A Little TLC…

A little Chicken Soup for Holly the Goddess‘ mood…

The highway between Podunk and Hooterville can be a lonely stretch of road, and a dangerous one. The steep shoulders there have already claimed the life of one Podunk Ambulance EMT, and I’d rather not become number two. The road here is in a perpetual state of construction, the work progressing at a glacial pace. One day they will invent a way to make a shovel stand up by itself, and half of every Louisiana Highway Department road crew will become obsolete.

“You know those guys make eighteen dollars an hour?” Rookie Partner asks, pointing at the flagman as we pass a long line of stalled traffic. “All they have to do is talk on a radio and turn that sign around every few minutes.” She shakes her head.

“Who makes eighteen dollars an hour?” Paramedic Student wants to know, hollering from the captain’s chair in the back.

“I do!” I shout back at him. “Why do you think I come to work every day to baby sit paramedic students and rookie EMTs?” PS just grins and shakes his head. He only has a few shifts left to do to complete his paramedic clinical time, and he has elected to spend a week in Podunk, riding with me. The Missus and I have decided to move back up here, and I’ve spent the last week house hunting between calls.

“Who’s a rookie EMT?” RP asks indignantly. “I’m no rookie!”

“Okay, how many things do you have on your belt?” I ask, rolling my eyes. She immediately blushes a deep shade of red. “Here, let me count them for you,” I say with an evil grin, gleefully cataloguing everything she is wearing. “That’s quite an impressive display of doodads and paramedals you have there. I see a holster with a pair of trauma shears, a penlight and a window punch. You have a radio, a cell phone, a glove pouch and a pager. Here’s a stork pin, one-year service pin, CPR pin, National Registry EMT pin, and a pair of wings from Priority Air. I didn’t realize you were a flight medic! Let’s see what else…hey PS! What other kind of sparky little accessories do rookies wear?”

“EMT pocket guide,” PS offers helpfully. “Maybe an oxygen cylinder wrench? And don’t forget the seatbelt cutter!”

“How about it, RP?” I tease, knowing she has exactly those items in the thigh pocket of her uniform pants. PS and I laugh in delight at her embarrassment.

“They gave us the wings at the ground crew in-service,” RP says defensively, much to her regret as Paramedic Student and I collapse in peals of laughter.

“Unit Two, Dispatch,” the radio interrupts.

“Go ahead,” RP answers, still blushing furiously.

“Motor vehicle accident, just south of Hooterville on Highway 31. We have a report of a truck in the ditch, unknown injuries.”

“Unit Two en route,” RP confirms as she engages the lights and siren. “That’s just up the road,” she remarks to no one in particular. We pass the roadside cross that marks the spot where JoAnn died. The flowers look faded.

Just south of the Hooterville city limits, we spot the debris trail first. A pair of tire tracks crosses the road, cutting twin swaths though the roadside weeds on the opposite shoulder. Gas cans, trimmers, and assorted lawn care tools are scattered in a narrow swath leading to a Ford Ranger pickup lying overturned in the weeds. A spool of monofilament trimmer line has unrolled, pointing a neon-yellow, gnarled path to the wreck. A teenaged boy is standing outside his car on the shoulder of the road, his cellular phone pressed to his ear. He points frantically to the truck.

Thank you so much, Bystander Boy. We were wondering where the wreck was.

Paramedic Student is the first one out of the rig, barely waiting for the truck to come to a complete stop before he hops out carrying the medic bag. Rookie Partner isn’t far behind. I shake my head, walking around the rig to set the parking brake before I start unloading our gear. PS has reached the point that he’s capable of running calls without my guidance. I want to see if he can function independently.

I grab a spine board, a cervical collar and immobilizer and scramble down the steep bank. PS meets me at the bottom, looking a bit lost. “What have we got?” I ask him. He shakes his head grimly.

“The driver is pinned in the truck,” he tells me, “and she’d probably weigh about three hundred pounds on the hoof. Somehow she’s gotten twisted around, and she’s lying on her stomach with her feet pointing out the passenger window. Her face is all mashed against the roof, and her right arm is pinned between the dash and the ground.”

“Can she say where she’s hurt?” I ask. The roof of the truck is crushed in nearly to the top of the seats. I can see the woman’s legs sticking out of the passenger window, and RP worming her way into the driver’s window.

“She says her arm hurts, and she’s having problems breathing,” he answers. “So what do you want to do?”

“What do you want to do?” I shoot back. He grins.

“I already had RP call the Hooterville Fire Department for extrication. She’s in there trying to assess her now – I’m too big to fit. I figure we get some oxygen and a collar on her right now, and as soon as we can, extricate her out the passenger door.”

