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.

 

 

Dec
4


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Reflection 2/2

I’m a little disoriented as I sit in the front seat of an ambulance that is foreign to me and the unfamiliar dispatcher sends me to posts in my mostly urban county which are obscured by code numbers that I don’t understand. The computer on the console draws lines on a map telling us where to go as we fumble with the switches trying to find the siren.

“Medic-40, delta level response for a seventeen-delta-three, fall-not alert, switch to fire control three.”

“Uhh, Medic-40 copy.” What the hell is a seventeen-delta-three and how do I switch to fire control three?

Having finally found the siren and switched to the proper response frequency we are following the line on the computer in hopes of finding the call location. Rolling through traffic I see the familiar landmarks and denizens of the hood hanging on their normal corners. It’s somehow comforting to feel a connection with the hood on a day that seems so different in every other aspect.

Pulling up to the corner I see my neighbor, Darren, the lieutenant on the fire crew that beat us to the scene by only thirty seconds. Sitting on the stairs in front of him is Chauntel, a frequent flyer that I recognize from just last week, and her husband standing next to her holding a huge purse.

“Hey Darren, what’s going on?” The rest of the firefighters on Darren’s crew have bailed on taking care of the patient and are poking around my ambulance to admire the equipment and new ambulance smell.

“You know Chauntel right? Looks like she took too many of her Vicodin and wasn’t able to keep her feet under her while walking down the stairs. She’s not altered or anything, just feeling a little dizzy and complaining of knee pain.”

“Cool, I got it.” I kneel down to look at Chauntel as Darren joins his crew in opening cabinets on my rig. “Hi Chauntel, am I taking you to the hospital today or are you okay to go home?”

“I best go to the hospital, you know, jus to get checked out. I don’t think my Vicodins are work’n too well cuz I still got the pain in my knee.”

I help Chauntel onto the gurney and raise it up with the push of a button. Power gurneys; finally a career-extending piece of equipment.

As my partner drives us to the hospital I continue with my assessment of Chauntel.

“How bad is the pain in your knee?”

“It’s a ten outta ten! An’ it feels sharp!” Awesome, she knows our pain scale without having to be prompted.

“Do you want some Morphine for the pain Chauntel?”

“Na, I can’t have Morphine, I allergic to it! You got any Dilaudid?” Classic!

“Chauntel, you know I don’t carry Dilaudid. And when did you become allergic to Morphine? You weren’t allergic to it last week.”

“Well, I is now!” I’m not one to judge her pain level, or her, but the drug seeking mentality is fairly transparent to us at this point. I guess some things never change.

“How do you like the new uniforms Chauntel? Did you notice the shirt’s a different color?” Just making small talk as there’s not really that much to treat on this call.

“Oh, is those new? Now you mention it you got some pretty eyes. Is you married?” Seriously, that’s what you notice. Bloody hell with the eyes again!

“Yeah Chauntel, I’m married, and so are you. As a matter of fact your husband is sitting in the front seat.”

In a conspiratorial, quiet voice. “Well, he ain’t really my husband, I jus’ call him that. You mind if I take a nap on the way? I feeling kinda tired.”

“Go ahead Chauntel, we’ll be there in about ten minutes.” I switch to the captain’s chair to try to figure out how to use the new computer.

Now you put water into a cup, it becomes the cup. You put water into a bottle, it becomes the bottle. You put water into a teapot, and it becomes the teapot. Now water can flow or it can crash! Be water, my friend.

Bruce Lee, TAO of Jeet Kune Do

 

 

Dec
0


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Reflection 1/2

Reflection 1/2

re·flec·tion

1  :  an image, representation, counterpart

2  :  the act of reflecting or the state of being reflected

3  :  mental concentration; careful consideration – a thought or opinion resulting from such consideration

“The pessimist resembles a man who observes with fear and sadness that his wall calendar, from which he daily tears a sheet, grows thinner with each passing day. On the other hand, the person who attacks the problems of life actively is like a man who removes each successive leaf from his calendar and files it neatly and carefully away with its predecessors, after first having jotted down a few diary notes on the back. He can reflect with pride and joy on all the richness set down in these notes, on all the life he has already lived to the fullest. What will it matter to him if he notices that he is growing old? Has he any reason to envy the young people whom he sees, or wax nostalgic over his own lost youth? What reasons has he to envy a young person? For the possibilities that a young person has, the future which is in store for him? 

No, thank you,’ he will think. ‘Instead of possibilities, I have realities in my past, not only the reality of work done and of love loved, but of sufferings bravely suffered. These sufferings are even the things of which I am most proud, although these are things which cannot inspire envy.’ ” 

Viktor E. Frankl – Man’s Search for Meaning

With the top down and cool wind in my hair I accelerate on the freeway onramp to get up to speed and head for home on my last day with the company. But not my last day in the county…

It’s an emotional day, to say the least, and I have time to reflect upon the years as I navigate through the darkness to the normalcy that I call home.  Ultimately, I have an optimistic view of the future and that optimism has its origins in the accomplishments of the past. There’s a lot to be proud of in the work that my tribe of EMTs and Paramedics have done in this county. Through incredible adversity we have advanced street medicine to a finely honed machine. Though the machine sometimes throws a cog we always find a way around it to accomplish the tasks at hand. We have had outstanding leaders at the helm as well as the occasional drunken captain, but in the field we have always pulled together to bring the best possible care to our patients.

