Hands Part II

John directed one of the EMT’s standing around looking confused to grab a board and c-collar from the back of the rig. The EMT was new to the service and this was his first run. He looked to be in shock staring at the carnage in front of him. John yelled to him, make your way to the ambulance and pull a backboard and a no-neck from the C-collar compartment. John managed to break the trance and the EMT started to move toward the rig.

More ambulances were arriving now and beginning to evaluate Jake and the perpetrator of this accident. Donna quickly snapped the no-neck together and placed it around Emily’s neck. With help from a couple other EMT’s she quickly had Emily on the board and her experienced hands tightened the spider straps that would hold Emily to the board. Donna told me later it seemed as if she had been on scene forever before she was able to get Emily loaded. Donna and the patient rolled in the door almost 25 minutes to the second after the radio call, so she was actually on the scene less than five minutes as the accident scene was 20 minutes from the hospital.

The Mat-Su valley does not have an air ambulance service and the closest service is in Anchorage. We used to joke that the air ambulance only flew when it was sunny, dry, or when they wanted to. I don’t remember the type of aircraft used, but it was woefully inadequate for the vicious weather often encountered in the Alaska wilderness. I remember a call they received to come and pick up a patient on the Mat-Su Glacier. The winds were 50 mph steady and gusting up to 70 mph. The rescue crew told the air ambulance this and suggested they stand down and call the army and have a Blackhawk sent. The air ambulance did not want to lose the revenue so they called off the Blackhawk and attempted the rescue themselves.

After an hour delay waiting for the air ambulance to arrive, and three attempts and several near crashes, the rescue crew was told by the air ambulance crew that it was too windy to land. Call the Blackhawk. Another hour went by before the professional Army medics and the Blackhawk arrived. The Army guys made the rescue look simple and soon had the patient delivered to our ER. The neighbors were never happy about Blackhawks landing across the street from their homes. You could actually see the front of the homes pulse with the beat of the blades. At times I thought the homes would blow away like the little pigs straw home.

Donna and John wheeled Emily into the ER on the gurney and quickly parallel parked they gurney next to ours. Eight sets of hands grasp the backboard and lifted Emily onto the 4x4 wooden blocks. This leaves a space under the gurney where the x-ray techs can slide the films without having to lift the backboard every time a new picture is needed.

Doctor Grant did a quick assessment and picked up the laryngoscope and did a quick intubation. While he was doing this my fingers felt over Emily’s AC for a vein in which I could start a large bore IV. I was quickly able to find and start a 14 gauge and plugged in the saline I had prepared before the patients arrival. Other nurses were starting to arrive and assist in Emily’s care.

Right after we received the radio call we started the disaster call list. By the time Emily arrived a surgeon and most of the RN staff had arrived to help. I ripped into a chest tube kit as Dr Grant continued to evaluate the patient. The surgeon began to gather the equipment he would need to insert the chest tube. About this time Eric arrived on a back board and was wheeled to bed three in the three bed trauma room. Nancy, another RN, told me she would take Emily if I could help Dr Grant with Eric. It was eerily quite in the ER. We had all done this together so many times little in the way of speech was necessary.

I took a quick glance at Eric and didn’t see an IV. RT helped Dr Grant with the airway cart and I grabbed the IV supplies. As I felt for a vein in the right AC I looked up at Eric. Blood and gray matter were dripping from his ears. I turned to the lab tech and asked him to call the air ambulance to transport. I told him I would draw the necessary tubes. This is typical for a small hospital. Each staff member has to be able to wear many hats. He gave me no argument and handed me the blood transfusion band.

I was able to get a 14 gauge in Eric’s right AC. My hands fumbled with the syringe as I tried to get it to screw onto the catheter hub. By the time I got the blood drawn and the saline connected, it looked like a chain saw massacre. I ran around to Eric’s left arm and opened my equipment to start another IV. Larry the lab tech returned, and holding the precious blood tubes in his hands, labeled them with John Doe stickers I had placed on the mayo stand. With great care he annotated each sticker and placed them precisely on the tubes. If improperly placed the computerized equipment would not be able to read the labels. He also wanted to be sure to label them correctly because if Eric died the coroner would want the tubes.

