Ghosts: A Tale of a Career Paramedic.

Worst Day on the Job

No matter how long anyone has been in this buisness they have had a worst day on the job. Now, someone who has been in the field for a week most likely won't have had the same experience as someone like me that's been doing it 13 plus years. It's not everyday that a rookie gets a crack addicted hemophiliac baby that fell out of a tree. Those worst calls come once and a blue moon, even for us veterans. I've spoke of ghosts before, it's the very title of this book. Through the years I've acquired a several, a few in particular stand out. I can remember the first child I saw dead. 3 actually in the same day. I was sitting in the ER bay when the Fire Department rolled in, not with their ambulance, but their fire truck. As soon as they screached to a hault, 3 men from 3 different doors leaped out, still in their smokey fire gear. In their arms they carried 3 children, lifeless. I followed them into the trauma room where the 3 bays were instantly filled with new patients. I did my best to help with the unprepared and ill informed ER staff. I tried my best, but inspite of me, I froze. Stood there over the body of a lifeless 4 year old child. It wasn't until the Dr. came in next to me and told me to compress fast and hard that I snapped out of it. So I did, I did as I was told. By this time, the entire ER had filled with RN's, Dr's, Respiratory staff, and techs, the works. I wasn't sure how long we worked on the child, it didn't seem very long before the Dr. gave the orders to cease. In an instant a room that was filled commotion snaped to complete silence and we all stood very still. It was like we all just realized what had actually transpired. We all bore witness to the deaths of three children. The child I worked on was 4 years old, his twin sister lay next to him just a few short feet away. They were victims of a house fire. It wasn't the fire that had extinguished thier lives, it had been the smoke. They were been watched by their 13 year old sister when the fire had broke out. They were found hidding under their beds, their sister was found dead in the hallway, in an apparent attempt to find her siblings. As I left I stile one last look at the 4 year old boy I had just worked on. It was surreal, he looked asleep, so peaceful. If you had not know he was just in a house fire, you wouldn't had known. He wasn't smokey, no burn marks, just still and silent. At this time of my career I had been a paramedic for just shy of a year, this was the first real event I had seen. Yeah I had seen dead people, but all adults, and most of them from nursing homes. But these were children, lives stole from them at such a young age. Fast forward to a little over a year. It was my first shift on the elite 911 truck for the company I worked for. They had a dedicated car to the city which was a 24 hour car. Of the 6 people who staffed it on a 3 day roation, I would be one of them. I say elite, because at the time, they were. It wasn't filled with the old guys who wanted a slow station and a cake job. No, this was the city and it was a busy car. I wanted to prove myself as a medic, I wanted to know that when the shit got real so would I. I wanted my co-workers to respect me and know that I was legit. It was late evening, somewhere in the neighborhood of 22:00. A call came out from the fire radio; "Station 1 on the air for an MVA. 1 car rolled over with one person ejected." I jumped from my comfy recliner and swiftly walked to the ambulance and hoped in. The garage opened and the red and white lights blazed into the night. We were the first on scene, fire was shortly behind by the sound of the sirens. I stepped out onto the street and saw a long dark colored car on all 4 wheels, the tail end facing the street. The car looked in rough shape, the roof had collapsed slightly, and it bore several scratches. I walked around the back of the car just as fire had gotten there. Off a short distance was a young man standing on the side of the road, he looked a bit dazed. I turned around to look at the driver door to find my patient. She was limp, covered in blood and hanging out of the driverside window. A man was holding her head and using a BVM (Bag Valve Mask used to breathe for someone who isn't breathing). I asked where he worked and he told me for the city (not ours, another big city). He told me he has seen the whole thing. The car with our patient in it was driving fast and tried to go around a vehicle turning left on the shoulder. The driver had lost control on the shoulder and it rolled one complete time. My patient was lifeless and covered in blood. By this time fire had informed me that the kid who was standing just a short distance away was the second passenger of the rolled car, and that he had been ejected. I had them go do a standing backboard take down on him while I went to feel for a pulse on the girl. She was without one, she had died in the crash. I informed my partner that she was dead and also told him about thekid who was ejected. He decided we should work her and call a second unit for the kid while fire was already helping him. I was faced with a struggle. In EMT school I was taught about triage. The rules of triage are simple, esspecially concerning the deceased. In the event that are two or more patients rules of triaged are applied. If someone is unreponsive do the following:
