Tuesday, November 3, 2009

Perspectives, Volume I

The following events are not fictional, but they may have happened at different times, with different patients, at different places. Each one of the authors has had patients just like these, in situations just like those described. If you want to know what it’s like to live a day in the life of an ambulance driver, or a small town cop, or a small town ER nurse, join us for the story.

It’s the same story. On the same night. With the same people.

This is what we do, and working with paramedics and cops like these is part of the reason we do it. What follows is part 3 of the story. Start with Matt, the cop, for part 1. Then follow along with Ambulance Driver for part 2 as he picks it up and carries it before handing it – and the patients – off to me.

Then come back here for the conclusion. I’ll still be here.
The Saturday night shift in Small Town ER – a 3-bed ER in a rowdy little town – started with the usual fare of runny noses, sprained ankles, and anxiety attacks along with a few walkie-talkie “migraines” thrown in for good measure. Typical “clinic” stuff. Also as usual, I’ve been paired up with Moonlighting Paramedic working as an ER Tech (not as a nurse but I can sign off on what he does with some degree of confidence, at least) and Dr. Moonlighting Resident is in the call room waiting for his dinner while we work on getting beds cleared for the next wave waiting out in the lobby.Just the three of us on duty tonight, and I’m actually very lucky to have a competent hand with me (MP, not the Doc). Been known to work it by myself. It’s not uncommon.

It’s been busy but not crazy, and MP and I have just sent out for dinner ourselves in the vain hope that the simple act of doing so would not bring chaos to our door instead. Because, you know, God Forbid we actually get to eat.

I hear the tones go out on the radio. “Small Town EMS, Small Town Fire Rescue, Priority One call, westbound on County Road 234, rollover MVC with multiple patients. Life Flight has been notified.”


“Any word on dinner?” I ask MP as I grab the portable radio and stick it in my back scrub pocket so I can keep tabs on what’s going on as I go ahead and sign off on the discharge of the patients in the exam rooms – all two of ‘em – and MP begins to clear out the trauma bay. That one can wait for his x-rays from the lobby just as well.

“Nope, reckon it’ll get here when it gets here.”

“Medic One to Dispatch, we’re 23” (we’re on scene) comes out over the radio. I look at MP and I can see him itching to be out there with them. He’s real gung-ho like that.

Double-check the crash cart, clear the monitor entries and prep them for the inevitably incoming patients. Minutes/seconds used now are minutes/seconds saved when the patients arrive. MP brings in two more runny nose cases and puts them into the exam rooms. Time to light a fire under Dr. Resident’s ass. He picks up the phone. “Doc, Medic One’s out on a multi-victim MVC and I’ve got two back here you can clear out real quick if you’ll come on.”

He does, and we do, and I am relieved to hear over the radio that the chopper has been called down for one from the scene. Thank GOD for that. Not surprisingly, I also hear cussing and screaming in the background as Medic One talks to Dispatch. Saturday night in the ER usually smells like an old, stale brewery. Sounds like tonight will be no exception.

“Medic One to Dispatch, we’re 76 (en route) to Small Town ER.”

Here we go….

“Let me know when they get here.” Dr. Resident has refreshed his coffee and is walking back to his room.

My stomach growls. MP goes for a quick potty break, which is not a bad idea. Might not get another one for a few more hours.

The radio goes off: “Medic One to Small Town ER…”

We’re as ready as we’re ever gonna be. An unhappy Frequent Flyer Patient comes up to the desk demanding to know why he hasn’t been called back yet. I raise two fingers of one hand to tell him “just a minute” and grabbing my pen, flanked by MP, I answer: “This is Small Town ER, go ahead Medic One.”

Hey Babs, it’s AD on Medic One. We’ve got a 15 minute ETA on two victims from a rollover MVC. Victim #1 is a 17 year old male who was apparently ejected. Initially agonal respirations on scene, unable to maintain his own airway without positioning. He’s tubed, with bilateral breath sounds and initial etCO2 of 32, spO2 91% on high flow oxygen. GCS is 1, 1, 3. Left pupil is blown.” Vitals 86/40, HR 52, RR 20 (ventilated)….”

