The fire engine crew has done a great job. I walk fast to the knot of firefighters tending to our patient in the middle of the street, already stripped to his underwear, and on the backboard. With a shooting, I want to be gone in less than ten minutes. We’ll be done in five.
A well-run trauma call is efficient, creating speed. When it is flowing exactly right, I see the entire patient at once while my hands search and find miniscule details. I hear the tiniest aberration in the patient’s lungs. I perceive all movements of the crew, before they are made. I am a robot. I am a sponge. I am faster than is possible. I can see the future. And that feels amazing. Like heroin to a junkie.
I straddle the patient to begin my physical exam, while I’ve got the space, before we all get stuffed into the back of the ambulance, and before things get busy.
Hair and facial area are clear. Left ear’s got a through-and-through wound. Nothing to worry about. Eyes are open. He’s gasping for air.
He is gulping it in. He sputters, “I can’t breathe. I can’t breathe, man.”
I translate his words into his medical condition, He’s breathing. He’s talking. Good brain function.
I give him an answer, to let him know I do hear him, “We’re going to take good care of you. Hold on.”
Keep moving. Don’t slow down.
A brief check of the neck. Nothing spectacular. I move my hands away and a firefighter follows with a cervical collar.
Arms. Grazing shot, left upper. Nothing on the left lower. Move to the right arm. There’s one. Right upper. Check the armpits. Got one. Right chest, under the arm.
I smile inside and feel the adrenalin course through me, holding my high. God, I love it when I catch the tough ones. I admonish myself, Move it! Work!
Right lower arm. Nothing. To the hands.
I place two fingers in each palm and tell him firmly, “Squeeze.” He grabs them hard then I shake him loose, continuing my search at the chest.
Keep slow. Check everything. Bullet holes are small. Look everywhere.
My eyes follow my gloved hands as they touch every bit of his skin. I purposely run my fingers through puddles of blood on his chest. They hide bullet holes. There’s one. Just off center to the right. I continue on and, like a macabre finger painting, my gloved fingers leave bloody swirls down to his stomach.
I push on the four abdominal quadrants. My hands press deep without a problem. Belly is clear. I rock his hips back and forth while pressing down, then in. Pelvis intact.
I shift his underwear around, trying to maintain a shred of modesty for this guy. However, I pore over every inch of his body in the middle of an intersection, and I look at everything. One hole in the left butt. Shift on down. Another one, left thigh.
I am now below his feet. I yell, “Move your feet.” His toes move back and forth. Good. Responds to commands.
I stand up. Damn, my back. The muscles burn as the strain is relieved. The fire guys strap him onto the backboard while I strip off my bloody gloves and drop them between his legs. I’ll put on new ones in the ambulance.
Damn, this guy’s got…one, two, three… My fingers follow the progression of bullet holes I have found…four, five…six…seven holes in him. Who’d he piss off?
I never did look at his back. That’s all right. He needs a surgeon more than he needs me to roll him off the board. Besides, he’s shutting off any holes back there by laying on them. They’ll check at the hospital. My partner has the gurney beside us. Time to go.
“Okay, everybody, on three.” Four uniforms snap to their places around the board. “One, two, three.” Our patient sails up and onto the gurney. The gurney straps fairly fly then we roll to the ambulance.
I jump inside. Keep things flowing. We’re moving good. Only do things that are important; skip the fluff. One of the firefighters, Tom, jumps in the back with me. He sits above the patient’s head, and I start barking orders as I put on fresh gloves. “High flow oxygen by mask. I’ll get him on the heart monitor.”
Tom rips open a cabinet and grabs an oxygen mask. I start to grab the heart monitor but stop. I haven’t listened to this guy’s lungs yet and it’s about to get a lot noisier in here when we start driving. I’d better do that first.
I place the stethoscope in my ears and lean over the patient, bracing myself with my hand on the opposite wall. I sternly call out, “Take a deep breath. In and out.” Our man’s chest goes up and down. “Good. A couple more.” I move the scope over his chest, hearing full and equal breath sounds on both sides of his chest. “Good. Thank you.” Some of those bullets definitely hit lung tissue. I’m pleased that either the important stuff was missed, or he hasn’t degraded enough to show it. Tom drops the mask over our patient’s face and tapes it in place.
“I can’t breathe. I can’t breathe.”
The guy’s protests are muffled by the mask.
I try to calm him a little as I drop the stethoscope back in the bag. “That’s oxygen, man. Pure oxygen. Leave the mask on. Keep breathing.”
Don’t let him distract you. Keep working. Be efficient. That’s his best chance.
I reach over to the heart monitor on the bench next to me and pull the cords from the pouch. The three patches are hooked on already. I rip them off in order and slap them on his chest then flip the dial on the machine. The green blip flows across the screen, giving a constant reading of his heart rate. It’s 136. That’s fast but he’s got seven new holes in him.
I yell out to my partner, “It’s time to go. Drive smooth! We’re working back here.”
