I was in for my shift at exactly 1400 today, just as I was supposed to be. The paramedic I was relieving blew through after getting back from a call a few minutes later and I settled in for some of the administrivia that seems to dominate my days now. It didn't last very long, about 45 minutes after I relived the day paramedic the fire department and ambulance were toned for an "incoming medical". Essentially that means that a 911 call has been received and is going through the EMD process to determine what was happening. All they had was a street name.
The rescue roared off followed by the ambulance. Not knowing what was going to be happening I elected to head in that direction as well. A minute later the first update came in, motorcycle versus car, one party on the ground reported to not be breathing. A second ambulance signed on to bring us the additional personnel we might need if the patient was indeed not breathing and possibly without a pulse. Simultaneously the officer on the engine company also responding requested a helicopter to be dispatched to the scene as well.
The rescue and the engine arrived about a minute prior to us. Too short a time to give us any update. I and the ambulance arrived simultaneously to find the patient lying in the grass on the shoulder being attended by the firefighters, a motorcycle lying on it's side further down the shoulder and a small car stopped a few yards away.
The patient was clearly seriously injured. Even though his airway was full of blood and secretions he was shouting incomprehensible words in a loud voice. He had an obvious jaw fracture and abrasions to all his extremities. Some subcutaneous air was palpable on his chest and neck. One eye was swollen shut and the other eye was only sluggishly reactive. He clearly had a significant head injury.
His airway was cleared with some suction and we quickly got a cervical collar on him and strapped him to a long backboard. With three of us on each side of the backboard we rapidly moved him up the grassy slope and to the stretcher and from there into the ambulance. One of the firefighters hopped in along with the crew.
It was about this time that we found out the the helicopter had never actually been dispatched. The FD dispatcher had call, inquired of they were available but never actually asked them to launch. They would have a 15 minute ETA. We weren't going to wait. The engine officer asked that the helicopter be launched and meet us at the hospital. If it got there before us they would take the patient to the trauma center if not we would go inside and they could transfer the patient from the community hospital to the trauma center.
Around this time the second ambulance arrived and one of our most experienced EMT-Intermediates got on board. With him we had 4 EMS members, 1 paramedic, 2 Intermediates, and an EMT-Basic in the patient compartment. I told the firefighter we were all set and that he could hop out so we could leave. He refused. Twice more I told him he should get out so we could leave and twice more he refused not giving any reason why. At this point I decided that we couldn't waste anymore time and told the driver to head for the hospital.
Enroute we got two large bore IV's started, some high flow oxygen, cardiac monitor, capnography,
pulse oximetry and a second survey completed in just a couple of minutes. With 5 of us in the back we had plenty of hands, almost too many hands.
During the second survey I noted that the patient was having more difficulty breathing with no breath sounds on the right side, no chest rise, and ever so slight tracheal deviation to the left. All indications were that the patient had a
tension pneumothorax on the right side. I pulled out the decompression kit and prepared to decompress his tension pneumothorax. The relatively new EMT-Basic was watching with wide eyes everything that was happening and stiffened visibly as I took the 14 gauge catheter and inserted it in between the third and fourth rib on the right side of the patients chest. A large rush of air came out partially pushing the stylet out of the catheter. Within a few seconds the patients chest began to move, his lung sounds had returned and his oxygen saturation improved. The firefighter began to take exception with my treatment plan and made it known that he wanted to be constantly suctioning the airway rather than putting the patient back on the high flow oxygen. I told him in no uncertain terms that this was my decision and not his.
In an ideal world I would have intubated him to definitively secure his airway but with out the availability of paralytics that wasn't going to happen so we had to make do with frequent suctioning and assisting his ventilations when his rate grew too high or too shallow. Even with frequent suctioning and careful monitoring of his airway it was getting more and more difficult to keep it clear. I was glad we were making good time to the hospital.
We arrived at the hospital with one of the ED nurses (who is also a paramedic) and a surgeon waiting for us on the apron. We were ushered quickly into one of the rooms and from as I gave report things really started to go downhill. The helicopter landed 3 minutes after we went inside and the flight crew came in to the treatment room.
The ED doc decided that the patient needed to be intubated right away, probably a good call, but after he had the sedation and the paralytic given he decided to try a new piece of equipment that he hadn't used much before. The result was a total inability to visualize the airway landmarks and therefore an inability to intubate. The airway structures were swollen with free air in his tissues and grossly deformed. With the patient paralyzed and an
endotracheal tube unable to be passed managing this difficult airway was truly a nightmare. After a short time of unsuccessfully managing the airway himself the ED doc asked the flight crew to do a
cricothyrotomy, a procedure where a tube is placed through the cricothyroid membrane in the neck right around where the adams apple is. The flight crew did this with some difficulty but eventually the airway was managed. The did a chest x-ray to confirm the airway placement and started to give the patient some whole blood to replace what he was losing from his injuries.
At this point I left the room to help the crew decontaminate the ambulance and get some information for my report. On one of my trips in for supplies one of the docs not involved with my patient pulled me aside to show me the chest x-ray. A small pneumothorax on the right side that I had decompressed and what appeared to be an almost complete pneumothorax now on the left side as well. It looked quite impressive.
As we were leaving the patient was being transferred to the OR at the community hospital for a reason that was yet unclear to me, not that I really needed to understand it.
We returned to quarters to finish restocking and to return the additional personnel. When we had gotten back I approached the firefighter who accompanied us to talk about the situation and his only response was "no harm, no foul" and then walked away. I was pretty dissatisfied with that response and notified the appropriate people of the incident in our service and left it to them to look into it further.
More information as to the circumstances of the accident had come to light by this time and what we learned was that the patient had lost control of his motorcycle on a curve and when it went down was launched into the path of the oncoming car. The driver of the car had seen the patients motorcycle wavering and had braked hard so he was almost stopped when the patient struck the front of his car head first. Even though he had been helmeted with a full face there was no way he was going to avoid massive head trauma.
A couple of the crew on the call we pretty upset. One because the patient was his roommates best friend and the other because it was her first major trauma and she was overwhelmed. We spent some time talking about the call, what went right, what went wrong, what we could have done differently and, while still upset, everyone felt a bit better and realized that we had done a pretty good job.
A couple of hours later I got a phone call from the ED nurse/paramedic who met us on the apron to tell us that the patient has died on the operating table. I wish I could say that it was unexpected but, for me at least, it was the outcome I felt was most likely.
I felt bad for my crew and we all decompressed for quite a while afterward and even tough we had done a good job nobody felt much satisfaction from it.
The remainder of the shift was quiet. Paperwork, police statements, an interview with the medical examiners investigator filled the rest of the shift and when it was time for me to go home I was more than ready.
Total calls for the day: 1 ALS transport
Milage for the day: 24 miles
