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 nurses and cops like these is part of the reason we do it.


“588, major accident,” comes the voice over the police channel. The voice is matter-of-fact, professional, cool as smoke off dry ice. But something in the tone makes me perk up and take notice. I look over and Bodie is listening too, head tilted toward the scanner, his thumb poised over the mute button on the TV remote.

“Unit 588,” the dispatcher acknowledges.

“County Road 234, about twelve miles west of town. Serious MVC with multiple injuries. Roll EMS and Fire…uhhh, Care Flight too, Dispatch. I’m gonna need at least two ambulances here.”

“That’s us,” Bodie sighs, already moving. We’re both tired. We’ve only run four calls today, but it’s the second day of a 72 hour stretch, and in the hill country, where bigger hospitals are few and far between, one call can keep you tied up for a couple of hours. We’ve only just stopped rolling.

“It’s bad, whatever it is,” I predict grimly as I hurriedly stomp my feet into my boots. “Matt doesn’t get flustered easily.”

“Yeah, something in his voice…” Bodie agrees.

We are already in the truck, strapping in and flipping switches when the tones come across our pagers. “Small Town EMS, Small Town Fire Rescue, Priority One call, westbound on County Road 234, rollover MVC with multiple patients. Care Flight has been notified.”

“Small Town Medic One, rolling,” I acknowledge, stifling a yawn. “County, can you give us a better location on this accident?”

“Small Town 588 is out at a rollover about 12 miles west of town limits, Medic One. Officer advised three patients, all of them serious.”

“Ten-four, County.”

“Time out 03:15 hours, Medic One.”

Shit. Wrecks after midnight on Saturday are never good things. Not out here.

We callin’ for mutual aid?” Bodie wants to know. “Next closest one of our units is forty miles out.”

He’s right. EMS units from the neighboring county could get there five minutes quicker. That is, if they were already rolling.

“It’s a toss-up,” I judge. “Medic Two is probably already headed this way to cover. Just have them step it up to Priority One until we say otherwise.”

Bodie grunts in affirmation and keys the mike as I stare at my reflection in the side window. The strobes cast weird flashbulb patterns against the occasional scrub oak. Cattle eyes in pastures wink like a constellation of stars as their heads turn toward the sound of the siren.

“Prob’ly not as bad as it sounds,” Bodie muses hopefully. “Cops always think the injuries are worse than they are.”

He’s whistling through the graveyard.

I say nothing, my reply evident in my facial expression.

“Yeah, you’re right,” Bodie grunts in resignation. “He don’t git shook easy. On the other hand, we got fire and Care Flight already on the way. Be plenty of help when we git there.”

Keep whistling, Bodie. Matt called for two ambulances, vehicle rescue and a helicopter. On his own. He didn’t make that call for no reason. It’s going to be bad enough when we get there. And fire rescue is at least five minutes behind us. Add another fifteen for the bird, minimum.

“588, County,” the radio crackles again. Matt’s voice is clipped, terse. “ETA on that ambulance?” There is another sound in the back ground. Something gurgling. I switch to the County Sheriff’s Office channel and key the mike before their dispatcher can respond.

“Medic One to 588, ninety second ETA,” I answer. “What have we got?” I wait twenty long seconds for an answer.

“Rollover with an ejection,” comes the clipped reply. “Two critical, one moderate, one unaccounted for.”

Bodie and I trade a look.

Unaccounted for?

We crest a low rise and see the rear flashers of Matt’s duty cruiser in the distance. As we draw closer to the scene, a waving flashlight paints a pattern across the night sky like a searchlight beacon at a Hollywood premiere, beckoning us to a spot in the weeds some distance off the road. A debris trail punctuated by shards of taillight glass and scarred swathes of ground culminates in a wrecked Toyota 4Runner straddling the remnants of a wire fence. The Toyota looks like it has rolled over multiple times, the windshield gone and the driver’s door sprung. The cattle held in by the fence stand huddled in a far corner of the pasture, unaware of their new path to freedom. Maybe thirty feet beyond the SUV, Matt is kneeling in the grass near something we can’t see.

