Let me tell you about my morning. It started at 4 AM, when we were toned for a patient at the jail having a breathing problem. It was a simple call with an easy fix (Albuterol and Atrovent work wonders for asthmatics), but the timing was just right to ensure that after finishing my report, there was no point in going back to bed. And, as soon as I was off at Riverton, I had to drive to the next town over for another 24 hour shift. Such are the joys of making a living in EMS.
By the time I finished writing my report, taking a shower, doing station duties, and making a small breakfast, I had about an hour and a half to kill before shift change. I took a cup of coffee from the thermos I always keep full of tungten-strong french roast and carried the novel I was reading to the picnic table out back. The weather forecasters were threatening us with a hot, sticky day, but for now the weather was pleasant. The sun had come up, but not so long ago that it had completely chased away the tendrils of dawn pink from the sky. I reflected that although getting hauled out of bed at 0 dark stupid always sucks, now that I was up, there were worse ways to spend the morning.
That, of course, is when the tones dropped. Before the cacophony of high pitched sqeals and whoops that call us to work had stopped, I was mentally figuring times. If the call was close, and if the patient wanted the local hospital, I calculated, I might just make it to my next job on time.
"Attention Riverton EMS, response is needed to 17 Highway one mile South of 28 for a one-vehicle MVA." Crap. These calls often turn out to be nothing-the patient was out of the vehicle before we got there, and didn't want to go to the hospital, or the car has driven off before we arrive. But when they're something, even if it's a minor something, they're time consuming.
I chugged the rest of my coffee down, and, on the way to the ambulance, stopped by my locker to pick up my bunker gear. Our fire gear provides pretty good protection against the broken glass and sharp bits of metal that tend to litter accident scenes. Climbing into the passenger seat of the ambulance, I glanced in the mirror to make sure my partner was on the way out. He was, and I reached across to get the clattering diesel that powers our truck started. A moment later, he climbed in, and we pulled out of the bay. Kevin pushed the button that activates our LED light show, and I turned the knob that cranks up the noise makers. I grab the radio handset "Rescue 1, Central, we're en route, miles zero."
About a mile down the road, dispatch calls to tell us that a civilian on scene was reporting that the driver was still in the vehicle. So much for getting to the next job on time.
The accident scene is on one of the main two-lane highways through the county where it intersects a gravel road. A combination of highway department engineering and weird topography mean that the gravel road sits atop high, steep embankments on both sides. The car, a Ford hatchback, is at the bottom of a ravine on one side of the gravel road. It's about 60 yards from the road surface, and I'll be damned if I can see how the driver got there. Usually, when a car leaves the road, the path it takes will be marked by churned up dirt and broken plants. If the vehicle rolled on the way, bits of broken car, along with papers, purses, CDs, cell phones, and the other junk people carry in their cars will mark the path of travel like breadcrumbs. As we get close, I can see some churned up dirt, but, while that trail leads to the car, it starts about 30 yards from the road. Kevin says what I'm thinking. "What the fuck did this guy do?" A bystander is frantically waving at us and pointing to the vehicle. He bounces up and down as he points, a gray haired gentleman looking like a toddler doing the pee-pee dance. "We see it, jackass," I mutter. "Calm the fuck down."
We pull up, and I hop out as the ambulance rolls to a stop. There's some water at the bottom of the ravine, and the ticks are said to be bad this year, so I take a moment to pull on my bunker pants as I survey the scene. A civilian, probably the one who had been talking to dispatch was squatting next to the passenger side of the car. Of the driver, I see no sign. Leaving Kevin to carry down the backboard and C-collar, I make my way down the embankment. The civilian starts talking as I walk up. "I've been trying to keep his head still, but he keeps moving it. He was unresponsive when I got here, but he's talking now."
The patient himself is laying face-down, with his head slightly out of the open passenger door, his torso in the passenger footwell, and his legs draped across the driver's seat. Both airbags have deployed, and the windshield is broken on the passenger side. There's a small puddle of blood on the ground under the patient's head, and he has several abrasions on his face and forehead.
So. He left the road moving fast. He wasn't wearing his seatbelt. When the steep angle of the embankment caused the car's nose to plow into the ground, he went flying across the passenger compartment. The broken windshield and abrasions suggest that his head hit the windshield. Since the airbags deployed, there may have been two impacts, one that set the bags off, and another that tossed the guy into the glass. His airway is open, and his breathing is regular. There's blood dripping from his face, but not enough to be concerned about. But I can only see the patient's back and face. I can't tell what's going on in front.
Kevin walks up with the backboard. Although he's the shift captain, and therefore the boss most of the time, I have a higher medical license, and on medical calls, I run the show. "Have dispatch get a bird on air standby" I say. In other words, have a medevac helicopter start flying our way. I turn back to the patient. "Hey, buddy, where do you hurt?" He says something but I can't make it out. "Do you know where you are right now?"
"At work." he says. Not good. At all. He's almost certainly suffered a head injury, and his level of consciousness is altered. By ground, we're at least 40 minutes from the nearest level 1 trauma center. And this guy needs a level 1 trauma center. I turn back to Kevin. "Go ahead and have the helicopter come to the scene. We're going to fly him from here." By now, I can hear the engine coming, and after calling for the bird, Kevin radios the engine crew to set up a landing zone. The best option is to shut down the highway and land the bird right there. We're about to piss off a lot of commuters.
