http://www.youtube.com/watch?v=vX07j9SDFcc
Today, I heard the news that one of my patients from many many years ago died. Let me tell you the story.
It was a cool night many years ago and I was working in a hospital based ambulance service. I was considered a "senior" medic but still not completely experienced.
If was a Friday night, about 10pm. We received the call about a traffic collision in Sonic parking lot with a female complaining of difficulty breathing. "Great" I thought, "another teenage girl hyperventilating from a minor collision".
We start responding and we hear the local fire suppression units get dispatched to the same incident for "vehicle smoking"..."Ok, it may be more than I thought".
As we are responding I notice alot of glass in the highway about 2 stores before Sonic and three vehicles where they are not suppose to be in the Sonic parking lot. One was in the shrubs in front of Sonic, one was against another vehicle in the parking lot, one was in the middle of parking lot where walk up orders are taken. Everyone is alright, except one. I call for additional ambulance to respond to location and move to the vehicle in the shrubs in front of Sonic...the one with the driver trapped...the one smoking.
Ok, the smoke was actually from the dust from the airbag deploying, so fire suppression units were not needed. However, heavy rescue was needed.
The female driver, looks to be in her early 20s, is unresponsive with snorous ventilations. I climb into the back of the vehicle along with a student riding with us that night to climb in. Its a small car, not a great deal of room to work, but it is something that I habitually do on entrapped patient calls. I carefully lift her head back into a neutral alignment while opening her airway, a basic EMT student clumbsily places the cervical collar on the patient with my instructions...hell, you have to learn somewhere. Airway now opened and patent, patient is still breathing slowly and is still unconscious. We start assisting ventilations with a bag valve mask and high flow high concentration oxygen.
The Lt for the fire service approaches me to ask my opinion on extrication. I am a simple person. I know very little about heavy rescue and use of the Jaws of Life along with other extrication tools. I depend on the firemen to know their job. So I told the Lt, who was good friends with me, to do what he needs to do to get her out. He knows that I will be in the vehicle with the patient. They cover the patient, the student, and myself with a heavy blanket to protect us from the glass and metal that will be cut.
While we were under the blanket, I got the student to maintain neutral alignment while she was in the left corner of the back seat of the vehicle while I got immediately behind the driver's seat where the patient was, still unresponsive. I bend myself over the seat, insert the laryngoscope blade into her mouth and visualize the glottis and me placing an ET tube throught the glottic opening. Secondary confirmation along with securement of ET tube.
I never knew that this is was a difficult way to intubate a patient, but no anesthesologist would have even attempted that intubation. And not many paramedics would have attempted it or gotten it.
By the time I got her intubated and the tube secured, the fireman had the roof cut and driver door moved out of the way. We extricated the patient to the LSB and secured and quickly loaded her into the ambulance. Once in the privacy of the ambulance, we cut the patient's clothing and started the two IVs.
Quick transport to the hospital with the patient waking up. The ED doc, a friend of mine, during his assessment of the patient, pointed to me and told the patient "you can thank him for saving your life". The patient was transferred to the Level I trauma center at the MED in Memphis and she was quickly forgotten.
Over 2 years later, a nurse came down to the ED where I was working and was asking for me. "Oh shit, who did I piss off now?" I told her it was me and I got a big hug. I could hear her crying alittle bit. I could feel her tears on my neck. She told me who she was, I didn't remember her name. She told me that she had a vehicle collision at Sonic a couple of years earlier. I finally did remember her.
She told me how the trauma surgeon told her again that the paramedic that intubated her did save her life. She told me how she cleaned up, got off drugs, finally became the mother her two small children needed, went to LPN school and is working as a nurse. She told me "thank you Michael"...her eyes told me she meant it.
I told her not to thank me, I was just doing my job. She said no, you went way beyond the call of duty.
We talked alittle more and she went back to work. I soon left that job to work with the current Ambulance company I work for.
I learned today that this woman died a few years ago in a motorcycle incident. Riding in Memphis with her boyfriend "just around the block", she fell off the back of the motorcycle, striking her head. Not wearing a helmet, the traumatic brain injury ended her life.
For some reason, this knowledge has depressed me alittle. Many many people have died around me. Dead is a common companion for us in my profession. Can someone explain to me why this one person's death has effected me.