“I’ll check the truck,” Bodie offers, heading toward the Toyota and the shirtless man sitting dully on the ground at the open driver’s door.

I find Matt kneeling in the grass at the head of a young man of maybe eighteen years, holding a jaw thrust as the kid struggles to breathe. Every spasmodic breath is an all-too-slow, gurgling fight for air. Both of his arms are curled to his chest in decorticate posturing, his face a bloody wreck.

“I think this one was thrown clear,” Matt says grimly. “Two more in the truck – one trapped in the back seat and busted up pretty bad. He said there are two more, but this kid is all I’ve found.”

“Hey AD, I got a bad one over here!” Bodie calls urgently. I look over my shoulder to find him leaning in the back passenger window of the Toyota, tending to someone I can’t see. The shirtless guy is standing up now, staggering around with the remnants of a bloody shirt held to his head.

“This one needs help,” Matt reminds me urgently. “He can’t breathe.”

Which means he probably isn’t going to make it. And I need to decide which kid gets my attention. So which one do I let die?

“Let him go,” I tell Matt. “He’s gone.” Matt doesn’t move, just looks at me. “You’ve got a wreck scene to work, and I’ve got two patients that can be helped,”
I reason.

“But he’s breathing,” Matt protests.

“Not for long, and I have two critical patients and one other we still haven’t found. He’s not the priority, Matt.”

“He’s breathing.” Still Matt hasn’t moved, his elbows on the ground on either side of the kid’s head, stubbornly holding the jaw thrust that keeps the kid from ceasing his breathing efforts altogether. He stares up at me defiantly, the kid’s blood smeared up his forearms well past the protection of his nitrile gloves.

Shit,” I relent, “you win. I’ll be right back.” I sprint for the rig and return with my portable suction unit. I kneel next to the kid, suctioning his airway with one hand as I dig through my jump bag with the other. I insert an oral airway in the kid’s mouth and hand Matt a BVM. “You stay with him,” I direct. “Bag him twenty breaths a minute or so. Fire Rescue oughta be here in five minutes or so, and the bird should be here in twenty. I’ll send you some help as quick as I can.”

I turn back to the SUV to help Bodie, and run smack into the shirtless guy. His eyes are glassy, his breath reeking of alcohol. The bloody shirt he is holding to his head glitters with broken windshield glass. Glass fragments are imbedded in his forearms, and blood runs down his elbows to drip onto his bare feet. The only item of clothing he still wears is a dirty pair of cutoff jeans. Vomit streaks his bare chest, collecting in the front waistband of his jeans.

“Whoa, partner,” I tell him, cradling his head in my hands, “I need you to hold still. What’s your name, man?”

“James Ashley Heaton,” he slurs, trying mightily, and failing, to carefully enunciate every syllable. “I don’t gotta talk to nobody ‘thout my lawyer here,” he states.

Riiight. Something tells me James has heard the words “Will the defendant please rise?” before.

“Fine with me,” I tell him as I steer him back toward the SUV. “Sit here and don’t move.” Thankfully, James complies without much in the way of protest. I ease him to a sitting position against the driver’s front tire and wrap a cervical collar around his neck.

“Wasn’t driving, neither,” he volunteers to no one in particular as I poke my head through the open driver’s door.

Bodie is kneeling on the console between the front seats, assessing a young man with his face pressed against the front passenger seatback. The kid’s legs are folded back underneath, the lower legs lost in seat cushion and twisted metal. The impact has caved in the passenger side of the SUV, buckling the rear passenger seat and pushing it forward and left. Our boy was apparently sitting in that seat, buckled in.

“Just hold on, son,” Bodie soothes. “He’p is gonna be here right quick. What’d you say yer name was? Tony? Just breathe that oxygen Tony, and we’ll git you outta here in a jiffy.”

“Where’s Bobby and Arnold?” the kid whimpers. “You gotta help Bobby and Arnold!”

“We got people doin’ jest that, son,” Bodie assures him. As they talk, I scan the interior of the SUV.

Both airbags deployed, front windshield gone. Driver’s door sprung, and maybe thirty inches of intrusion on the passenger side. Blood on the front passenger airbag.