1. Check for responsiveness. (tap and shout) I knew just by looking she was unconscious so I skipped that step.
2. Check for breathing. (Look listen and feel) She was not.
3. If not breathing, open airway. (So I did)
4. If still no breathing black tag patient and move on.
Black tags signify death in the field. There are 4 colors in triage. Green meaning walking wounded and least priority for transport. Yellow means delayed, can wait up to an hour before transport. Red is immediate, 1st priority transports out of the incident. Black tags are left until all others have been transported. So I had a black tag patient and even without making contact with the kid I knew he was a red tag. He had been ejected from a car after rolling over, its an automatic red tag. So I wad ready and prepared to black tag the young lady hanging out of the window and help the kid who had been ejected. But my partner wanted to work her and I was still very new, and much less confident, so I did what he did. As we were loading her i to the ambulance, fire informed ke that my patients mother had showed up on scene and wanted to ride with us to the hospital. Great, I have a dead 18 year old with massive injuries, and I'm sure a panicked mother, not what I needed. I told fire sure, but under the condition that she sits up front and doesnt ask me questions. I had a lot to do, I wasn't trying to be mean, I just had to be focused on my patient. Luckily for me and my partner the mom did as instructed. We started towards the closest trauma center, a solid 25 minutes away... Fun. We got ROSC (Return of Spontaneous Circulation) on the way, so at least we didn't have to do CPR the whole way. This call was very educational and surreal, a weird combo. The surreal part was when I was checking the back of her head for and obvious holes, major bleeding or fractures. What I found was a larger avultion or tear in her scalp. Large enough that I was able to put my whole hand under her scalp lone and hold her skull in my hand. Trippy. Educational because when we got her to the trauma room at the hospital she lost pulses again. The trauma surgeons immediately cut open her chest and removed her rib cage. All the core organs were there staring at me. The heart was quivering, she had went into a lethal heart rythm called ventricular fibrillation, or vfib for short. Her lunhs inflated and deflated with every ventilated breath. From the frothy red bubbles oozing out of her lungs on inhalation, it was obvious she had pneumothorax. Epi was drawn up in a needle and put right into the quivering heart. Next they took two small paddles and shocked it into a normal'ish beat. The surgeons took a big clap and cross clamped the aorta just above the stomach. They did this to keep the blood to the core organs, Brain, Heart and Lungs. And off to surgery she went. She might have been in that room maybe 10 minutes at best. They were ridiculously efficient. Now for the bad part. All of that up to that moment wasn't heart wrenching or horrifying. Honestly, i was way to busy on focused to really be bothered by it. What sucked was that I had forgottwn to get a signature for my paperwork. And of course every RN and Dr. were busy and or absent when I needed it. I had to get one, so I had to go find the mom who had rode in with us. By this time she had been moved to the surgery waiting room. And now that the excitement of the call was leaving and the surge of adrenaline was diminishing, the slide show of the call began to play out in my mind. From the beginning I have always tried to review, to see if I had made a mistake or if I could improve. It was late and the scheduled surgeries were well over, so the mom, now accompanied by her husband and a priest were all alone in the eerily quiet waiting room. It was the look of utter dispondance and shock that struck me the most. You could see that the event was starting to set in as reality. I'm sure most of us have had moments like that. "Is this really happening"? It did happen, it was real, and they were beginning to realize that. They asked me as I approached if I knew anything about their daughter. All I knew is what I had saw, what her condition was when they whisked her off to surgery. I felt obligated to tell them everything. I felt like they should know. Who knows how long it would be before an update. And even when one did come, it would be some impersonal surgeon with large words and little to no comfort. I've always hated how terrible a lot of Dr.'s are at bed side manor. So I told them everything I had seen and knew. I got my signature, wished them luck and offered my best and I left. The last loom I got of them was the priest laying a gentle hand on the moms shoulder as she burried her face into her husbands upper chest by the shoulder, the nook as many women call it. About a week later we were on a SNR, refusal in the same city as the car accident. My partner was off with the not so ill patient talking about sports, baseball or golf, I can't really remember. I looked down at the table and right on top was a newspaper. Oddly enough it was opened to the inside and a large article was off the the right page. "Young woman, 18 dies in tragic car accident". The picture seemed familiar. I began to read it, sure as shit, it was my patient. Sadly her injuries were to severe and she had succumbed to them. The article wasn't just an editorial piece. Most of it was written by her younger sister of 13. She wrote how she was going to miss the times they would bake cookies together and decorate them. How she would no longer be able to go to the mall and clothes shop with her sister. I was damn near in tears, even now as