Saturday, October 24, 2009
Friday, October 23, 2009
The Horror
The Sadness of a Father
The call came out as “chocking” some 14 miles away. “Damn, this is going to be bad or complete bullshit”…usually bullshit, either someone didn’t swallow right, or the drink went down the trachea causing the coughing and tracheal spasms we are all familiar with.
No other information came in as we are responding…
We arrive on scene and immediately, the ambulance sinks in the muddy driveway, we are stuck. I leave my partner to tend to the ambulance and call for an additional one for transport if needed, I gather the necessary equipment and walk calmly to the apartment…oh yea, we were never advised of an apartment number by dispatch. I was met by a middle aged man, not upset or unusually stressed, not rushing us, just calmly walking beside me trying to engage in small talk. Again, bringing my sense of urgency down to a normal level.
I walk into a Hell that no parent wants to find himself or herself in. A father, someone I know, is bent over his 2 month daughter and with tears rolling down his face, is doing mouth to mouth and chest compressions…
“Michael, she is not breathing. If anyone can save her, its you!...”
I immediately get in resuscitation mode. Quickly checking for a brachial pulse and other signs of life, my hands wrap around the chest of this perfectly formed infant and compress her heart between the sternum and the vertebrae of the thoracic spine. She is perfectly formed, looking so sweet, and except for the cyanosis around the face and the limp body, you would swear she was sleeping. No signs of trauma, no petieciea (sp) noted, just a perfectly formed dead infant…
My mind remembers holding Hannah Rae and Josie at this age…
Back to the task at hand, my mouth covering the infants mouth and nose as I breathe the 17% oxygen that is in my exhaled breath into the little lungs. Her chest rises, the air is getting in…my hands pressing against her chest and back, trying to get the perfusion pressure of her little heart up so blood will start to flow, all the while obtaining a history of the incident and a medical history, listening to key words…laid her down for a nap about an hour ago, came in not breathing, started CPR immediately…
I call for an additional ambulance for transport, get the infant oral airway sized and inserted, start ventilating with the infant bag valve mask and continue compression. My partner arrives and takes over CPR, I apply the cardiac monitor and see asystole, the absent of any electrical activity. No IV site immediately presenting itself and the infant’s neck is to fat for an external jugular cannulation…I immediately insert a pediatric intraosseous into the small leg of the infant, the IV fluids flowing…need a weight…estimate at 3.5-4 kgs…initiate Epinephrine every 3-4 minutes weight based…
“Michael, I did everything correctly. Why didn’t it work?”
Attempt to intubate the infant, her small glottic opening was so anterior, approximately at the level of C1 vertebrae that visualization of it wasn’t possible. The transport truck arrives and the medic walks in, seeing what I got and clears a path to the ambulance. I move to the ambulance, partner two steps behind me with equipment that is still attached to the infant, other equipment and trash left to be picked up in a bit…I continue the chest compression and the mouth to mouth to the ambulance…placed on the ambulance and the other medic attempts to intubate, the results the same as mine…we take turns with the chest compressions and ventilations, pushing the correct vasopressor medications, I place an NG tube…something new to paramedics in our area, except I place it in her mouth and withdraw approximately 60mLs of air from the small stomach of the child…her skin color immediately improved…I call our dispatch to notify receiving medical facility…”2 month old, 3-4 kgs, cardiac arrest, not intubated, IO, epi q 3-4 minutes, 6 rounds of meds so far, asystolic on monitor, placing NG tube now, ETA still 10-15 minutes…”
I hear the dad in the front seat of the ambulance crying quietly to himself…I can hear those quiet tears fall over the sound of the siren that is ringing through the rural air…the quiet converstation between a new and the season medics on the unit.
We arrive to the hospital with the ambulance door open and staff waiting. We calmly continue the resuscitation as we walk the infant into the primary resuscitation room, hand off the infant and I give my report to the ED doc…my hands are shaking from the norepinephrine neruotransmitters that have been released by my brain, sending my body into a severe fight or flight reaction, but my voice was calm and quiet…
40 minutes later, I walk with the ED doctor to tell this dad the bad news. As soon as he saw me and the ED doctor walking together he knew…and the strength that he had for the entire time of the resuscitation left him…and he became only a father.