My mostly urban county has taken a toll on us yet it has given us so much more than is easy to recount in a single telling. The high call volume gives us a variety of experiences early in our careers. Those that survive the first few years have the mark of a battle hardened soldier on their foreheads. We may bear a few more worry lines and some new gray hairs, but we can also boast of relationships, forged in the trenches, that will last a lifetime. Some of those comrades will ship out tomorrow to take our flavor of street medicine to other counties. I wonder how they will be received when they finally reach their destination. Will they look back with fondness to the mostly urban county of our origin? Will they see themselves as finally having escaped the chaos? Maybe they will be ostracized in their new system and find that coming home is the only tolerable option – it’s happened already and we haven’t even started the transition.

The freeway takes me into the outskirts of the county and closer to home – I’m just one car in a constant stream of headlights and tail lights blurring into streaks reflected in the glass buildings in the empty office parks. As the economy fell the new buildings became empty and now stand as hollow glass blocks, devoid of occupancy; a sea of monuments showing us the economic reality that we all tried to deny until it was too late. In a real estate parody of the Occupy movement they stand idle, refusing to leave, yet their message is lost in obscurity.

 

 

Nov
2


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Scrum 2/2

The call came in as “chest pain with shortness of breath.” It’s a typical EMS bread-and-butter call that we get a few times a day. Nothing out of the ordinary in this one or in the notes in the MDT. Having just left my sleeping 5150 patient in the county hospital I’m giving John a break on the driving as I know where this call is and I’m tired of giving turn-by turn directions to someone who’s not familiar with the county. It’s a pretty basic Code-3 run through the urban downtown until I run into the riot and have to re-route up a one way street to get away from the bottle throwing mob.

Finally I make the turn to my street and see the fire engine parked on the side. There’s another skirmish line of SWAT protecting this street from rioters and one of the officers heads in my direction immediately. “Turn off your goddamned lights! You’re going to incite these assholes!”

I flick the lights off and slide out of the rig to find my patient. He’s sitting in front of a homeless shelter and I recognize him as a frequent flier from many previous calls. The fire lieutenant makes a bee-line for me as I’m walking up.

“What the hell! I gave you routing directions to come up from the south. Don’t you know there’s a riot over there? You come in here with lights and siren and you’re going to work them up even more. What the hell is wrong with you?”

“Yeah, I noticed the riot. My dispatcher didn’t give me anything. Just ‘chest pain’ and this address.” I’m not going to get into an argument with this guy in the midst of a riot. I’m going to grab my patient and get the hell out of here and let my supervisor sort it out later. I have the luxury of being able to ignore the rants of a fire lieutenant because I don’t fall into his chain of command. Yet it’s that same separation that seems to have led to the breakdown in communication that led me to unintentionally endanger everyone on scene. I walk past him to check out the patient.

John’s eyes are the size of saucers as he’s pushing the gurney up to the patient and we load him into the rig. “Code-2 to county, let’s just get out of here!”

As John is getting egress directions from a SWAT officer I’m doing an initial work up on Charles, my new patient. I cut the hospital band off of his wrist – he was in another hospital this morning – and go down the typical chest pain protocols. John’s pretty worked up and I’m getting bounced around the back of the rig quite a bit but I don’t care at this point.

Charles gets the normal chest pain meds: aspirin, nitroglycerin, etc. In less than ten minutes we are rolling him into the county hospital triage room. I ask John to get a follow-up set of vitals as I pull my cell phone to contact my supervisor.

“Hey Rich, it’s KC on Medic-40.”

“Yeah, what’s going on?”

“Did you know there’s a riot down town because dispatch sure as hell doesn’t! They just sent me Code-3 to a chest pain call in the middle of it. I ran into a skirmish line of SWAT and maybe 400 protesters while running hot. I pissed off PD and fire because I came in with lights and siren. Dispatch never gave me routing or a heads up on the riot. The fire LT was pissed because he gave routing to his dispatch but it never made it to us. I walked into this thing blind and put everyone at risk for escalation!”

“OK, hold on a minute.”

I hear Rich come up on my radio addressing dispatch. “You need to put out an all-page. No one is to run Code-3 in downtown. We have SWAT activity and protesters near Medic-40’s last call location. Get on the phone with PD and find out what the perimeter is and make sure our units have intel to get around this.”

Addressing me on the cell phone again. “Okay, I’ll be up there in a few minutes. Are you guys okay?”

“Yeah, we’re fine.”

My pager starts vibrating on my belt: AVOID CODE-3 IN DOWNTOWN. PROTESTERS AND SWAT ACTIVITY NEAR MAIN ST. PER PD: PROTESTERS ARE ON THE MOVE, NO SET PERMITTER, NO LIGHTS AND SIREN IN DOWNTOWN.

