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"When *#%!

Hits the Fan!"

"Unit 12 your location?" the mobile 800 megahertz radio interrupts the drone inside the ambulance cab.

"Unit 12, west bound 26, approaching Cedar Hills," I respond from the navigators seat.

"Unit 12, respond to 2346 Barnes Road, apartment #206 for a GSW (gun shot wound). The scene is secure per Washington County SO (Sheriff Officer) on scene."

" Unit 12, copy, GSW at 2346 Barnes Road, apartment #206, responding," I reply back.

My partner Don reaches his right hand up to flip on the master switch to the emergency lights. A glow of red, blue and white lights reflect off of the highway around us and the nearby cars. It has begun to rain with small droplets now appearing on the windshield. Don slows to change lanes to the right for our exit is approaching ahead.

"Clear on the right," I inform Don after I make a head check out my window. I reach back to the laminated city map behind the center console, flip on the map light and confirm the location given to me.

"You know where you're going Don? I ask.

"Yeah, I know RIGHT where it is," he emphatically replies. As we approach the stop sign at the end of the exit ramp, Don activates the siren to warn oncoming vehicles. The simultaneous wail and yelp of the siren echoes into the night. It is about eight o'clock on a Friday evening. Vehicles slow and attempt to pull to the right and stop. After a bit of confusion and chaos the intersection is clear and safe to proceed into.

Don makes a right turn onto Cedar Hills Boulevard and accelerates into the left lane. Barnes Road is ahead about an eighth of a mile. Another right turn puts us less than a minute out from the scene. The flashing of other emergency vehicles can be seen ahead on the right in an apartment complex parking lot.

"There it is, on the right," I inform Don.

"Yeah, I see it" he confirms back to me. Don slows to turn into the driveway and proceeds slowly over the speed bumps in the road ahead. He positions the ambulance next to the curb on the left ahead of the police and sheriff vehicles already on scene. A simultaneous scene survey reveals crime scene tape already cordoning off the steps heading up to the second floor. Sheriff and police officers are positioned at the base of the staircase as well as at the top.

"Medcom, Unit 12 has arrived on scene." I inform the dispatch center.

"Copy Unit 12, on scene." The dispatcher replies. I grab my portable radio, glance out the window for traffic then open the door. I step out on to the wet pavement shutting the door behind me. I pull out the airway bag and drug kit from the side compartment. Don continues to the rear of the ambulance and opens the back doors to gain access to the gurney. The gurney lock is pushed as an audible "POP" is heard to signify it's release. The EKG monitor is already strapped to the mattress with the patient seat belts. I meet up with Don at the rear doors and swing my bags onto the top of the gurney. Don takes a position at the foot as I push from the head. After a quick lift over the curb we meet the officers at the bottom of the stairs.

"They're up in room #206, up and to the right guys" an officer informs us.

"Thanks, appreciate it." Don acknowledges. The gurney is secured down at the base of the steps as we retrieve our equipment and begin the walk up to the second deck. I am ahead of Don with the airway bag. Don is behind with the drug kit and EKG monitor. As we reach the top of the stairs the officers continue to guide us to the correct apartment.

The front door is open. It is dimly lit inside. I step onto a dark green, carpeted, unlit living room. The kitchen light is on with an officer visible, standing in the middle of it, listening to a distraught, crying female.

"In the bedroom guys," the same officer, who's holding a pen and notepad, raises his arm and points to his right while making eye contact with me. I turn and see a bedroom lit up with an incandescent light and two officers crowding the doorway. I can hear a muffled, inspiratory groan coming from inside the bedroom. As I part the two officers at the doorway I find two more officers, one standing at the foot of the bed, another at the near side and a plain clothed male on his knees at the end of the bed as well. His arms are up on the comforter, his bloodied head is between his arms and his face turned to the left. His respiratory rate is somewhat rapid and his groan almost sounds purposeful.

"What happened?" I ask a general question to the officers present.

"It appears that this guy shot himself after an argument with his girlfriend who's out in the kitchen," an officer replies.

"What did he shoot himself with and where?" I ask.

"Where not sure but..." The officer interrupts his sentence by moving his right hand up to his mouth, his hand taking on the form of holding a weapon, then pulling the imaginary trigger.

"Where's the weapon?" I ask with concern.
At that moment, I witness the officers start to look at each other with a "I don't know, do you?" look on their faces.