“Sounds like a plan,” I agree, “except Hooterville VFD can’t lift the truck. Podunk VFD has high-lift airbags. I’ll call them.”

PS scrambles around to the driver’s side of the truck to speak to RP. I kneel down next to the passenger window and peer inside. I can see nothing but two thick legs leading to a mass of pale flesh protruding from under a uniform shirt of some type. Near the driver’s window, I can see the top of RP’s head as she attempts to place a cervical collar on the woman’s neck.

That ain’t gonna work. This woman is built like a snowman. You’ll never get a collar to fasten around her neck.

The woman’s legs and abdomen, what little I can see of them, look reasonably intact. I reach in as far as I can and palpate as high as her knees.

“What the fuck was that?” the woman screams. Rookie Partner, startled by the woman’s scream, bangs her head against the steering wheel and curses.

“What was what?” RP asks, concerned. Her flashlight beam plays crazily around the cab of the truck.

“Relax, it’s just me,” I call reassuringly. “You need anything over there, RP? There’s no way I can reach her.”

“Some oxygen would be nice,” she calls, “and some 4×4 gauze. She’s got a nasty cut on her head.”

“You got it. I’ll have ’em for you in a second,” I reply as another thought occurs to me. “Hey, how are you reaching her? How far in there can you get?”

“I crawled in on my stomach,” she says matter-of-factly. “I can get my head and shoulders in here, but not much else. Did PS tell you that her arm is -…”

“Yeah, he did,” I answer, cutting her off. “We’ve got Podunk VFD on the way with some high-lift airbags. You get out of there before they start lifting this truck, understand? It’s not safe for you to be wedged in here. Drop whatever you’re doing and get out of the way.” Before she can reply, another flashlight beam appears from the bed of the truck. PS, scuffed and dirty, pokes his head through the rear window.

“Somebody asked for oxygen and bandages?” he asks, grinning.

“How did you fit in there?” I ask incredulously as he passes the oxygen mask across to RP’s outstretched hand.

“There’s a gap right under the side of the bed about two feet to your left. I crawled under.” I shake my head in wonder and resignation.

Both of you are a little too sparky for your own good. But I was just as foolish once.

“Okay, do what you can,” I tell him, “but the same thing goes for you. When they start lifting, you get out.”

“Why?” he asks reasonably, pointing his flashlight beam around the bed of the truck. “The truck can’t get any lower than it is.”

He’s right. As long as he’s in the bed and not the cab, he’s not in any danger if the cab collapses any more. There’s no fuel leaking, and we’re on level ground. He can stay.

“Be careful,” I warn him as I scoot back out of the ruined cab. A Podunk volunteer firefighter scrambles down the steep bank. “Whatcha got?” he wants to know.

“Big woman in an overturned Ford Ranger,” I answer. “We can’t tell how bad she’s hurt, but she’s complaining of difficulty breathing. She’s lying on the roof of the truck with her feet sticking out the passenger window,” I continue, pointing. “My partner says her arm is sticking through what’s left of the windshield, pinned between the dash and the ground.”

“Doors first, then lift the truck?” he muses.

“Yeah, that’s what I figured,” I agree, “but you’re the expert. If you can get the doors off, we can at least reach her a little better. But you’re probably gonna need your airbags and some cribbing to lift the truck a little. Oh, and one of my guys is underneath the bed of the truck, trying to work on her. Watch out for him, would you?”

“Sure,” he grunts, waving his crew down the bank. “Must be a little sumbitch to fit in there,” he says, shaking his head.

Not all that little, my man. Just totally ate up with Sparky EMT Syndrome is more like it.

The fire captain starts barking orders, pointing here and there, and his crew fires up the generator and the Hurst extrication tool and gets to work. In short order, two mangled doors are on the ground, and several cribbing blocks are wedged under the hood and bed rails of the truck. These guys may be volunteers, but they’re good.

With the doors off, I can see much more of the woman. She’s scraped up a bit, but she’s still moving, carrying on a conversation with RP that I can’t make out over the roar of the generator. PS crawls out from under the truck, then reaches back into the truck and drags out the medic bag.

“She ain’t breathing good,” he tells me grimly. “RP’s got oxygen on her, but she’s struggling. She just can’t breathe lying flat like that.”

“Well, they’re lifting the truck now,” I tell him. “RP should be able to get her arm loose, and hopefully we’ll get her out in a bit.” We both walk around to the driver’s side of the truck to where RP has wormed up to her waist into the cab. The firefighters have wedged a pair of airbags under the hood and are slowly inflating them.