We always used John Doe or Jane Doe stickers for traumas. It just makes it quicker to provide treatment. One night at another small hospital I was working at, we received a young Mexican male trauma. I told the clerk to make Jose Doe stickers for him. The next morning when he woke up he told us his name was Jose. The PC director who was pissed at me for suggesting the clerk make such un-PC stickers, never apologized to me.

After starting the second IV and securing it I grabbed my stethoscope and completed my assessment. There were no visible signs of trauma except the blood and gray matter oozing out his ears. His pupils were fixed and dilated. About this time the third patient arrived. This was the driver who caused the accident. One of the other nurses offered to take over with Eric and I went into the other room to start on my third new patient.

As I left the room I noticed the surgeon had already finished peritoneal lavage and was placing a second chest tube. He was telling the x-ray tech to call surgery and tell them what trays to set up. When we initiated the disaster call the supervisor had called in the surgical crew and had the OR prepped. For a small hospital we had our act together.

I entered the room with the third patient and immediately was overcome with the smell of alcohol. Dr Yee, a pediatrician, had responded to the disaster call and was attempting to intubate the patient. He tried several times and gave up. He turned the laryngoscope over to the paramedic who had ridden in with the patient. He strained and fought to see the vocal cords but after several attempts he gave up also. We attempted to bag the patient in between attempts but were only able to get the SpO2 up to 70%, not compatible with continued brain function. I called the OR and asked if there were any anesthesiologists available. I talked to a nurse anesthetist and she agreed to come down and try to intubate.

She arrived shortly and made one unsuccessful attempt. Before I could stop her she unfastened the C-collar and radically tilted the patients head and intubated her. Well I guess being a quad and alive is better than dead, I thought. We refastened the C-collar, bagged her, and the sats rapidly came up to 92%.

I noticed she did not have a running IV and I watched Garner, an RN, trying to start one in her other arm. He was doing the same thing I often do when trying to start a difficult IV. He had his eyes closed and was feeling his way along her arm, starting at her right AC. I looked at her left arm, nothing. No veins visible. I felt her left arm with the fingers of my left hand. I write with my right hand, but for sensitive work I always use my left hand. My fingers at first lay on her arm with a feather light touch. Nothing. I then closed my eyes and began to feel her arm again. Maybe. I thought I felt a faint deep vein in the AC.

Garner was attempting his second start and it didn’t look hopeful. I glanced at the BP monitor, 70/0. Damn, this chick needs IV fluids fast, and lots of them. The doctor and paramedic pushed on her belly. Firm and becoming distended. When is the last time you started a central line, I asked Dr Yee?

Too long, he said. And, I think her right lung is already down so I don’t want to go digging around in there. Do you have any IO needles?

Sure, right behind you in the trauma cart. Emily was on her way to surgery and someone had the forethought to push the trauma cart into the room with us.

Dr Yee grabbed a large bore IO, cleansed her leg with betadine, and thrust the IO into her tibia. He dug around in the trauma cart and his deft fingers secured the IO to her leg. He grabbed one of the saline lines awaiting connection and attached it to the IO hub. Grabbing a 60 cc syringe he attached a 19 gauge needle and began to pump fluid into the patient’s marrow. Seeing this, one of the nurses took over for him and soon had fluid running into the patient 60 cc’s per pump. It wasn’t perfect, but it was something.

I pulled a 14 gauge cath out and started fishing in her left AC. After fishing about for a short time I got a flash of blood in the hub. Damn, this was not a gentle flash this was the flash you get with an arterial line. I turned to the doctor, want an ABG I asked.

He looked at me and at the catheter. Sure, it’s about time for one anyway. I asked for an ABG syringe and drew the blood. I handed the syringe to RT and pulled the cath out and put pressure on the site with my other hand. I wrapped a little coban around her elbow and grabbed a 16 gauge cath. Starting above the coban, I began to fish again. This time I got a gentle flash in the hub and tried to advance the catheter up her vein. No go. I tried all the tricks, no luck, it just wouldn’t advance. I had an idea though. I taped the cath in place and went and got a Seldinger kit. I went and told Dr Grant the problem and he came and was able to get an 8.5 french trauma cath inserted.