"We haven't found it yet" one officer finally admits. At this point I really don't care who didn't do what. All I know is that we're not going to do anything else until someone finds a weapon! Don and I step back and remain outside as the officers begin a careful search inside the room.

"Here it is, I've found it!" an officer finally belts out standing beside the far side of the bed. "The slide is open, it looks like a .38 caliber. I'll secure it if you guys want to go ahead and do your thing," he instructs us as he stands, straddling the weapon on the floor next to the night stand, electing to leave the weapon in situ.

We leave our equipment outside the bedroom door. Don proceeds to the patients head and starts looking for the source of the bleeding. His gloved hands quickly become bloodied as he runs his fingers through the victims hair.

"I've found the bubbling brew!" Don exclaims, smiling with morbid sarcasm in his voice. I bend over with a facial grimace to take a look at his finger pointing at his find. I continue the exam by cutting the back of his shirt open. His back is clear, revealing no additional trauma.

"Hey, can you hear me?" I ask him with a loud voice, my hand on his shoulder giving him a firm shake. The patient continues to groan without an appropriate response.

"Lean him back for a sec Don. Let me look in his mouth." I request, taking my mini-mag light out of it's holster on my right hip. I twist the lens to turn it on and pull the patients chin down. I can see a lot of blood pooling in the patients mouth and I see what appears to be a round entry wound at the top of his palate. I check a radial pulse at his wrist and find it to be rapid, regular and strong.

"Gary, what do you want to do with this guy? Don asks.

"There's a lot of room out in the living room, let's move him out there and work on him. What do you think?" I inquire.

"Sounds good," Don concurs.

The apartment appears fairly empty. It's hard to tell if these people are just moving in or if they are on their way out. Either way, they're making it pretty easy for us to find a work space (space is always a necessary commodity when working on a patient and more often than not, hard to come by. The lighting isn't good and this is going to be an issue as we progress with the call).

I take the lead and lean the patient back so I can place my arms under his armpits from behind. Bending down, I reach through and grab each of his wrists in my opposing hands (this gives me better support and leverage and helps keep his arms from inverting up over his head. A flaccid body with no muscle tone is very heavy and difficult to manage). In tandem, Don and I pivot the guys body around so Don can manage his legs. I lift his body up off of his knee's as Don pulls his legs out from underneath him. I lose my balance and sit back on the edge of the bed.

"You okay?" Don asks with concern.

"Yeah, I'm good." I reply. "You see anything on his chest or belly?" I ask trying to avoid missing anything.

"No, nothing," Don responds after lifting up his half cut shirt. I can see silhouettes moving out in the living room now. Tan overpants with suspenders and a blue t-shirt soon become apparent as I recognize the arrival of the local firefighters. One in particular, Mark, appears in the doorway first.

"You guys need a hand?" Mark asks with a motivational look on his face.

"We're moving this guy out into the living room. Can you guide Don out? I request.

"Got it," Mark replies.

"Ready? One, two, three!" I count out loud as we both stand in unison. Don walks backward out the bedroom door as Mark guides him with a hand on Don's belt.

"Where you guys putting him?" Mark asks.

"In the middle of the living room is good." I grunt with my arms full. Don lays the patients feet down on the carpet as another officer spots me as I lay his torso down.

"What happened to this guy?" Mark inquires.

"He put a gun in his mouth and shot himself. He's got an entry wound inside his mouth and an exit wound out the top of his head. The weapon is secure in the bedroom with the officer. He says it looks like a .38 caliber. As you can see, he's breathing on his own and he has a strong radial pulse." I respond trying to give Mark as pertinent and detailed of a turnover as I can (Mark is a Paramedic as well and can assist us in advanced life support if needed).

"Let me know what I can do for you guys and I'll give you a hand," Mark offers.

"Can you put my airway bag over here next to me Mark?" I request pointing back next to the bedroom doorway. "And, do you guys have some suction?" I ask referring to a portable suction device that is commonly carried by first responders.

"Portable suction!" Mark barks out to his fellow firefighters. My airway bag and a battery operated suction machine appear quickly and are placed beside me within easy reach.

Now that I have the patient laying supine on his back his airway is quickly becoming compromised from the copious amount of blood that is pooling in his mouth. I suction this thick serous fluid with a rigid plastic catheter that is attached to flexible tubing coming from the suction machine. The cyclic groan emanating from the suction machine produces a syncopated cadence along with the moan coming from the patient! Thick clots are now becoming apparent and starting to plug the end of the suction catheter causing the groan of the machine to take on a higher octave (a pretty morbid, harmonized symphony if you ask me)! Don and Mark simultaneously begin to place the patient on the EKG monitor, obtain vital signs and prepare to obtain intravenous (IV) access in the event the patient needs fluids or medications.