My next duties are to call the hospital and start an IV. If I can get enough time, I might even try a blood pressure. As long as he’s got a pulse at his wrist, though, I honestly don’t care. It’s good enough.
But there’s a problem: It takes me five minutes to set up, and completely start, an IV. I’ve got four.
I did notice Bill, my partner, had flooded an IV and left it hanging from the hook above my head. He had been busy while we were packaging this guy. I love working with a good partner.
I yell to the front of the ambulance, “Hey, Bill. Can you call the hospital? We’ve got a lot to do back here.”
Bill yells back, “Sure. You’ve got about three minutes.” One less thing to do.
I shift down to prep our patient’s left arm for the IV. I rip and tear packages, laying them out as I like them, then stretch the tourniquet around his upper arm and tie it snug.
“I can’t breathe. I just can’t breathe.”
I glance up at his chest. He’s breathing way too fast. His skin is getting pale, and he’s sweating. Damn, he’s getting worse.
“Tom, can you get out the bag-valve-mask? He needs to be bagged.”
Tom reaches in to the jump kit on the floor and pulls out the BVM. He pulls the oxygen mask off the patient, throwing it aside, then places the BVM’s mask over the guy’s face, squeezes the bag and forces 100 percent oxygen into his lungs.
I’m trying to find a vein. This guy is young, but his body type is one with a very fine layer of fat all over. Just enough to hide his veins.
“I can’t breathe, man.”
Ahh, not again, I yell to myself. I’m getting pissed.
I look up. His eyes are wide with fright; his mouth gasps for air. He rocks back and forth against the belts that are holding him down.
Something ain’t right. This guy’s breathing problems are slowing me down. The basic approach to medicine at any level is called the ABC’s. It’s actually a mnemonic for Airway, Breathing and Circulation. If you don’t solve one, don’t move on to the next. I have been trying to solve “B” ever since we got into the ambulance but, everything we try isn’t working. I keep looking for an IV while, in my head, I run through the problem like two guys screaming at each other.
His lungs are clear. The air is getting to the lungs. Why can’t he breathe?
He took two bullets to the chest. His lungs are hit.
But I heard air all over. They haven’t collapsed. Why isn’t that enough? He’s still got a good pulse at the wrist, so his blood pressure is still good. He’s still got enough blood.
His pulse is fast. He is bleeding inside like a burst dam.
I quit the IV for now, mostly out of frustration. I have to solve the breathing problem. I grab the stethoscope.
“Tom, bag the guy.”
Tom presses the oxygen in as fast as the bag will re-inflate. I hear great air. What the hell is going on? He’s getting good air to his lungs. Why can’t he breathe?
I’ll think about this while I try the IV again. The tourniquet is still on. Nothing new has popped up on his arm. Damn.
“Scott, it’s getting hard to bag.”
I look up. The patient is no longer fighting. His eyes are staring up and are glazed over. I look at the heart monitor. He’s still clicking along at 140. Shit. I can’t keep up with this guy. Time to intubate.
I grab the bag with the intubation equipment and tear into it. I rip open the package to one of the tubes, hook up a syringe, and inflate the balloon on the other end. This is to test the balloon to make sure it will hold air. I deflate the balloon, grab the laryngoscope handle, and attach a curved blade. It is wide and flat to move the tongue out of the way. I bring the blade to a 90 degree angle, turning on a light bulb at the end. The mouth is a dark place. I’m ready to go.
“Tom, move out of there. I’ve gotta intubate him.”
We switch places. This puts me above the guy’s head. I pull his lower lip down so I don’t catch it with the blade and mash it all to hell. If this guy lives, no use giving him a fat lip. I push on his jaw to open his teeth, get the blade in, lift his tongue out of the way, see the vocal cords, and shove the tube all the way into his lungs. His mouth won’t move.
Shit. His jaw’s clamped shut.
I feel the familiar swerve as we pull into the hospital. Out of time. Damn. He’s not breathing either. “Tom, keep bagging him.”
We switch places again. I pop the tourniquet off the guy’s arm on my way by and put the heart monitor by the back door. I switch the oxygen tubing to a portable bottle and turn it on, laying the bottle between his legs. Bill is at the back doors. Time to get out.
The gurney’s legs touch the ground. I say to everyone, “Go in easy, guys. Let’s not dump him.” Catching a curb as we go in. That would be the shits. We all move quickly into the emergency department. Bill and Tom are driving the gurney. I’ve taken over bagging the man as we roll straight into the trauma room full of people. Bill and I lift the patient on the backboard to the hospital gurney. A respiratory therapist takes over bagging. I step back and begin with a firm voice,
“We have an approximately 30-year-old male with multiple gunshot wounds about his body.”
The entire room is listening to my report. However, all of them are like a rubber band held at its limit: taut and anxious to fly. I only have about thirty seconds before they will pounce on this guy.
