Featured image: Accident scene image
provided by author (dated 2022)
From The MÉLANGE
Occasional Journal of Health
“Allegiance 5153 to Grayson dispatch. We’ve got… two vehicles, one truck on its side, one car with significant intrusion, apparent rollover… bystanders attempting extrication, one patient entrapped, multiple bystanders. We’ll need additional units, and a helicopter on standby based on mechanism.”
There’s some good news: We have daylight, it’s only 4 p.m. this Christmas day. The trapped patient in the crushed car is screaming bloody murder, which means she has a patent airway, and I can leave the intubation kit in the bus. For now. Fire trucks and police cars begin to arrive, and I’ve zeroed in on our entrapped female, the highest acuity patient based on first impressions. I had put on the day-glow vest en route. I get out, take my ceremonial Zen breath then snatch the scene bag from the back of the box before walking to the car.
Two bystanders are vainly trying to pry the passenger door open, and two firefighters arrive in short order, ushering them to the “bystander pen” (in this case, just a tree that’s clear of the debris field) and setting out the extrication equipment. The passenger side is crushed in, and the roof is smashed, with busted-out windows all around. It appears the car was t-boned at high speed, rolled over, and landed wheels-down at a shallow angle in the ditch. The driver “self-extricated” before we arrived and is triaged into the “walking-wounded pen” (the other tree… over there).
The driver’s side door, while damaged, opens enough to grant access.
“My name is Brad, I’m a paramedic for the county. Can you hear me, ma’am.”
“Yes,” she pants, “my leg fucking hurts, it’s fucking crushed.”
I dust the gravel of broken windscreen from the driver’s seat and crawl in. A firefighter has arrived behind me and asks me what I need.
“C-collar, shears,” I say. I’m a bit embarrassed because on a good day, I’d already have them in hand. He ruffles through the scene bag and delivers them shortly.
The airbags have deployed, so concerns for getting clobbered with a delayed bag ejection are eased.
“Can you tell me your name ma’am,” I say, reaching back for the collar and shears.
“Jamie,” she says, pushing back her hair and wiping down a torrent of tears. “Oh it fucking hurts so bad!”
“Ok Jamie. The fire department has to cut open your door to get you out, so we have a little time to help with your pain and get a better idea of how bad you’re hurt.” She replies with a peal of crying and a face twisted in terror.
“You’re breathing ok, that’s good. Did you get knocked out? Go unconscious?” She nods: No.
“Do you remember what happened?”
“It just came out of nowhere, fuck, oh my god, my leg, we got hit by a car, fuck.”
“I’m going to put this collar on your neck. It’s a brace intended to keep it stable in case there’s a spinal injury.” The usual script just rolls off my tongue as I quickly feel her neck, skull, and orbits. No crepitus, no pain: pleasant surprise. I gather her hair as best I can (it’s a nest of glass and dried blood), slide the collar like a shoehorn under her neck and bend the device back on itself to lock the brace into place.
“Extrication’s go,” the firefighter says through what once was a passenger car window.
I look down into the footwell of the passenger side. Her right leg is mangled, but intact. Bleeding appears controlled. The foot itself looks to be clear of the damage — a Christmas miracle. She’s cussing and crying enough, I know that odds are good her brain, spine and lungs are uninvolved. Enough to give the thumbs up to the heavy rescue crew.
The pneumatic spreader whines and chugs to life. A firefighter’s jacket is draped over us as the unholy clamor of buckling steel and pneumatic pressure bite at the door; a rain of glass pitter-patters onto our improvised Kevlar tent. I do a quick head-to-toe: palpate the neck, ribs, extremities, abdomen, what I can reach of her legs. No bleeding; no new yelps of pain in tender spots; no fountains of vomit or blood from brain injury or hidden traumas. Lucky girl.
“It hurts so fucking bad,” she cries.