I lift the driver’s airbag and peer underneath.

No steering wheel deformity, no axle displacement. All of the side windows are shattered, and the roof is caved in several inches.

“Where were Bobby and Arnold, Tony?” I ask him. “Which one was driving?”

“Jimmy was driving,” Tony answers in a half-scream, half-groan. “He was drunk, wouldn’t let me drive. He won’t let anybody drive his truck. God man, this hurts! You gotta get me out of here!” he pleads.

The kid in the field must be Bobby or Arnold. So someone is still missing.

“I’m going to go look for the other one,” I tell Bodie. “You got this?”

“Nothing else we can do until we get him extricated,” Bodie shrugs. “His legs is busted up pretty bad, and his pulses are thready. Prob’ly got some internal injuries, too.”

“And I’ve got the driver out here, drunk off his ass and maybe with a head injury,” I tell him, “and Matt is bagging one that’s circling the drain. Plus, one still missing. When the fire guys get here, we’ll get this one extricated and fly him to Big City Memorial.”

“We still need Medic Two?” Bodie asks as I back out of the SUV. By way of reply, I take the portable radio off his belt.

“Medic One, Medic Two,” I radio. “We’re going to need you here. We’ve got two critical, possibly three critical, and one moderate.”

“Ten-four, Medic one,” they answer. “Thirty minutes.”

I walk around the SUV, my flashlight playing across the broken ground, looking for a broken body somewhere out here in the tall weeds, afraid I’ll find the lifeblood of yet another young life ebbing into the sandy soil. Thankfully, I find no one, and the sirens of the Small Town Fire Rescue interrupt my cursory search. A rescue truck and a small tanker pull to a stop behind Matt’s cruiser, and a string of wig-wag headlights in the distance herald the arrival of even more help.

I approach the ta
nker just as Mr. Clean climbs down from the rig. A brawny six-four, with a cleanly shaven head, Mr. Clean strikes an imposing figure. He gives the SUV a glance and then turns to me. “How many, and how bad?” he asks tersely.

“Bodie has a bad one in the back of the Toyota with lower extremity trauma and internal injuries,” I tell him. “We gotta get him extricated first. Life Flight is inbound, and we need an LZ set up and marked. The driver is sitting over there with a C-collar on, and he’s doing the Sergeant Schultz routine – he don’t know nothin’ about nothin’.”

“Just those two?” Mr. Clean wants to know. “County said three, maybe four.”

“Matt has one that probably ain’t gonna make it,” I answer, “and we haven’t found the fourth one, if there is a fourth one. Can I get a couple of your guys to help me get Matt’s patient packaged?”

Matt’s patient. Damn. But that’s what he is right now, until I can take over for him. Not the kind of thing they prepared him for in First Responder class at the academy all those years ago.

Mr. Clean nods curtly and starts barking orders. Not bothering to wait for my helpers, I trot to my rig and fetch a spine board and the ALS airway kit. As I trot back over to the kid in the grass, I find my two helpers have somehow beaten me there and have already taken over for Matt.

“Still hanging in there,” one of them informs me as I kneel beside him. “The cop was doing a good job of ventilating him.”

“Keep ventilating a little bit longer,” I tell him as I assemble my laryngoscope. “Let me get his airway secured, and then we’ll get him secured to the board.” I toss a pair of trauma shears to the other firefighter. “Get him exposed, would you? Try to get me a quick set of vitals, too.”

“Where do you want me?” the ventilating one asks. “Should I move?”

“Just keep bagging,” I direct. “I’ll need you to hold spinal alignment while I intubate, so you’ll have to scoot over a bit once I’m ready. Once I’ve got the tube in, hook the bag back up and start ventilating.”

I lay my tube restraint and CO2 detector on the kid’s chest, grab the tube in my right hand, and nod for him to scoot over. I lay down on my belly at the kid’s head, sliding the scope in for a quick peek. Gravel digs painfully into my elbows.

