise where SWAT teams from across the world and EMS teams work together. As always the realistic wounds and Hollywood quality makeup is unnerving to look at. The blood in the injuries flows and sprays just as it does on the streets and the actors are true to character. Despite knowing it’s an exercise the adrenaline flows very much as it does at a large unknown incident. The SWAT operators and tangos are using simunition shot from real service weapons and the explosions were controlled pyrotechnics with all kinds of bark yet very little bite. The man who got a needle stuck in his chest was a very elaborate mannequin with moving eyes, chest rise and fall, and accurate lung sound generation. If left alone for too long he eventually stops breathing. Once the computer recognizes the needle-decompression it restores bilateral lung sounds. 

Exercises like this train us for the things we hope we will never see. I performed my duties better this year than I did last year and it helped me to recognize areas where I need improvement. The SWAT and EMS interaction is invaluable for the safety and efficiency of all participants. The sooner life saving measures can be taken on scene the more people we can save. Three recent mass shootings come to mind where this cooperation would have made a difference. 

And yes, I did recognize the secretary from last year’s exercise – she was one of the first black tagged victims/actors. We never get a second chance to make a save on the streets, but it was nice to get a second chance here.  

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Necromancy Revisited 1/2

Necromancy Revisited 1/2

nec·ro·man·cy

1 : the practice of communicating with and learning from the dead to predict the future

2 : see also - necromancer; one who practices divination by conjuring up the dead

re·vis·it·ed

1  :  to visit again

2  :  to re-examine (a topic or theme) after an interval, with the view to making a fresh appraisal

The phone is ringing in the bank manager’s office, which is odd. The last time the hostage negotiator called the phone rang at the teller’s window. Thinking that possibly there has been some progress on getting his demands met, he walks to the ringing phone and picks it up with his left hand as his right hand holds down the “dead man’s switch” – a button that needs to be pressed to keep the bomb from going off. If he takes his finger off the trigger, his vest will explode.

“What do you want?” With the anticipation of talking to the hostage negotiator on the other end he’s already setting the tone with an aggressive stance yet no one answers him. Looking up from the phone and out the window he sees a tiny puff of smoke on the adjacent building that is quickly followed by a round hole in the window and spider web crack lines extending to the frame.

That was the last thing he saw as the bullet from the police sniper travelled through his head. He releases the “dead man’s switch” as he falls back, but he never hits the floor – his vest explodes, sending shrapnel and body parts throughout the building.

From forty yards away, staging with my police escorts and the rest of my EMS team I see the fifty-foot ball of fire come out of the window. Crap! Now I have hostages with blast injuries. This is going to be a very bad day!

I walk into the command post to meet the SWAT team leader and get the briefing prior to the assault to attempt resolution of the hostage situation. Camouflaged SWAT members are checking gear and loading weapons as the commander calls for our attention.

“Okay gentlemen, this our latest intel.” The SWAT commander is pointing to a rough floor plan drawn on a white board. “We have three tangos holding approximately ten hostages. I’m getting real-time intel from sniper teams who are in place now. They report the leader has an explosive vest and the FBI SWAT team just raided their home base and found bomb-making material. The good news is that it’s just a black powder device so we’re not dealing with high-yield C-4. The bad news is that we don’t know what the triggering device is or how it’s connected.

“In approximately ten minutes your SWAT team will rappel down from the sixth floor to the mezzanine level. You will then stack along the west wall at which time we will call the phone in this office. It is our expectation that the tango with the explosive vest will answer the phone, at which time our sniper will take out the target. We are told that a single shot from a .308 will weaken the window and allow entry. You will take your team through that window and eliminate the additional tangos. Remember, you have a room with approximately ten civilians.

“Once you secure the room you will call for EMS. They will be staging down the block and enter through the front door. You will provide force protection while they address any life threatening injuries and extricate any wounded. EMS, remember you are entering a warm zone which was hot just a minute prior. I need the SWAT team leader and EMS team leader to come together on how to work together and extricate any wounded with all haste while staying safe. That is all gentlemen; you have ten minutes.”

The SWAT commander walks out on his way to the forward command post as the SWAT team leader, Vinny, and I look over the rough floor plan together. Vinny’s a serious man dressed in his camouflage uniform with an imposing M-4 rifle slung over his shoulder.

Vinny is pointing to the floor plan on the wall and walking me through their method of clearing the room. “Once we have the tangos down I’ll set an internal perimeter and secure egress through the front doors. I’ll alert you via radio that it’s clear to enter. We’ll give you two operators, with your team, on force protection. How are you going to work the room?” He’s a no-nonsense, straightforward kind of guy who seems to know his business.

“That sounds good. I’ll start on a clockwise lap of the room to get a patient count and identify the first out critical patients. As I tag the wounded I’ll spin my guys off on treatment and facilitating egress. I’ll want to stage the wounded for pick-up and transport to the left of the entrance. We have rigs staging, ready to do a drive by and transport to the hospital. It would help if I can use some of your guys to help cary people out. If any of the wounded are heavy it may take four people to get them out.”

“Easy enough, I’ll send you two operators at a time when you need them. Otherwise we’ll stay out of your way and let you work on the wounded. You good?”

“Yeah, I’m good, stay safe.” A blue nitrile fist hits a tactical glove fist and we return to our respective teams for final preparation.

From my vantage point, a half block away, I see ten ropes fall to the ground on the west wall of the building. In a silent rappel, ten SWAT operators slide down the ropes and fall into a stack formation at the corner of the building.

The radio on the officer next to me crackles to life. “Sam one in position.” It’s Vinny on his throat-mic, telling the commander that he’s ready in a whisper.

“Tac-com copies, Sam one. Sniper two, do you have visual?” The tactical commander is getting ready to put things in motion.