“Hey RP,” I shout, prodding her leg with my toe, “back out of there.” When she doesn’t respond, I grab her by the belt and slowly drag her backwards out of the truck. She looks up at me angrily. “I said to get out of the truck,” I tell her curtly.

She has ground dirt and weeds into the front of her uniform shirt, and her forearms are bleeding from the bits of broken glass embedded there. I soften. “Look, get back up to the truck and clean some of that glass out of your arms. We’ll be ready to move her by the time you get back.”

Looking heartbroken, RP climbs up the bank. “She was doing a great job,” Paramedic Student says quietly. “The lady was scared, and RP was reassuring her. She promised the lady she wouldn’t leave.” I sigh and look back up the bank. Rookie Partner is standing outside the truck, rinsing the blood from her arms with sterile saline. Her eyes are red.

“Okay fellas, you might be able to get to her now,” the fire captain tells us, nodding toward the truck. PS and I get on our knees and peer into the driver’s side of the truck The woman is lying with her face pressed against the roof, eyes closed and gasping painfully through the non-rebreather mask. She is wearing a cervical collar that lacks a good bit from fitting around her neck, although RP has attempted to secure it with several wraps of tape. The collar is even more-or-less straight. Paramedic Student and I trade a look.

“Straight out headfirst, and then log roll her onto a board,” PS says decisively.

“And the quicker the better,” I agree. Before we can ask for one, a spine board slides into view on the ground between us. RP is on the other end of it, both arms wrapped with roller gauze.

“Let’s go!” she says to me defiantly. She looks like she’s been crying. “What are we waiting for?”

I say nothing, just gesture for her to stabilize the woman’s head as I kneel down and gently tug the woman’s arm free. From the elbow down, it has an ugly white color, but amazingly it doesn’t seem to be broken. The woman doesn’t make a sound as I move it into line with her body.

“Okay RP, on your count,” I say as Paramedic Student and I each grip the woman’s shoulders and upper arms. At RP’s direction, we pull the woman out of the ruined truck as gently as possible. It is not what I would call a graceful or pretty move. We quickly log roll the woman onto the board and strap her down. Several firefighters grab handholds on the board, and we pass her up a human chain of hands to our stretcher, sitting lowered at the rear doors of our rig. The woman is only making occasional agonal breaths as we load the stretcher. RP is crying openly now, tears trickling down her face as she slams the rear doors. I grab a bag mask resuscitator and hand it to PS as he positions himself in the captain’s chair at the head of the cot.

He starts ventilating the woman as I cut her shirt off. There is an embroidered patch that says “Mike” on the left pocket of the uniform shirt.

She doesn’t look like a Mike. Her husband maybe?

I listen to breath sounds as PS ventilates, and hear nothing but diesel engine and road noise. I do manage to hear a pulse, though. She’s still alive.

“I can’t get a seal here,” PS says, frustrated. He’s trying to keep his seat and ventilate at the same time, unsuccessfully trying to keep a mask seal with one hand. I g
rab the mask with both hands, keeping a seal with a jaw thrust as PS bags, and after a couple of minutes the woman’s color is better.

“One of us is going to have to let go at some point,” I tell him, pointing out the obvious. “How about you try to do it solo while I set up your intubation gear?” He nods seriously, focusing on maintaining a good seal. He’s gotten into a bit of a groove. Maybe every other ventilation goes in. I quickly set up the laryngoscope and a tube, and hand it to PS. He inserts the laryngoscope blade and peers around, looking for the vocal cords and finding nothing. He raises his eyes to meet mine.

“I can’t see a thing,” he says uncertainly. “You want to try?” I shake my head.

“Why can’t you see a thing?” I ask him. “Does she need suctioning?”

“She’s real anterior,” he says, squinting and moving his head back and forth. The frustration is evident in his voice. “All I see is the base of her freakin‘ tongue!” I reach forward and press firmly on her cricoid cartilage, just below her Adam’s Apple.

“How about now?” I ask. Paramedic Student’s face lights up like a little boy at Christmas, and he smoothly passes the tube between the woman’s vocal cords.

“Got it!” he says triumphantly as he inflates the cuff. A few squeezes of the bag later, and I can tell he’s right. Her breath sounds are equal on both sides. Winking at PS, I hand him a tube restraint. “Now strap it down while I get an IV, Supermedic,” I tell him as I wrap a tourniquet around the lady’s arm. Two minutes later, I’m seriously considering asking Supermedic to switch places with me, because it’s starting to look as if I’m not going to find a vein.