The kid’s arms reflexively contract in decorticate posturing, drawing towards his chest as his back arches. The firefighter grunts and shifts his body, trying to hold the kid still. There are remnants of blood and vomitus in the back of the kid’s throat, but I manage to get a fair view of his epiglottis and the lower border of his glottic opening. Delicately, I slide the tube in and sit back up. Before I can tell him, the firefighter has the bag reattached. I inflate the cuff and secure the tube. As he ventilates – way too fast – I check breath sounds.

“We’re in,” I decide. The CO2 detector turns a cheerful yellow with every exhaled breath. I look up to see the other firefighter attempting to straighten out the kid’s left arm, a blood pressure cuff dangling from it.

“Pulse 64, BP 108 palp, as best I can tell,” he informs me. “I was trying to auscultate one when he started bucking.”

“A palpated pressure is good enough for me,” I grunt. “Let’s get him packaged and loaded.”

The firefighters and I finish stripping and assessing the kid. Aside from a few smaller abrasions and lacerations, his injuries seem to be limited to the head trauma. His face is a wreck, however. From palpating his head, it feels as if his upper jaw and nose are fractured. Thankfully, there is no blood in the ears, and no CSF in the blood coming from his nose.

But still the posturing. And at least a LeFort II fracture as well, maybe worse. I was damned lucky to get him intubated. He’s damned lucky to be alive.

Oh, who am I kidding? This is the worst kind of luck. This kid is dead. He just doesn’t know it yet. If he does survive, he’ll be a vegetable.

I keep my thoughts to myself as we carry the kid to the ambulance on the spine board. I notice Matt and a DPS trooper interrogating the driver as we walk past. He’s standing up against the SUV, shaking his head belligerently despite the best efforts of a firefighter to maintain some semblance of spinal alignment.

“I wudden even inna Goddamned truck!” he shouts defiantly. “You sumbitches ain’t got no right to hold me!”

“Listen asshole,” Mr. Clean growls over the shoulder of the DPS Trooper as Matt looks on. “We know damned well you were in the truck. Were you driving, or a passenger? How did you get out? Were you thrown clear? We need to know this shit for medical reasons…”

I stop listening to Jimmy bray drunkenly about his fucking rights as I climb into the back of the rig.

Fucking coward. We’ve got one mangled kid in the truck who only wants to know if his buddies are okay, and another one probably going to die, and the bastard who caused it all is only worried about beating a DUI charge.

I pull the tattered remnants of the kid’s jeans from underneath his hips and toss them on the floor of the ambulance. One of the firefighters grabs a blanket and covers his nakedness while I search for a likely vein. I can hear the thump of a helicopter rotor in the distance

One quick poke inside his left elbow, and blood quickly fills the chamber of the fourteen gauge catheter. I tape the catheter in place with the Ambulance Driver Gorilla WrapTM; three wraps with three-inch tape. It’s ugly, but strong. I’m drawing up the succinylcholine and etomidate when the distant thumping rapidly morphs into a roar and a downdraft that rocks the ambulance.

A few moments later, a firefighter pokes his head through the open rear doors of the ambulance. “Helicopter’s on the ground!” he announces unnecessarily, a sparky little rooki
e grin on his face. He looks about fifteen years old, excited as hell that Mommy let him go Save Some Lives tonight. His veteran brethren just roll their eyes and grin.

Ah, to be young and sparky, where you look at wreck scenes as exciting and not the future site of a forlorn white cross.

I push the sedatives and paralytics, and within seconds the kid is flaccid, no longer arching against the straps. I take the time to attach monitor electrodes and the capnograph lead and take a quick automatic blood pressure.

104/56. Not perfect, but good enough.

I nudge the firefighter standing beside the stretcher. “You mind staying here and ventilating him for a bit?” I ask him. “I gotta go talk with the flight crew.”

“Sure thing,” the firefighter nods, glad to be of some help.

“Just keep this number hovering around 30,” I instruct, pointing at the capnograph tracing on the monitor. “Maybe sixteen breaths a minute or so. If anything changes, send somebody for me. I’ll be back in a minute.”

I step out of the truck and trot back toward the knot of people gathered around the SUV. The flight medic meets me halfway, greeting me in the universal language of flight crews:

“Whaddawegot?” he asks.