About this time I could feel the pulsing of the helicopter landing next to the hospital. I went outside and ran across the lawn to meet the fight nurse. I filled her in on the situation and explained we would need them to come back immediately for a second patient. She said she would call her base and arrange to have another flight crew meet them at the landing pad to facilitate a rapid turn around time. She and the paramedic made their way into the ER and evaluated Eric. When she was ready we wheeled him to the waiting chopper and hot loaded him into the back. I glanced at the monitor as we pushed him into place, 1t was reading in the high 180’s. Fluid continued to drip from his ears, it didn’t look hopeful.

I went back inside and asked Garner to take a manual BP on our intoxicated patient.

70/30 came the reply.

We both had the same thought. I headed into the trauma room and grabbed the MAST pants while Garner undid the spider straps. We unpacked the MAST pants, the one and only time I have ever used them, and placed them on the patient. Garner pumped them up as I hung another bag of saline. I opened the trauma tubing up and dumped a liter of fluid in. Larry from lab arrived with four units of O-negative blood. I pulled off the empty saline bag and plugged in the first unit of blood. I opened the valve on the Y-connector to let the life giving fluid flow. Like cool molasses the blood eeked its way into the tubing. This wasn’t going to do. I opened the saline up on the other side of the Y-connector and let some saline run into the unit of blood. This thinned it some and I closed the saline valve. I gave the blood a little squeeze and it began to flow freely down into the tubing and into the patient.

Larry left and came back shortly with the BAC, 289. That’s three times legally intoxicated.

Ted, the flight paramedic, and Lisa, the RN nervously watched Eric. His pressure was falling and his heart rate was over 200. Then it happened, his monitor showed asystole. Ted continued to bag while Lisa felt for a pulse and checked the leads. All attached. She felt for a carotid pulse. None. Ted reached over and began to push on Eric’ chest while Lisa pulled some epi from the drug bag. She opened the IV wide and pumped the first amp into the IV. She then took over compressions, crossing her palms she placed them in the center of Eric’s chest and rhythmically compressed his small heart against his spine.

She hollered to the pilot to radio the ER that they had a hot offload.

The pilot radioed their ETA and was informed the second crew would be waiting to board and leave to get the second patient.

Once on the ground Eric was rapidly transferred to a gurney. Lisa perched herself on the side of the gurney and continued compressions as techs and nurses rushed the young body to the trauma room. Lisa reviewed what had been given and what had been done so far as the doctor trotted alongside the gurney.

Once in the trauma room more epi was pushed and compressions continued. They kept at it far longer than was practical. It was hopeless, Eric was dead. Slowly the crowd filtered from the ER. Lisa said she would stay and do aftercare. Kathy, a pool nurse who worked our facility and the facility that received Eric told me about this one night. She was working the night Eric came into the ER. She was not part of the trauma team but entered the trauma room after Eric was pronounced and after Lisa had completed aftercare.

It’s not always possible to detach yourself from patients who die, Lisa was no exception. She had her own 13 year-old at home to care for. Kathy found Lisa standing at the sink with the water running over her hands and tears dripping down her cheeks mingling with the water as it swirled down the drain. Kathy said she went over and turned off the water and turned Lisa around and held her in her arms for a long time.

The second crew arrived and we did a second hot load. I gave report to the flight nurse and related the BAC of 289, positive for marajuna, cocaine, and opiates. I would learn later that this scum survived, albeit with some brain damage. Her occupation was alcohol and drug rehab counselor for the State of Alaska.

About a week later I was relieving the ICU nurse so she could go to dinner. Our hospital was so small that I would relieve the OB nurses and the Med/surg nurses for dinner also.

The ICU nurse told me about her patients, one of them being Emily. She had survived and was still intubated. After the ICU nurse left I went into Emily’s room. She stirred as soon as I entered. I approached the bed and she reached up and grabbed my hand. She had no idea I had helped care for her when she had arrived. Holding onto my hand she made scribbling movements with the other hand. I told her I would get some paper. I was totally unprepared for what was going to happen next. She might have been told before this moment and forgotten because of the drugs, but I’ll never know. I gave her a pen and held a piece of paper where she could scribble on it.

She wrote one word, family.

She then reached up and grabbed my hand again. I stood motionless, what was I to say. Her family was no more. Her life was no more. Tears formed in my eyes and I slowly and imperceptivity shook my head from side to side. She squeezed my hand harder and tears streamed down her face. We held hands for a long time. Her life would never be the same. My life would never be the same either.

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