My job is quickly getting nowhere fast! Blood clots the size of toothpaste coming from the tube are starting to come out of the patients nostrils! The patient is starting to clench his teeth down now making it next to impossible to suction through his mouth (when a person's brain is starved of oxygen one response to this "hypoxia" is for the muscles of the jaw to tighten)! Blood is everywhere...pooling in his eyes, dripping down his face and out from between his clenched teeth! And, to add to this deteriorating mess, the battery to the suction machine starts to lose it's power taking on the growl of a slowing record on a turntable!

"I'll go get another battery," a firefighter initiates as he starts the trip downstairs to his truck.

"Give me a towel or something! I ask in frustration as an officer finds a kitchen towel and hands it to me. I wipe the mess away the best I can when without notice...the patient coughs forcefully!

"Argh!" I yell out. "You've got to be kidding me!" rocking back onto my heels. My glasses are covered with blood now dripping off of them. My face feels wet as well. Another towel is handed to me as I take my glasses off to wipe away the mess.

"This guy needs to be paralyzed so I can intubate him!" I inform Don and Mark with an obvious rise in my inflection.

"We ain't going to be able to do anything if we don't get an IV on this guy!" Mark looks up at me with wide eyes obviously referring to their difficulties (paralytic agents are used to relax a persons muscle tone, in this case, to facilitate the passing of an ET tube. The IV route is the preferred route of drug administration)."Try to ventilate him!" Mark suggests trying to come up with a temporary solution for me.

Don gets up and runs down to the ambulance, passing the firefighter who's running upstairs with the fresh battery, to where we keep the Rapid Sequence Induction (RSI) kit (a kit containing the medications necessary to paralyze in a rapid and sequential manner). Another firefighter breaks out the bag valve mask (BVM) and attaches it to a bottle of oxygen so I can attempt to oxygenate the patient. I do my best in obtaining a tight seal around the guys mouth and nose with the resuscitation mask while I squeeze the bellows of the BVM. This soon becomes futile as well for I am blowing blood everywhere (it is next to impossible to pass anything around or through a patients clenched teeth or through an obstructed nose)! Don returns with the RSI kit and continues with their difficult task.

"We've got one!" Mark exclaims as he and Don finally find an IV site and secure it to the patients arm. Don and Mark quickly crunch numbers as they come up with the proper dosage's for the medications that they are about to administer to the patient. They draw up Succinylcholine into a syringe and pull out the Lidocaine. I've transferred my responsibility to a nearby firefighter as I prepare my equipment in anticipation of intubating the patient.

"You ready?" Don looks up at me with one syringe in hand, the other in Mark's, waiting for my acknowledgement. I finish up my preparation.

"Yep, go for it." I knod, giving Don the go ahead. The two medications are carefully administered. The room becomes silent as we wait for the drugs to take affect (the paralyzing agent, Succinylcholine, usually has a quick onset of action. The muscles will fasciculate or start to tremor as the drug takes affect. The patient will stop breathing and the muscles will become flaccid as the medication reaches it's full potential).

After recognizing the signs we were all anticipating I proceed with the intubation of the patient. Lying myself prone on the floor, I gently insert the laryngoscope blade (a wide, curved or straight, metal blade attached to a handle held in the left hand) into the patients mouth, lifting and sweeping the tongue up and to the left so I can visualize the patients vocal chords (the trachea (breathing tube) is attached to the vocal chords which are a landmark in order to help successfully intubate a patient). I quickly realize that suctioning is required first for the patients mouth is again full of blood. The fresh batteries of the suction machine groan like a champ as I clear the patients mouth the best I can. I can see the vocal chords easily and look to pick up the ET tube with my right hand. Grasping the curved, thirty centimeter tube with my thumb, first and second fingers I begin to insert it into the patients mouth towards it's critical destination when, POP! left hand shoots towards the ceiling as the tension of my hand, holding the weight of the patients head off the floor, releases! The head hits the carpet with a dull THUMP! ! I look down in the dim light.