FFP decides to go somewhere else. Folks in the lobby, apparently onto what’s going on, have trickled out one-by-one deciding to go somewhere else or just wait and come back later.

“.…Victim 2 may be the driver, apparently self-extricated at the scene. Apparent ETOH on board, uncooperative with history and exam. Numerous small lacerations and abrasions, the worst of which is a 4 cm forehead lac. We have him immobilized as best we can, PMS intact x 4, no neuro deficits. GCS 15. Eyes – PEARL. Vitals 136/74, HR 112, RR 14. See you in fifteen minutes.

“Fifteen minutes!! Hot damn, dinner just arrived and we have time to actually eat!!!!

But first we call in X-ray, CT, Lab, and Respiratory so they’ll either be here or be close by when the truck comes. Pop the crash cart open and have everything ready to roll. Make sure there are enough gloves for everybody. Place blank charts in the room and fill out the chief complaints since we already have those. After we wolf down dinner, I make a call to the doc to give him the report. Then MP and I mosey out to the ambulance dock for a quick smoke while we await their arrival.

The ambulance doors open to the sounds of Patient Two’s displeasure with his situation.


Oh, joy.

AD shakes his head as he preps Patient One and the stretcher to roll out. I smile. “Out stirring up trouble again, I see.”


“Well what can you expect with all these shit magnets on tonight?”

As Patient One is unloaded and Escorted into the Trauma bay I get the scoop: His name is Bobby and he is a casualty of typical teenage boy antics gone terribly wrong. Driving too fast, drinking, having a grand old time, and they took a bad curve with a little more bravado than their vehicle could handle. Parents are on their way.

“Last BP?”

“70/palp.” AD says.



“Hey MP,” I call out, “will you do a quick triage and stick a 14 in Jimmy Boy there? He needs a line and bloodwork. And a foley *wink*. Send a drug screen and call CT to clear his spine and look at his head while they’re at it.”

“I’m one step ahead of you.” Who says belligerent patients don’t get good care? They get top-notch care!

Doc shows up just as we are transferring Bobby over to the ER stretcher and getting him hooked up to the monitor, which is showing a heart rate now in the 40s. This kid’s going fast. As the doc makes a quick assessment I start gathering the appropriate meds from the crash cart.

“Doc, the other one is obvious ETOH and combative but it was a rollover. MP’s getting a line and blood work will be cooking, I sent him on to CT to clear head and c-spine.”

Oh, cool.”

MP has done his thing – minus the Foley, since he knew I was half- kidding about that, and he’s needed in here right now anyhow. This one needs a lot more but most importantly, he needs to not be here in the Bandaid Station.

MP takes over things with the doc and the crash cart. I grab the phone and dial.“Doc, I got Big City Hospital Trauma on the line. They’re getting Dr. Iamgod to the phone for ya.”

I hand him the cordless phone and then turn to the registration clerk who won’t leave until I sign the consents with her attesting to the fact that the patient is unable to sign for himself and that it is indeed a medical emergency necessitating immediate intervention without parental consent. I give her my quick scribble and move on. MP, Respiratory, and the doc are handling the patient for now and so I just keep things moving.

I turn to Dr. Resident and ask a question I already know the answer to: “Air or Ground?”


Out in the field the chopper can be called without all the hullabaloo involved in a COBRA transfer. But the second they hit the hospital premises, COBRA takes effect so it’s paperwork and procedure all the way, baby. All the way. Bureaucracy at its finest. Leave one thing out and the receiving hospital will complain and then the powers-that-be come down on this hospital and all the fallout will go to the ER Charge Nurse. Have to have an accepting facility and an accepting physician. There has to be a doctor to doctor report and a nurse to nurse report, transfer paperwork filled out and consent for transfer signed by SOMEBODY, everything documented, charting up to date and copies made to send, an inventory taken of all their worldly goods on their person, the whole freakin’ nine yards. Anything to interrupt care in the process of trying to get them appropriate care. One nurse, one tech, one green doc, two difficult patients. And somebody’s got to organize it all. That job falls on the charge nurse, never mind the fact that she’s the ONLY nurse in the department.