I hold my friend for several minutes…a tear never left my duct…
Until now, 2 months later, writing about it…
We restock both units, complete the necessary patient care report, and go available for the next assignment…which came quick enough…grandma is bedconfined and needed transport back home…
The call came out as “chocking” some 14 miles away. “Damn, this is going to be bad or complete bullshit”…usually bullshit, either someone didn’t swallow right, or the drink went down the trachea causing the coughing and tracheal spasms we are all familiar with.
No other information came in as we are responding…
We arrive on scene and immediately, the ambulance sinks in the muddy driveway, we are stuck. I leave my partner to tend to the ambulance and call for an additional one for transport if needed, I gather the necessary equipment and walk calmly to the apartment…oh yea, we were never advised of an apartment number by dispatch. I was met by a middle aged man, not upset or unusually stressed, not rushing us, just calmly walking beside me trying to engage in small talk. Again, bringing my sense of urgency down to a normal level.
I walk into a Hell that no parent wants to find himself or herself in. A father, someone I know, is bent over his 2 month daughter and with tears rolling down his face, is doing mouth to mouth and chest compressions…
“Michael, she is not breathing. If anyone can save her, its you!...”
I immediately get in resuscitation mode. Quickly checking for a brachial pulse and other signs of life, my hands wrap around the chest of this perfectly formed infant and compress her heart between the sternum and the vertebrae of the thoracic spine. She is perfectly formed, looking so sweet, and except for the cyanosis around the face and the limp body, you would swear she was sleeping. No signs of trauma, no petieciea (sp) noted, just a perfectly formed dead infant…
My mind remembers holding Hannah Rae and Josie at this age…
Back to the task at hand, my mouth covering the infants mouth and nose as I breathe the 17% oxygen that is in my exhaled breath into the little lungs. Her chest rises, the air is getting in…my hands pressing against her chest and back, trying to get the perfusion pressure of her little heart up so blood will start to flow, all the while obtaining a history of the incident and a medical history, listening to key words…laid her down for a nap about an hour ago, came in not breathing, started CPR immediately…
I call for an additional ambulance for transport, get the infant oral airway sized and inserted, start ventilating with the infant bag valve mask and continue compression. My partner arrives and takes over CPR, I apply the cardiac monitor and see asystole, the absent of any electrical activity. No IV site immediately presenting itself and the infant’s neck is to fat for an external jugular cannulation…I immediately insert a pediatric intraosseous into the small leg of the infant, the IV fluids flowing…need a weight…estimate at 3.5-4 kgs…initiate Epinephrine every 3-4 minutes weight based…
“Michael, I did everything correctly. Why didn’t it work?”
Attempt to intubate the infant, her small glottic opening was so anterior, approximately at the level of C1 vertebrae that visualization of it wasn’t possible. The transport truck arrives and the medic walks in, seeing what I got and clears a path to the ambulance. I move to the ambulance, partner two steps behind me with equipment that is still attached to the infant, other equipment and trash left to be picked up in a bit…I continue the chest compression and the mouth to mouth to the ambulance…placed on the ambulance and the other medic attempts to intubate, the results the same as mine…we take turns with the chest compressions and ventilations, pushing the correct vasopressor medications, I place an NG tube…something new to paramedics in our area, except I place it in her mouth and withdraw approximately 60mLs of air from the small stomach of the child…her skin color immediately improved…I call our dispatch to notify receiving medical facility…”2 month old, 3-4 kgs, cardiac arrest, not intubated, IO, epi q 3-4 minutes, 6 rounds of meds so far, asystolic on monitor, placing NG tube now, ETA still 10-15 minutes…”
I hear the dad in the front seat of the ambulance crying quietly to himself…I can hear those quiet tears fall over the sound of the siren that is ringing through the rural air…the quiet converstation between a new and the season medics on the unit.
We arrive to the hospital with the ambulance door open and staff waiting. We calmly continue the resuscitation as we walk the infant into the primary resuscitation room, hand off the infant and I give my report to the ED doc…my hands are shaking from the norepinephrine neruotransmitters that have been released by my brain, sending my body into a severe fight or flight reaction, but my voice was calm and quiet…
40 minutes later, I walk with the ED doctor to tell this dad the bad news. As soon as he saw me and the ED doctor walking together he knew…and the strength that he had for the entire time of the resuscitation left him…and he became only a father.
I hold my friend for several minutes…a tear never left my duct…
Until now, 2 months later, writing about it…
We restock both units, complete the necessary patient care report, and go available for the next assignment…which came quick enough…grandma is bedconfined and needed transport back home…
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