I pass off c-spine (control of the patient's head to protect his spine) to Kevin and jog back up to the truck. I need more stuff. I grab the trauma bag from the shelf and yank down the IV start kit I keep taped to the wall of the ambulance. I mentally chastise myself for not grabbing this stuff in the first place. Blame it on a lack of caffeine in my system. On the way back down, I yell to the engine crew. "Hey, we're going to need some help here!"
Back at the car, the first order of business is to get the patient onto a spine board. Given the mechanism of injury, there's a good chance he's got a spine injury, and I need to see his front. As firefighters and EMTs arrive, I climb over the patient and into the back of the car, where I perch with my boots on the seat. That position will give me the best access to the patient once he's rolled over. Climbing in, I hear dispatch advise us that the bird is 20 minutes out. Too damn long, but I'll think about that once I get a look at the rest of my patient.
The board in place, we roll him over. At first, I don't see any other serious injuries. Both sides of his chest are rising and falling equally. His pelvis looks intact. No jugular vein distention, and his trachea is midline. His face is scraped and bruised, but I don't see double black eyes or the shadowy bruises behind the hear that can indicate a skull fracture. Then I notice his right arm. The hand is pointed at a 90-degree angle away from his forearm, but the bend is several inches down from the wrist. The skin of the wrist is pulled tight across what looks like the distal (far) end of the radius. "He's got a broken arm!" I call out as I grab ahold of his forearm. For a moment, I'm baffled. I need to splint it, but the hand is in such a weird position that I'm not sure how. I turn to Kevin. "How in the hell should I splint this?" Kevin's not a medic, but he's a damn good EMT and has been at it for a long time. As he has many times in the past, Kevin demonstrates the truth of the saying, "Medics may save lives, but EMTs save medics." Kevin suggests using a flexible splint rolled and bent to match the distorted shape of the forearm. It works.
But there's a problem. I'm manipulating the patient's arm. The patient's obviously and colossally broken arm. He should be screaming. I shouldn't be able to do this without dosing him with high-octane narcotics. But, although he's awake and talking, he's not showing much reaction to the pain.
Dispatch advises us that the helicopter is making better time than expected. Good. The other crew members slide the patient out of the car and began carrying him up to the ambulance. I take a moment to look more closely at the car. It hasn't rolled over. The damage to the front is minimal. The roof has no dents, even at the top of the windshield. The broken glass has to have been caused by his head.
In the ambulance, Kevin and I get to work. Carl, the Assistant Chief, jumps in too. We continue the oxygen the patient has been on since shortly after we reached him. Kevin hooks up the monitor, which will provide an EKG reading as well as basic vital signs. One problem: I need to get an IV started, and Kevin needs a place to put the blood pressure cuff. But the patient has only one we can use for those things. I yank off the patient's shoes and examine his foot for a possible IV site while Kevin gets a blood pressure. There's nothing in the foot, but Kevin tells me he feels a good vein in the patient's left arm. I look. I can't see it, but I can feel it. To get to that arm, I have to straddle the patient. I hate starting IVs that way, but this time I get lucky, and I hit the vein immediately. We run warm fluids wide open.
As we've been poking and prodding at the patient, I've been talking to him. He's becoming more coherent. He knows where he is. He understands that he's there because he crashed his car. He was in the hospital two days ago for extremely high blood pressure, but he doesn't remember how high. I perform a quick stroke exam, and find nothing to suggest that that's what's going on. The cardiac monitor looks good. Kevin points out a small bruise on the patient's abdomen. A bruised abdomen can be a very bad sign, but this one looks old, and when I felt the patient's belly, I didn't notice anything untoward. Still, I make a mental note to tell the helicopter crew about that.
By now, I can hear the bird overhead. Carl steps out of the back of the ambulance and drives us 100 yards or so to the landing zone. The helicopter crew arrives, and I brief them as we transfer the patient to the bird. A moment or so later, it lifts off and roars away towards the trauma center. Everyone on the crew has seen the bird take before, but we all stop to watch. I turn to Kevin and say the same thing I always do after a medevac, "No matter how many times you've seen it, or how many times you've ridden in one, helicopters are freaking cool." And they are.
The highway patrolman on scene has examined the accident scene, and tells us what he thinks happened. The guy drove off the highway, crossed several hundred yards of grass, then shot up the embankment with enough speed that he launched all the way over the gravel road before hitting the ground halfway down the opposite embankment. The trooper, Kevin, and I look back down the road, mentally tracing the car's path. After a moment, I turn to the the trooper. "So, he did a Clark Griswold," I say. I do my best Chevy Chase impression, hands on hips and staring at the horizon. "Fifty yards...." It's not often you can make a state trooper chuckle.
The back of the ambulance looks like a toddler has had a particularly destructive temper tantrum in it. Bandage wrappers, saline flushes, needle caps and other detritus are scattered on the seat, on the cabinets and on the floor. "Let's just get back and fix it at the station" Kevin says.
We get in front, and I pull out my phone. I've got to call the next job and let them know I'll be late.