And so right now I’m really wanting to shoot AD for not calling another chopper out to the field. But Dr. Iamgod accepts the patient so I call Big City Hospital Chopper Line for transport while MP breaks out the Epi, Atropine, and the Dopamine. We now have a 25- minute ETA on the chopper.

I call dispatch to notify them so they can get the fire department out to the helipad. That’s in case the jet fuel catches fire. That’s just standard procedure here at Small Town Hospital.

See, I have to make those calls. We don’t have a unit clerk and by default I double as the House Supervisor. I’m lucky to have somebody in Registration tonight and she’s tied up doing her own job. Many nights we have to do that too. The fun part is when I have neither a tech nor a registration clerk after 11pm. Those nights really suck.

And police are swarming. Family members and friends are crowding the ER lobby. Some are crying. Some are angry. Some have decided, “Well, since I’m here anyway, maybe I can get them to look at this bump I’ve had on my elbow since the ninth grade…”

….and it’s then that I notice that Jimmy has been returned to his exam room. Sure is awful quiet for somebody who was raising all immortal hell earlier. The CT tech has sent the image for radiology reading 30 miles away and is awaiting a faxed report.


No response. I hit the lights and check the pupils. Mite bit sluggish but reactive. Vitals stable. Breath sounds clear. Belly soft.

Snoring. The stench of his breath permeates the room. The deputy sitting with him rolls his eyes.

Likely just sleeping it off, but I’d still like that CT report back. Just in case. That’s why I “requested” it in the first place. Belligerence could be from the alcohol, but we can’t just automatically assume that’s the case. Could be something else going on in there.

Call to the lab: “We got that ETOH in exam 2 yet?” I’m banking at least a 250.

“It’s coming off now,” she tells me. “354.”

I pull the bandage off the forehead lac to check it. Still bleeding but not so much. Nice hematoma coming up there. Dude probably got at least a good concussion out of that hit.

Back to the trauma bay to check on progress. I walk in just in time to see Bobby’s arms begin to bend and his hands begin to clench. “We need some O-Neg,” Doc says. “Squeeze it in.”

Only one person in the hospital can get that from the hospital blood bank and it has to be retrieved from there by that person, about 3 pages worth of paperwork filled out and double-signed to retrieve it, and it cannot be brought by the lab. That person is, by law, an RN and that person is, by default, me. I go and get it and bring it back, hanging it on a pressure infuser. We’re terribly short of actual hands.

As I hang it, I look at Bobby.

His lungs rise and fall from the rhythm of the Respiratory Therapist’s hands on the ambu bag. His blood pressure is only being maintained on a dopamine drip, and he’s posturing. This is what “life support” is. X-ray had done a side view of his neck on the stretcher and the film is hanging in the room. C1 and C2, the top two bones in his spine, aren’t broken but they’re a little farther apart than they should be and they’re a little bit out of line. We’re breathing for him but it’s getting harder to do – his belly has gotten firm indicating a belly bleed and now that blood is collecting and putting pressure on the diaphragm, giving resistance to the ventilatory effort. Before long it will be impossible to inflate his lungs and that will be the end of that. We’re giving him blood to replace what he’s losing – even if he is losing it internally, we’re giving medicine to keep his blood pressure up high enough to actually pump the oxygen into all those cells to keep his organs alive… everything his body should be doing on its own, we’re doing for it – and for what? If he survives he’ll live the rest of his life on a ventilator and likely in a vegetative state. The kid who took off riding and partying with his buddies tonight has died and he’s not coming back. All that’s left is this shell.

And there’s not really much more we can do here but maintain until the chopper comes. Doc is just standing back looking at him. For a split second, so am I and so is MP. We all have kids about that age. It’s hard to see.