Come on, AD! Your reputation as the all-seeing, all-knowing Paramedic God of All You Survey is at stake. Don’t miss this stick!

Luckily, even a blind squirrel finds an acorn now and then, and somehow the 18-gauge catheter I’m holding finds a vein in her left forearm. I suppress a triumphant grin as I hook up the line.

Yes! The blind squirrel can eat for another day!

Fifteen minutes later, we’re pulling up to the ambulance bay at Big City Regional Medical Center. Our patient is still unconscious, and I can’t quite figure out why. Her pressure is a bit on the low side for a big lady like her, but it’s good enough at 104/64. Her heart rate is ninety, and she’s only making an occasional effort to breathe. Her lungs sound good though, and I can find no injuries more serious than the scrapes and cuts on her face and right arm. There’s even a good pulse in her arm.

“Reckon she’s got a head injury?” PS wants to know.

“Could be,” I shrug, “but her pupils are equal and reactive. She withdraws from pain. If she were in shock, I’d expect it to look worse than this. I just don’t know,” I conclude helplessly.

“Maybe she just got tired out from laying on her chest like that,” PS muses. “She must weigh three-fifty. Kinda like a CHF patient can’t breathe when they’re lying flat?”

“Might be something like that,” I grunt in agreement as Rookie Partner opens the rear doors. “We might never know what it was.” RP’s eyes are red and puffy, but she’s no longer crying. I say nothing to her as we roll the lady inside, and she immediately takes the stretcher back to the rig as soon as we move the lady to the hospital’s bed.

“She’s still upset,” PS observes quietly. I nod, saying nothing as I watch her leave. Outside, I find RP sitting quietly on the low retaining wall bordering the ambulance bay. She is taking deep drags on a cigarette, and her hands are trembling. I sit down next to her and hand her a Coke.

“Thanks,” she says shakily. “Is she gonna be okay?”

“I don’t know,” I answer honestly. “Her vital signs are good, and I can’t find all that much wrong with her. Maybe she’ll come around. My question is, are you going to be okay?” I ask gently.
“I promised I wouldn’t leave her, and I left her,” she says almost inaudibly, her lower lip trembling. “She was scared, and I promised I’d stay with her. But you made me leave. Was it because I’m a girl?”

Was it? Maybe a little. But I was looking out for a rookie EMT who wasn’t looking out for herself. If PS had refused to get out of the truck, I’d have drug his ass out of there, too.

“You made a promise you couldn’t keep. But you also put oxygen on her. She might not have made it this far if it wasn’t for that,” I point out. RP says nothing, just takes a shaky drag on her cigarette. “Look, you’re a good EMT,” I tell her. “But you can’t take chances with your safety. I know you were taught never to enter an unsafe scene, right?”

“Yes, but sometimes -”

“Sometimes you enter anyway, even when you know it isn’t entirely safe,” I finish. “You take a calculated risk. In this case, the risk to you wasn’t worth the benefit to her. It was my call.”

She still doesn’t respond, and I gently nudge her with my elbow. “Look RP, we don’t save all that many lives, even when we do everything right. We reassure people, and sometimes we ease their pain a little bit. I guarantee you one thing, though…”

“What’s that?” she asks, looking up at me.

“When that lady wakes up,” I continue, looking pointedly at her, “She’s not going to remember the man who strapped her to a board, or the one who stuck a tube down her throat. But she will remember the girl who held her hand and reassured her while she was trapped in her truck, and she’ll be grateful. That’s something, whether you think so or not.” RP nods, taking another drag on her cigarette. A state trooper pulls up, double-parking behind a Mercedes in the doctors’ parking lot. Seeing us sitting in the ambulance bay, he saunters over just as PS walks outside.

“You guys bring in the wreck from Podunk Parish?” he wants to know.

“Yeah, the lady was in pretty bad shape,” I tell him, “but she’ll probably make it.”

“Did you guys pick up her purse or identification?” he asks, flipping open a small spiral notebook. “There wasn’t anything in the truck, not even an insurance card. You get her name?” Jeff and I exchange clueless looks and shrug our shoulders.

“The nametag on her shirt said ‘Mike,’ but I don’t think it’s her shirt,” I offer. “I didn’t even think to look for identification.”

“Martha,” RP furnishes, sighing as she crushes out her cigarette butt. “Her name is Martha. She told me while I was in the truck with her.”

Postscript: Martha did indeed recover from her injuries, and when she dropped by Podunk Ambulance’s station in Hooterville a couple of weeks later, she brought Rookie Partner some cookies and a card to show her gratitude. Hugged her neck, too. Paramedic Student and I were not mentioned.