"Please, give me some light!" I plead as an officer quickly shines his flashlight at my hands. I find the detached laryngoscope blade still in the patients mouth, the handle in my left hand!
"What in the world?!" I explode out loud. I quickly remove the blood coated blade from the patients mouth attempting to reattach it to the handle when I feel someone tapping me on the back. I turn and look over my right shoulder, the flashlight beam following my every move.

"Gary, the weld broke!" Don exclaims, his face lit up by the bright flashlight circle shown in his face. "Look!" he points with his finger. I look back down at the two pieces, one in each of my hands.

"How did that happen?!" I ask myself looking at the top of the laryngoscope handle (I can't lie but right now I'm drawing a blank as to what to do next!).

"We've got a disposable laryngoscope down in the truck!" Mark reports out loud. "It's in the side panel next to..." Mark continues to give instructions as Don, again, hightails it downstairs to the fire truck.

"Ventilate the guy!" Mark instructs. I reach over and pick up the BVM. The bellows and mask is sticky with drying blood. The patients mouth has filled up again so I suction the dark red fluid, watching it travel through the tubing as it adds to the filling reservoir. I squeeze the BVM with every breath I take.

Time seems to be moving so slowly as we wait for Don to return with the extra equipment.

"Where the heck is he!" I exclaim to myself looking back to the front door. Just then I hear the crackling of plastic in front of me. I turn back around to see Mark reaching into a bag, pulling out a plastic package which I soon recognize to be that of a tracheotomy kit (it is taught to keep this device readily available in case, "*#%! hit's the fan!" during an RSI procedure). My level of anxiety drops and my excitement rises to another level as I realize what is about to transpire!

"Great idea Mark!" I quietly exclaim. Mark continues to open the package as I instruct a fireman to continue to suction and ventilate the patient the best he can. I don sterile gloves and begin to prepare the patients neck, sterilizing it with alcohol and betadine swabs first.

I raise my head and note that a
sheriff officer with a white, handlebar mustache is standing at the foot of the patient with a camera hanging from a strap around his neck. I quickly deduce that he is the crime scene photographer and get a fantastic idea in my head.

"Excuse me!," I raise my voice trying to get his attention. "Would you be able to get pictures of this for us?" I ask with intentions of documenting this rarely performed field procedure and use it for future educational purposes. Without answering, the officer grasps the camera in his hands and begins to make adjustments. He holds the camera up to his eye when brilliant flashes of white light start to illuminate the room while clicking of shutters adds to the cacophany of noises already present.

Getting back to my task at hand I locate the cricothyroid membrane [a physical landmark on the front of the neck, the insertion site below the larynx (voice box)] with my right forefinger. Pinching the skin over the site between my left fingers, I take a surgical blade in my right hand and make a horizontal incision through the skin and fatty tissue. There is minimal bleeding. I take my right forefinger and place it into the incision, resting it against the membrane.

"I'm ready when you are Mark." I anxiously wait keeping my finger in place.

There is jingling at the front door. We turn to see Don arrive from his wild goose chase.

"I couldn't find the darn thing!" Don exclaims a bit out of breath. "Oh, that'll work too!" he continues, seeing the change of treatment plan already in progress. With the tracheotomy kit readied Mark replaces my finger with his and begins the procedure (a large gauge, break-away needle is used to penetrate the crichothyroid membrane. This enables the insertion of a plastic catheter which in turn faciltates the introduction of the tracheostomy device itself).

"Help me out Gary." Mark asks, his hands starting to shake uncontrollably.

"No problem Mark, I've got ya." I respond, placing my hands on his, helping to guide the catheter in place (the plastic catheter graduates in size and increases the diameter of the insertion site as it is advanced and Mark is having considerable difficulty inserting the last of the device).

"Stand up, you have to sit on it!" I exagerate. Mark stands to straddle the patient and applying firm, controlled pressure with both hands, seats the device into place against the patients neck. After assisting with securing the device, the BVM is attached and I resume ventilations without difficulty. Finally the patients airway is secure and blood is prevented from entering his airway!

The patient is evenually packaged and moved downstairs to the awaiting gurney by the firefighters then transfered to the ambulance. A fireman drives the ambulance while Don and I both ride in the back with the patient while further care and treatment is given enroute to the trauma center.

"Phew!" I exhale with relief.

1 comment:

Allison said...

Holy crap that's intense. Why not the tracheotomy sooner, 'cause that was the first thing I thought when you mention blood pooling in the mouth. Of course, I wasn't there in the heat of the situation.