“Doc, his mom and stepdad are here – you might want to go talk to them before the chopper lands. I’m sure they’re going to want to see him before he goes out. And the CT report on the other one is coming in over the fax now and you still need to go eyeball him. Chopper should be about 10 minutes out.”

Doc takes a deep breath and slowly walks out of the room, head down. He’s a new guy and this is a hard night for him too. He went to med school to make a difference and to save people. Medical School gave him all the ideals and the theory, and now here in residency – without his mentor but with MD behind his name and all the expectations that go with that – he is getting hit with a hard dose of reality. We can’t save them all.

I follow, to check on the CT report myself. It’s clear. Good. We can pump the guy full of fluids and a banana bag until his ETOH level comes down enough for the deputies, still hovering nearby, to cart him off to jail. But he can wait.

I go back to Bobby’s bedside. MP is monitoring him and RT is still struggling with bagging him. I hear a soft knock on the door.

The parents.

I step outside the room to talk with them. I know Doc already has, but before I bring them in they need to be prepared for what they’re going to see.

“C-c-can we see him?”

Mom is wiping her eyes and holding on to her husband, who’s just barely standing himself.

I place a hand on her shoulder. “Yes, I’ll bring you in to see him but I want you to understand that he’s not going to be able to talk to you, okay?”

Okay.” She sniffles.

“He has a tube in his mouth that we’re breathing for him through. There’s a real big bandage on his head and he’s swollen so he won’t look quite the same right now. And he has wires and IV lines and all.”


“And we’re going to send him to Big City Hospital where they will do everything they can for him. In fact, we’re flying him out in just a few minutes and after you see him I just need for you to sign a paper saying we can send him where he needs to go, okay?”

She sniffles and wipes her nose. “Okay.”

I peek into the door. “I’m bringing his parents in.” MP nods as he turns the Dopamine up a little higher and prints another rhythm strip off the monitor to add to the documentation he’s been fervently trying to catch up in time to get copies made and handed over to the Flight team.

They shuffle in, huddled together. The second she lays eyes on her son she runs up to him, caressing his head. “I’m here, baby, Mama’s here,” she croaks through her tears as she rubs his hair back and kisses his forehead. Her husband is standing beside her with one hand on her shoulder and the other holding his son’s hand. He shudders and a tear falls.

I love you, boy.”

These are their goodbyes.

I have located a fresh box of Kleenex and offer it to Mom. “There’s the helicopter,” I tell her, gently indicating the sounds overhead. “It’s time to get him ready to go.” She nods, with her tissue up to her face, kisses her son one last time, and they come with me out of the room. Mom signs the transfer consent and I make sure they have directions to Big City Hospital so they can meet their son there. They determine that it’s best they go ahead and leave now since the drive takes so much longer than the flight. I secure a cell phone number from them…just in case.

Flight team takes one look at the boy and they all shake their heads in unison. Report is given and we begin to load him up onto their stretcher, taking extra care to keep the lines from being entangled. I hang the second unit of blood and squeeze it in as they move him, keeping one eye on that and one eye on the monitor as he is moved.

And then….

Uh. Guys? Can you stop moving him a minute? Looks like V-fib on the monitor.”

Everyone backs away and the rhythm doesn’t change. A quick check confirms it.

The flurry of activity starts. Chest compressions begin. There are shouts of “clear” as we send shocks through his heart. More drugs being pushed through an IV line. This is it, I think.

We all think that.

And we’re all wrong.

Just as suddenly, we get a rhythm back. A good one. His heart beats once more. He has a pulse. For a second, we all stare at the monitor in utter disbelief.

RT removes the ambu bag and Bobby is hooked up to their transport vent. Report is completed, the blood transfusion is done, and copies of his chart and x-rays are placed into an envelope to go along with him.

A crowd has gathered outside to watch the helipad. Family, friends, neighbors, and just nosy bystanders are lined up across the parking lot to witness the final flight of a young boy whose life is ending far too soon, a young man whose hands should be clutching a girl and a set of car keys instead of the final futile traces of life.