“Ok Jamie, we’re going to get some pain meds on board while we have a second.” I realized as I said it that my narc kit is locked up in the ambulance safe. Fuck. My partner Ellen arrives, after triaging the other patients, right in the nick of time. “I need an IV, Ellen, I gotta grab the narcs.” I’d send her, but I’m the only one with access to the safe.
“Got it,” she says, quickly procuring a start kit from the scene bag. I double back to the ambulance, Incident Command spots me and gives me a few words: “Your bird’s in the air. LZ established; road’s shut down. One other patient with a medic. No other ambulances available. You need anything?” I glance back at the car, the extrication is coming along, good timing. “I need the stretcher, a backboard and a frac bag to patient one.” A nod of acknowledgment, and I continue to the truck to fetch the Good Drugs. It’s a real Christmas treat to have so many hands on board. Too frequently, all the gear humping is on me. I return quickly to find Ellen has a beautiful patent line with a pigtail ready for me. The passenger door is off the car, I have a quick look at that right leg, and enter in the driver’s side again to push 10mg of morphine and a flush.
“Jamie, any changes? I have the pain meds here, we’re gonna take the edge off before we pull you out. Are you allergic to morphine?”
“No, uh, fuck… I’ve never had it, I don’t know.”
“Ok, I’m giving you morphine. It might make you feel sick, but it will take the edge off. Tell me if you are going to throw up, ok?”
“Ok,” then more reassuring crying. Lucky girl.
“I’m going around to the other side to get you out, ok?” I take the opportunity to cut her seatbelts and brush glass and gravel from her lap.
“Ok.”
The backboard, stretcher and frac bag arrive as ordered, and efforts from two firefighters are already underway.
She’s seated more or less normally in the passenger seat, with the seatback sprung all the way back nearly flat, and her right foot is clear of the crunchy bits. Two field splints get strapped to her leg with gauze.
“Ok, we’ll nose the head of the backboard under her butt and bring her out feet first, in-line,” I say to the firefighters who are already in place, familiar with the technique. Plenty of hands, for a change. Thank you, Santa. We gently get the right leg out from the footwell with much attendant screaming. The other limbs follow swiftly, dressed neatly along the length of the six-foot backboard and secured with 3 seatbelt straps. Collared, splinted, doped and boarded — fully packaged. We heave the litter onto the cot and hustle her over to the truck.
Alright, now we get started for real. Ellen and I scissor up the length of each pant leg and grab a proper contour splint from the cabinet. “Pedal pulses present,” she says, and makes an “X marks the spot” with a sharpie. “Looks like a tib-fib, maybe ankle too, closed fracture, no uncontrolled bleeding.” There’s a hint of surprise in her report: Ellen saw how jacked the car was.
I’m checking pupils with a penlight and palpating the neck, skull and face again, in case I missed something. Shoulders, clavicles, ribs, hips: stable. Palpate the four abdominal quadrants: soft, non-tender. “Do you have any medical conditions? Diabetes? Seizures? Surgeries? Is there any possibility you’re pregnant?” Brief response: “No, uh, no.” Blood pressure cuff, 4-lead EKG, pulse ox, recheck the IV site. Looking good Vitals good. Simple trauma. Lucky girl. That car was a crushed beer can.
The ambulance’s side door opens, and another firefighter medic ushers in the driver of the crushed car, a twenty-something stoner kid. He’s covered in small abrasions and has blood on his face and hands. A bang at the back doors follows soon after.
“Your bird’s here, crew’s ready.” Two women in trademark blue jumpsuits amble in. This is becoming a very crowded kitchen. The FF-Medic is looming over me, the bleeding stoner kid takes a seat in the captain’s chair and gets a C-collar. The flight crew had their own monitor, so we swap out our B/P cuffs, leads and SpO2 and wire up the stoner kid.
“24-year-old female,” I start for the waiting flight medic. “Restrained front passenger, apparent T-bone with roll-over, entrapped. Denies LOC, A&Ox4 on contact, extricated and packaged. Main concern is right tib-fib and ankle, apparent closed fracture, strong pedal pulses as marked. Good sensation distally as well. Hips appear stable. Alert, pupils PERRL, no pain or DCAPBTLS in neck, back, shoulders, thorax, abdomen. Denies history, denies meds, denies pregnancy, no evidence of ETOH. 10 of morphine via 18-gauge LAC. Pressure’s beautiful, 98% on room air, sinus tach on the monitor.”