I write this my emotions are swelling up. Not only had all my efforts been in vain, but now it became very personal. Her younger sister will forever be without her big sis, and won't be able to clothes shop or decorate cookies together. That call was shitty enough, but it wasn't my worst. My worst has haunted me almost every other day since it happened. It has affected the way I treat certain calls and forever changed the way I approach calls. I was called to a Dr.'s office for a transport to the local hospital for a possible fractured leg. It came in as a BLS (Basic Life Support) no epuipment needed. What that means as it was determined by the patients Dr. that his condition was not serious enough for Advanced Life Support or ALS and all that was needed was the cot for transport. So we arrived and walked in with our cot only (refer back to the rule for always bring your equipment). Our patient was sitting in a size to small wheelchair in one of the exam rooms. He was alert and appeared in no distress. We struck up comversation and came to find out that he had falling a few days ago at home and has had increasing pain in his upper leg and difficulty walking since. Upon assessment of his leg we saw that it showed heavy bruising, deep purples, blacks and blues. If you didn't know it was a leg you would have thought you were looking out of a telescope into a distant nebula. His leg was also extremely swollen and warm to the touch. Remember these findings for later. The bruising, swelling and warm feeling extended from his upper thigh to his ankle. The Dr. came in and told us he was pretty sure that his leg was broken, but the patient due to him being overweight and inability to walk, couldn't get in the X-Ray table. So that's what we were there for, to take him to the local hospital for an X-Ray to confirm the findings. The Dr. td us that they were finishing some paper work and we would be ready transport in about 10 or 15 minutes. So we had some time to kill so why not shoot the breeze. Small talk began. Our patient was a U of M fan and me my partner were State fans. So obviously some friendly pokes were exchanged. He and his wife who was there were also just recently married, 6 months to the date. They had both been widowed and had found each other and fell in love. They were a very cute newly wed couple. In the 10 or minuyes we waited we actually had found out a lot about one another. It was a rather pleasnt interaction. Time came for the transport and due to his condition we offered two ootions to get to the cot. Option 1 was to wheel him as close to the cot and help him stand on either side of him, and have him pivot on his good leg and sit on the cot. Option 2 was to call for the fire department and have about 4 or 5 people pick him up and put him on the cot. The issue with this option was, the hallway was tiny and allowed no room for maneuvering. And the exam room was spacious enough for the patient and his wife plus us, but not really anybody else. So our patient decided on Option 1. We got him as close as possible to the cot and got on both sides of him and helped him to a standing position. We pivoted on his good leg and sat him on the cot. We helped his legs up to the cot, being gentle and careful of his more than likely broken right leg. When we had him straped in he told me he was feeling a little short of breath. I had no equipment with me, it was all in the ambulance about 150 feet away in the parking lot. So having no oxygen to give him, I did the next best thing. I told him Id sit him straight up to help with his shortness of breath (One thing you are supposed to do in DIB calls) and promised him as soon as we got to the ambulance Id put him on some oxygen. I felt a little bad, but I was also told by a Dr. that no equipment was needed (refer back to the rule of always do your own assessment). He said that would work just fine. We raised to cot up to full height and began to walk out to the ambulance. Now yhe hallway was tiny as I had mentioned earlier. And with our patient sitting fully upright, high fowlers, I couldn't see him as I was at the head of the cot. My partner was at the foot end and had direct line of sight to our patient. So in other words if anything had turned south, I figured he would know well before me. As we backed out of the hallway I noticed that our patients right leg was lazily hanging off the side of the cot. I thought it odd, but I thought maybe that was more comfortable for him. And again, my partner would notice if anything was a rye. We got to the ambulance and locked the cot on the hook. My partner lifted the feet so I could pull the wheels up. All of a sudden a torrent of urine began flowing off my side of the cot. I very ignorantly didn't have gloves on and had to quickly move them out of the way. My first reaction was anger. I was turned to him and was just about to yell at him for pissing all over my cot and almost on me, and then I saw his face. His head was slumped slightly and awkwardly to the right. His eyes were lifeless, his face a pale greay, lips blue. Time seem to freeze for a split second, and in that time everything clicked, the dots all connected instantly to paint the picture. PE, or Pulmonary Embolism. A blood clot that breaks loose from a large vein, usually the leg. It finds a new home in the pulmonary artery. The circulatory system is a closed loop. Any blockage shuts it all down. And clogging the circulatory system means no oxygen to tue brain or heart, which means death, quickly. He had suffered a fall three days ago resulting in a fracture to his femur. Since he had no immediate medical attention the fracture continued to