On the other side of the helipad, away from the crowd, stands a man conspicuously alone, watching, bewildered. He looks as if he’s about to jump out of his skin. But he waits until the stretcher is loaded, not daring to interrupt. I step back as the blades begin to churn loudly. Over the shrill engine and the sounds of the props picking up speed, I barely hear it: “Ma’am! Ma’am!! Nurse!!” I turn my head to locate the source and I see him running toward me through the din. His face is stark with fear. And confusion. And grief. And worry. I move away from the chopper toward him until he stops breathlessly in front of me. Over the sound of the wind and the engine and the rotors he shouts, “I was on the job when I got the call…” It almost seems like an apology. He takes a breath and his frown deepens. His eyes are pained. His voice shakes. “WHAT happened to MY BOY?!?”

The wind churns up dust and debris, forcing the crowd back as the rotors build up speed enough to take flight. I motion for Dad to come inside with me where we can explain things. It won’t go well. Inside the ER Jimmy continues to sleep off his drunk, oblivious to the fact that his future is now going to have to be in the hands of a public defender.

I don’t feel sorry for him.

As I escort Bobby’s father through the wave of people crowded in that tiny area, a very irate patient demands to know, “What about this bump on my elbow? Am I gonna have to wait all night? I thought this was an Emergency Room. What if I’d been dying? Then what? I’d just die here in this waiting room wouldn’t I?”




I called the flight team for an update before I left at the end of my shift. The flight nurse, a normally stoic and highly professional young man, called me back. “Our boy didnt’ make it, Babs,” he told me, his usually steady voice shaking with emotion.

I noticed something else right off the bat too: he’d used the phrase, “our boy”. That’s a first. Something about this kid really got to him.

He crashed as we were landing,” he continued. “We just couldn’t bag him anymore. There was just too much pressure against the diaphragm, we couldn’t inflate his lungs. We tried. We tried. They cracked his chest as soon as we got him in there, but…… ” He took a deep breath. “Blood just poured out everywhere .….” Another deep breath. “When the family got there….”

Another deep breath. And a long, deep sigh. “It–it wasn’t pretty

He sighed again. His voice began to trail off. “It wasn’t pretty. It wasn’t pretty. It just…it – it wasn’t pretty.”Nothing about tonight was pretty. And the worst part? Nothing about tonight had to happen in the first place. But for the irresponsibility and callous disregard of one person for all his “friends,” it wouldn’t have.

Senseless shit. I finally have the luxury of time to be angry. I finally have the luxury of time to feel. Anything.

But I needed to go home and wash the night off in the shower and try to get some sleep. Because I had it all to do again in just a few more hours.

I just had one thing that I needed to do first.


I drove the half hour to another town, to another house. On the way, I thought about Bobby. I thought about his mother. And I also thought about that image – the mother’s family huddled together on one side of the helipad while his father stood alone on the other. I could relate to him. I knew his place because it’s the same as mine. He worked long, irregular hours. He missed important moments in his son’s life while he tried to earn a living. And now he would never get to make it up. He didn’t even get to say goodbye.

I pulled into the driveway and parked. They’re usually up by now. It was a longshot, because we don’t get along. His wife hates the fact that I breathe air. But I had to ask.

He answered the door and looked down quizzically at this frazzled, pale, shift-weary woman standing on his doorstep in her scrubs.

It was a bad night. We lost a kid. I just…I just need to hug them.”

He studied me for a second and then nodded. And then he called the kids to the door.


  1. Thanks AD for your powerful writing! I just recently "found you" and as a soon-to-be EMT student and fellow human being feel blessed to read the posts here and in your blog. I'm learning a lot and am learning that it's OK for me to keep being compassionate and caring for others no matter what.

    This was a senseless tragedy but all too common. I sure hate to say that part. :(

  2. Actually, it's over here: http://perspectivesseries.wordpress.com/vol1-bobby-jimmy/

    Just sayin', since I wrote it. :)