“From the top he has one through and through to his left pinna; one in his right, central chest; one in his right arm continuing through to his right chest; a graze shot to his left upper arm; one in his left butt, and one in his left thigh. Initially he was conscious and stating difficulty breathing. His lungs are clear, bilaterally, heart rate of 140 sinus tach, good radial pulse. Enroute, he degraded to skins diaphoretic and pale, decreased respiratory, to currently apneic. He maintained a pulse rate of 140. I attempted oral intubation but failed due to his locked jaw. I was unable to get an IV.”
I step aside and the entire room jumps to action. I roll the empty gurney out of the trauma room. I turn it toward the ambulance bay and punch the wall plate to open the doors.
I punched it harder than was needed. But that’s how it starts: the shift from robot, sponge, all-knowing caregiver – failure, back to being human. Now, all I see is the end of the gurney as I run away from my patient. I am leaving him so I can no longer hear his ragged breathing. I am no longer using my stethoscope to crawl inside his chest and visualize the carnage. He is finishing the dying he started in my ambulance, and I am running away.
The skin on my face is stretching tight. My vision curls in from the outside as the end of the gurney passes through the doors. I can now feel the scream boiling over I have been stuffing down since I first got on scene. It is still in my stomach, but I am too close to the hospital.
My hands are on the gurney. My fingers are my guide. If it was up to my head, I would run away. I would run down the street, and I would let all that has just left my stomach come screeching out in a loud, sickening wail. But I trust my fingers to not let go of the gurney. I turn toward the ambulance as the scream rises like a burst pipe under pressure.
The doors of the ambulance are open and the refuse from our attempts lies scattered on the floor. I slam the gurney at the back of the ambulance. The scream is almost to my throat. It’s a rising geyser, out of control. I can’t stop it any more. It scorches my throat. It burns as I try to hold it there.
The burning fills me to my eyes, and the tears roll out. I choke back a sob. I stumble to the front seat and crawl inside. The heat washes over me, and I let go.
I failed him! He was talking to me! When we met, he was talking to me! I couldn’t intubate him. I couldn’t get him enough oxygen. I didn’t give him enough. I couldn’t even get the fucking IV! What the fuck did I do for this guy?! Nothing!
I sit in the front of the ambulance and let the tears flow.
I open my eyes. A doctor stands next to me. One of the doctors that had been inside.
“I heard that you were having trouble with this patient.”
I nod my head. I wipe the tears from my face. “Yeah, I couldn’t get anything done on the way in.”
“I just want to tell you there’s nothing you could have done. He is too messed up. You did the best anyone could have done.”
The doctor walks back in the hospital.
I sit in the front of the ambulance and feel the heated air of the afternoon. It is a soft cocoon. It surrounds me and allows me to pull myself back together slowly. I don’t move. I barely breathe. A tear runs down my cheek, and I feel its trail dry on my skin. I don’t wipe it. I want to feel. I want to feel something, but I start small: The dried streak of a tear.
I replay what I did, what I saw. I had a guy with seven bullet holes in him. At least two of them were critical. Again, I see my hands moving over his body. I evaluate my progression, top to bottom. I had been efficient. We had gotten him off the street fast. Nothing had been missed.
I had done my work on the way to the hospital. Tom had been a great help, gotten him oxygen, and switched to the BVM when I asked. We had switched to the BVM because the oxygen mask wasn’t enough. The patient had needed more. He was still conscious, so I couldn’t intubate him.
Could the guy have taken a tube while conscious? God knows I couldn’t. It’s the size of my index finger. And to get it in, I have to wrench his tongue out of the way. No, I was right to wait on the tube. It was just bad luck. When he needed the tube, his mouth had locked on me.
So, what about the lungs? I heard a lot of air moving in and out with his breathing.
There was nothing wrong with his lungs. They were working fine. The bullets had thrashed too many arteries. The blood needed to carry the oxygen was pouring like several loose fire hoses into his chest cavity.
We had given him a thorough exam. We had gotten him to the hospital quickly. We had done everything we could on the way in. There had just been too much damage. That I can’t fix.
To do my job, I have to find it. I can ask questions about it. If I have a medicine to change it, I can try. But with trauma it is all about speed. How fast can I get him under a surgeon’s knife? That we had done.
The squawk of the radio brings me out of my reflection. Now the heat is uncomfortable and stifling. I have to decide. I could just leave. I could just start walking, leave it all behind, and never have to experience this again. I tell myself that option is always there.
No, I can’t do that. I do love this job. I have the privilege of being the person others call when they need help. This guy had needed my help. He had needed it badly. I had given him my best. I had been smooth, efficient, calm, and precise. The crew working with me had been fast and accurate.
This guy had seven bullets put inside him by another person. That was the problem handed to me, my partner, and the crew from the fire engine. The guy had died from those injuries. We hadn’t failed him. The problem was bigger than we could turn.
The positive thing is, because of our guy today, the next critical patient will meet a crew of emergency professionals who have been down this road before. We will give that next guy our best, topped with the lessons learned. That is a team in which I want to be a part.
Later, I get the patient’s name from the hospital staff and I put the response times for the call on the paperwork. We were on scene in four minutes. We had him in the hospital eight minutes later. Darryl Robert Preston died in about six.
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