bleed slowly, resulting in the heavy bruising. At some point most likely due to the lack of movement and severity of the injury a blood clot formed in his right leg. It was lodged precariously in his major vein that runs the length of your leg, probably near or around the knee. This back up of blood caused inflammation which causes heat. The second I saw his lifeless face, it was like the show seconds from disaster played in my head. I saw the while thing play out from start to finish. I knew in one second that he had died of a massive PE. The next few moments are a bit of a blur. Everything from that moment happened rapidly, faster than it had ever happened before. We loaded him up, started CPR, secured the airway, established venous access. All the while the wife was standing just outside the open side door, watching her newly married husband flop on the cot with every violent thrust into his cot. In the midst of everything happening, I could hear her crying. Not weeping, but that cry you have when something terrible happens in front of you. The cry you have when it hasn't excatly set in as reality. It's almost as if the mind has a default cry to when it see's such things. Somewhere in the craziness I had manged to I'm sure scream for help over the radio. They must have been close, because they got there quick. I can't think of his name, the other medic, but I knew he was new. He had worked with us for a few years as an EMT, but he had only recently been licensed as a Paramedic. He secured the wife in the front seat and he hoped in a drove to the closest hospital. I remember asking the with enroute if he had any history of blood clots. She was able to reply under the tears that he had just been put of blood thinners because his Dr. was worried about him getting them. We arrived at the hospital and rushed into the trauma bay. I gave a quick report with heavy emphasis on my suspicions on a PE. The Dr. seemed to agree with my assessment. Usually I turn over care and let the ER staff take over. Not this time, he was my patient, he had died on my watch, I was going to be here to whatever end. It wasn't long, we all knew it, he was gone. His brain had been deprived of oxygen for to long, and with a clot blocking everything, no matter the quality of CPR we did, the brain wasn't going to get any oxygen. She called it, gave the time of death and we all stopped. I stood there looking at him. It was my time for that moment when it finally sets in as reality. My trance was interupted by the Dr. She asked if I was ok, I wasn't, and I didn't lie about either. She told me she knew how I felt. She had someone die right in front of her, and that it really sucked. Sucked was an understatement. I had had many of cardiac arrest at this point in my career. Doing CPR on someone was nothing new. I had myself ceased efforts in front of family, pronounced countless souls. But I had never had someone die in front of me. Esspecially someone I had developed a report with. 30 mins ago we had been ribbing eachother over our respective college teams. Laughing and joking. Now he lay there dead, no more laughing or watching U of M games. The Dr. suggested that I sit down and collect myself, but my job wasn't done yet. I had to tell the wife. I felt responsible, I felt as if I had failed in some massive way. It was my duty to tell her that her husband was dead. I walked with purpose to the waiting room where she was off to the side alone. I pulled a chair and sat right in front of her. I think she knew what I was gonna say, she had been there from the start. Even if she knew it was still a blow to her. She began to cry earnestly, loud enough to attract the attention of the other people in the waiting room. I don't know excatly how long we were there together, but I do know that she was not the alone in crying. I for months after been severly fucked up over that call. I obsessively reviewed that call in its entirety in my head. Looking for anything I could have done differently. It wasn't until one of my most trusted partners sharred some worth advice. "Sometimes we stop the ball from rolling off the cliff, sometimes we might speed it up. But it was already rolling before we got there." In other words, we can't fix everything. Sometimes the injury or illness is to severe for the resources or skill set we have. I have since made peace with it. In reality there was nothing I could have done to prevent it. Even if I had noticed all the signs of a DVT (Deep Vein Thrombis), there was nothing else I could have done. The ball was rested precariously on tue edge of a cliff, all it needed was a little nudge. Unfortunately for me and my partner, we were the ones to give it that nudge. It really gonna happen eventually. Either there in that office, enroute to the hospital on bumby Michigan roads. Transfering over to the bed at the ER or slidding over to the table for the X-Ray. The clot was large and lodged very loosely. I still think about that call often. When the night is quiet and I'm aline with my thoughts. I think about the wife and what she had to witness. How they had only been married for 6 months. They had both been widowed, and now she was for a second time. That's when I made up those two rules. Alwaus bring in your equipment and always do your own assessment. Even if I had brought in my equipment it wouldn't have mattered, he was dead even as he began to feel short of breath. But I still have decided to not get caught with my pants down anymore, and to not blindly trust even a Dr.'s assessment. My worst call wasn't a bloody mess or a mutilated body. It was a person who I had gotten to know briefly, die in frint of me.