“Sniper two, clean line of sight, we are go.”

“Tac-com copies. All teams we are go in ten seconds. Out.”

After waiting for what seems like an eternity, everything happens at once. The sniper fires and the sound of breaking glass is quickly followed by a huge explosion; a fireball comes out of the broken window. As soon as the flames recede, Vinny’s team moves around the corner in lethal stack formation and enters the building. A few seconds later the rapid fire of the M-4 can be heard from the inside of the building. Short bursts of six shots followed by another short burst of eight shots. Some sporadic returning fire and then the final burst of six shots echo out of the building.

The radio crackles to life again. “Three tangos down. Initiating final sweep now.”

The officer next to me leads us up to the forward staging area just twenty feet from the front doors. I can see movement through the windows as the SWAT operators are clearing the room and securing weapons. Smoke is still pouring out of the office window where the explosion came from. Two SWAT operators force open the front doors and secure the egress while the radio crackles again; “Code-4, EMS is clear to enter.”

“Copy. EMS coming in now.” I lead my team towards the front doors.

 

 

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Impalpable 2/2

Impalpable 2/2

We’ve been driving for twelve minutes with lights and siren and we’re still miles from the call location. Our ambulance travels further into the hills on this foggy morning, in a desperate attempt to find the curvy ridgeline road where a bicyclist has been hit by a car. The update came in a few minutes ago that CPR is in progress and the Parks Department Fire Rescue is on scene.

I’ve been going over CPR ratios with my military EMT student who is anxiously peering into the front compartment. He’s twenty but looks like he’s twelve with a fresh, bootcamp buzz cut and black-rimmed glasses.

We can tell we’re getting closer as passing bicyclists are pointing back up the hill as we go by. We round the bend to find firefighters doing CPR on a man in the middle of the street. I walk up to the scene carrying my monitor and suction with my student in tow.

I set my monitor on the uphill side of the patient because blood is flowing downhill at every compression. I tap the firefighter who’s doing CPR on the shoulder and ask if my student can get some compression time while I start assessing the injuries and looking for a pulse. The firefighter pulls back and I feel at the bloody neck for a pulse while listening with my stethoscope for heart tones and breath sounds.

Nothing.

“Resume CPR.” My student starts compressions on the chest like a machine and I have to remind him to count it out for the others while I’m attaching electrodes. I’ll get an electrical reading of the heart on the next pulse check but I already know what I’ll find.

I suction out the mouth, which is a reservoir of blood that just keeps filling on every compression. The firefighters have been doing this for ten minutes and they know as well as I do that this guy isn’t coming back. As I’m waiting for the next transition of CPR the lieutenant shows me the helmet. The top is actually concave! Usually I see scrape and slide marks on helmets from a bicyclist. The concave nature of the helmet tells me a lot. I kneel down to feel the section of his head that corresponds to the helmet damage. Palpating the bones of the skull I feel them give away to depress into the brain. I look up to the lieutenant, “You can cancel the helicopter, we won’t be transporting.”

He walks away while talking into his radio as I have my student stop CPR so I can document the flat line of asystole – showing that the heart has no electrical activity – with a long printout from my monitor.

I switch my student into the airway position and show him how to use the suction while another firefighter picks up the compressions without losing a beat. Walking across the road to the guardrail I pull out my cell phone and hope for a signal while I stare at the hillside disappearing below me in the fog. After a few rings I hear a voice on the other end.

“Medical control, this is Dr. French.”

“Good morning Dr. French. This is paramedic KC on Medic-40 calling for base orders to discontinue resuscitation efforts on a traumatic arrest.”

“Okay, Medic-40, go with info.”

“I have a 43 year old male involved in a head-on bicycle vs. auto. BLS Fire has been on scene for fifteen minutes. The patient was pulseless and apneic upon their arrival. An AED was applied with no shock advised. They proceeded with CPR until our arrival. My monitor is showing asystole in three leads. I have a compromised airway that refills with blood upon every compression. I have a concave bicycle helmet consistent with impact to the car’s bumper and skull crepitus corresponding to the helmet damage.”

“Yeah, that sounds non-viable. Is that your assessment as well?”

“Yes sir, that is the consensus on-scene.”

“Okay, let’s call it: time of death zero nine forty three. Have a better day.”

“Thank you sir. You too.”

While on the phone I’ve been standing next the the guard rail at the side of the road and the fog lifts to reveal the hillside extending for miles below me with the city by the water and bridges extending across the bay that disappear in the marine layer. The view is breathtaking and I’d love to be able to enjoy it but I have other business to attend to.

Turning back to the task at hand I give a discrete nod to the lieutenant who’s standing over the CPR efforts. He unfolds the yellow rain blanket and covers the dead body laying in the middle of the road. As the rest of the scene comes into focus for me I see five men in matching bicycle spandex uniforms standing at the side of the road. Underneath the yellow blanket lies their missing teammate who was wearing the same uniform. It looks like I still have some work to do and it’s one of my least favorite aspects of the job.

“Hey guys, come on over here and let me explain what’s going on.” They are crying and shaking from the cold of the morning. I send my student back to the rig for blankets as I position myself with my back to the guardrail – this focuses them away from the bloody mess in the road and gives a majestic backdrop to the difficult speech I’m about to give. They huddle close as my student is draping blankets over their shoulders.

“We’ve been working on him for over twenty minutes now and he wasn’t responding to any of our efforts. I had a conversation with a doctor and we both agreed that it was time stop and pronounce death. What I can tell you is that he had very severe damage to the head and extensive internal damage to the organs. It’s very likely that he died upon the initial impact. I wish that there was more that we could do but his injuries were incompatible with life. I’m very sorry for your loss.”