The flight medic scribbles my report on a wide piece of white cloth medical tape plastered to her thigh, nodding with acknowledgement at each data point. Her partner fusses over the leads and monitor gear and introduces herself to the patient.
“Awesome,” she says, “sounds good. We’ll just get her on our basket and be on our way.” It’s a bit of a farce as we try to sort the stretcher straps from the backboard straps, get the backboard in the air enough to slide their flight litter under the backboard, and get all the straps sorted and buckled. With seven people stuffed into the ambulance box all grabbing and switching mismatched seatbelts for a few minutes, I started to hear “Entrance of the Gladiators” in my head.
Firefighters waiting outside take the stretcher and flight basket, loaded with Jamie, to the landing zone with the flight crew. I can now turn my attention to the kid bleeding from his head holes sitting at the other end of the ambulance.
My first thought is, “Well, shit. I sent the wrong patient to the helicopter.” Jamie had a simple tib-fib fracture, the kind of break you can get falling off a porch step. I made the call based on “Mechanism”: Mechanism of Injury, shorthand for how fucked her particular circumstances were. Odds were good she might have had a spinal injury, internal bleeding, a femur fracture or two, a dead fetus inside… a real Christmas gut-slinger.
Granted, I don’t have X-ray vision or a crystal ball, but after putting hands on the problem it looks like she got stupid lucky and just had a plain ol’ broke leg. Her boyfriend, the driver, was walking around on scene and was triaged by someone else. Might have signed a refusal form, even. But now that I lay eyes on him and get a report from the firefighter? Protocols say that bleeding from the ears trumps a broken leg, and Kevin here earned the bird, by the book. It’s always something, though. You gotta make calls based on guesswork and limited information. Until recent changes to the law, that might have been a $60,000 mistake for the patient, depending on the vagaries of her insurance terms and conditions and however that intersects with the fine print of my charting narrative. Likewise, the walking wounded stoner kid Kevin may have a massive subdural, and will have to ride ground-service 45 minutes or more to the nearest Neuro center in McKinney. Plenty of time to bleed into his braincase and stroke out.
And now back to the show.
The stretcher returns unladen from the landing zone; the thrumming rotor wash of the helicopter is slowly rising and fading away. Ellen and I strip the cot sheet and set off a hail of glass gravel.
A fresh sheet is tucked in, and we help Patient Two to the stretcher.
Mike, a young volunteer firefighter I know from the Gunter station, is giddy at all the excitement. He pops his head in the side door.
“Hey, y’all need a driver?”
“We do, Mikey. Light her up, Med City McKinney.”
Woop-woop.
Kevin is bleeding from his ear and nose, but it’s controlled. Which is to say: it’s not spurting bright red. There is no otoscope on the box so I can’t say if he just whacked his ear or if it’s coming from his brain. A field “halo test” (dipping the blood in gauze and looking for cerebrospinal fluid migrating out of the blood puddle) is negative. Good. He’s covered in cuts and scratches, but all the major systems are intact, no new ouchies or oomphs. Ellen and I both try to get an IV, no luck. It’s not something I ever got good at, finding veins with needles in truck beds speeding down country roads. Forty-five minutes of just talking to him to gauge his alertness levels and periodically checking his pupil response with a penlight. No projectile vomiting, no repetitive questioning, no nodding off or other signs of head trauma to speak of. Which is nice.
Ellen points out that I have time to do my chart. She’s not wrong. She takes sinister pride in her ability to wrap a chart before the bay doors close on arrival at the station. Really rubs it in. Goody two-shoes. Fuck charts!, I say. I have my chicken-scrawl notes and I will put charting off until it’s irresponsibly late, thank you very much.