Back at my deployment center after an exhausting day I clock out and head to my car. I put my gear bag in the trunk and pull out a trash bag with all of my uniforms in it and head back inside. Handing my bag of uniforms to the deployment coordinator I pull my ID badge and pager and hand them in as this is my last shift. With the top down and cool wind in my hair I accelerate on the freeway onramp to get up to speed and head for home on my last day with the company. But not my last day in the county…

Photo credit: AP Photo/Noah Berger

 

 

Nov
2


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Scrum 1/2

Scrum 1/2

scrum

1 – rugby – the method of beginning play in which the forwards of each team crouch side by side with locked arms; play starts when the ball is thrown in between them and the two sides compete for possession

2 – a confused crowd of people pressed close together and trying to get something or speak to someone

3 – a brief and disorderly struggle or fight

The limitation of riots, moral questions aside, is that they cannot win and their participants know it. Hence, rioting is not revolutionary but reactionary because it invites defeat. It involves an emotional catharsis, but it must be followed by a sense of futility.

Martin Luther King, Jr.

The high intensity LED strobes on the rig are lighting up the dark concrete canyons of empty streets in my urban workplace as I get closer to the call location. Sirens and the occasional air horn reverberate from the buildings as I creep through intersections and accelerate down the open streets. I pass City Hall and point out the tent city that was resurrected after a somewhat violent clash between the city police and members of the Occupy movement.

My EMT partner is helping to cover shifts in this county and is far from his normal surroundings of rural EMS calls. John is a part time EMT in one of the rural counties that surrounds my mostly urban county. He picked up this shift to get some overtime,  and being new in the EMS community, he wanted to come here to get some “action.” He’s about to get more than he bargained for as we get closer to the call location.

I round the corner just two blocks from my destination when I’m met with a SWAT skirmish line slowly backing towards my flashing rig. Thirty officers in full riot gear – extra padding in the uniform, full helmets with gas masks on, and plastic shields – are holding off a mob of four hundred angry people in dark clothing. The occasional bottle is lobbed from the crowd and breaks on the asphalt near their feet. The officer in charge whirls around to face me and a single motion from his baton-wielding arm is enough to convince me that I need to find another route to my destination. No arguments from me – this is the last place I want to be right now!

I pick up the mic as I point the rig up a one-way downtown street with headlights coming at me in all lanes. “Medic-40, we’re re-routing, we got blocked by protesters at Main street.” Driving the wrong way, up a one-way street, I’m giving an update to dispatch while pulling my ballistic vest from my bag and trying not to have an accident while I dodge oncoming traffic. I don’t remember this lesson being in my Emergency Vehicle Operation Course!

“You green-eyed mutha’ fucka’! I’m gon’ whoop yo ass like on Jerry Springer!” She’s screaming insults at me and balling up her fist as I escort her to the rig.

“Okay, you can whoop my ass later, let me check you out first.” Placating the psychotic patient has become something of an acquired skill in this county.

She called 911 saying that she needed an ambulance and then hung up. My dispatcher was unable to get her on repeated call backs so they sent us and a fire crew to see what’s going on. Seeing all of that in the call notes of the MDT I requested a PD back-up before we even got on scene. It’s just safer to have the guys with guns on scene when you don’t know what you’re getting into.

“Don’t you take me to no county hospital! I know my rights. You have to take me to EPS!” I’m taking a blood pressure as she yells at me. Just as I thought – way too hypertensive – she’ll need medical clearance before going to EPS (emergency psych services). She’s not going to like this because I’m now obligated to take her to the county hospital.

“Okay, here’s the thing. I need to put these restraints on you because you’re threatening me.” She struggles a little but lets me put the substantial leather wrist restraints on her – thereby greatly decreasing the chance that she can follow through with her threats to whoop my ass.

The city PD officers must be a little busy because they’re taking an eternity to get here. The fire crew simply escorted the screaming woman to the back of my rig and told me she wants to go to EPS. Before I even had her situated on the gurney the fire engine was driving away. Thanks a lot, guys!

“Why aren’t you taking your Seroquel?”

“I don’t like the way it make me feel! It make me all sleepy! Fuck you! Take me to EPS you green-eyed mutha’ fucka’!” Classic; the crazy person doesn’t like feeling normal so they stop taking their anti-psychotic medication. I’m about to make you feel VERY sleepy!

I’m drawing up a sedative in a syringe as the officers finally arrive and walk up to the back of my rig to face my not-so-pleasant patient. “I hear you want a green sheet, what’s going on?”

My patient seals the deal with her next outburst. “Fuck you! I’ll put you on a green sheet you bald-ass mutha’ fucka’. Let me up! I gon’ whoop his ass too!”

“Good enough for me. I’ll be back in a minute.” The officer walks back to his car to write up a 5150 form – a 72-hour hold for psychiatric evaluation – as his partner stands by in case we need any help.

As my patient is distracted by slinging insults at the officer I inject a sedative into her arm. With a green sheet in hand I have a pleasant drive to the county hospital and get a chance to do my paperwork while my patient snores like a chainsaw on the gurney.

 


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.”