“One severe head injury in my rig,” I tell him, not breaking stride. He falls into step beside me. “We have one being extricated with lower extremity fractures and probable internal injuries, and one walking wounded,” I finish, gesturing at Jimmy, still being interviewed by Matt and the DPS Trooper. Jimmy could not be described as compliant.

“Git that fuckin’ light outta my eyes!” he roars belligerently. The cervical collar is askew on his neck, and a piece of tape across his forehead has pulled loose at one end, causing the gauze pad placed there to dangle wildly with each turn of his head. “I already tole you Tony was drivin’!”

“If you’re talking about the kid pinned in the back seat,” the trooper mutters in disgust, “I ain’t buying it.” He reaches behind his back, producing a pair of handcuffs from the pouch on his belt.

When Jimmy sees the handcuffs, his bravado fades and he wilts against the truck. “Hey man, my head hurts,” he whines. “I think I broke something. I need to go to the hospital.” Disgusted, Matt turns to me, one eyebrow raised.

It figures he’d have a stainless steel allergy. Don’t think you’re getting off easily, scroatbag. I’d bet my life that Matt will be waiting at the hospital when you’re medically cleared.

“Fine,” I hear the DPS trooper say. “Just walk with me over to this ambulance over here…”

I watch as Matt and the trooper escort Jimmy over to Medic Two’s unit, just arrived on scene. Mr. Clean trails behind them, grinning as if he’s watching something fun. I shake my head in disgust.

“You want us to take the head injury?” the flight medic asks as we watch several firefighters sliding a spine board into the back seat of the SUV. Bodie, still in the back seat, barks orders.

“Actually, take this one,” I reply. “Mine will most probably arrest in your bird before you get there. You might be able to do this kid some good, though.”

The flight medic nods his understanding and waves his partner in toward the SUV. She kneels down and flips back the straps on their litter. The firefighters, shuffling in step with the board carried between them, back slowly out of the SUV, feet first. Bodie follows them out, still holding spinal alignment. He grimaces and straightens painfully. They gently lower Tony to the litter and strap him into place. His color is terrible, and he can only manage a slight moan. His belly is distended, grossly out of place on his frame. Both legs are broken in several places.

Good luck, kid. Try to pick better friends next time.

“Ever find the other one?” I ask Matt as I pass Medic Two’s rig. He’s standing on the rear bumper, looking in through the windows. Mr. Clean is standing by the curb-side door, looking disappointed. Matt shakes his head.

“We got this one if you want,” Reggie, the paramedic on Medic Two, offers.

“Nah, he’s just got minor injuries, and we need y’all to cover the city until we clear. Just bring him over to my rig once Matt and the trooper get their info.”

Reggie nods his understanding and climbs into the rig through the curb-side door.

“Is he gonna make it?” Matt asks, jerking his head toward my rig. I step aside as Medic Two’s rear doors open and the DPS trooper climbs out. Reggie unloads the stretcher, and his partner digs through Jimmy’s shredded jeans, tossing Matt his wallet.

“Probably not,” I tell him honestly. “But you gave him the only chance he had. We’ll do what we can.”

“Shit,” he breathes, and I watch the gentle giant deflate just a little bit. “Well, I’ve got a scene to work and a family to notify.” Without another word, he turns and walks back to the SUV where the DPS trooper is making notations on a clipboard.

We wheel Jimmy to my unit and secure him to the squad bench. Reggie slams the rear doors, makes a “wind it up” motion Bodie can see in the rear view mirror, and presently I can feel us pull back onto the road, swing around and head back toward Small Town ER. I kneel between the stretcher and the squad bench on the ride in, setting up the portable ventilator on the kid and trying to ignore Jimmy heaping torrents of verbal abuse on my back. He’s much braver now that the prospect of jail has dimmed, however temporarily.

What’s that, Jimmy? You don’t even know my mother, so how can that be possible? You’re what? Gonna kick my ass? Maybe I should loosen the straps and let you give it a whirl.

I plunk wearily into the captain’s chair and thumb the speed dial button on the cellular phone, bracing myself against the sway of the truck. I have to raise my voice to a near-shout to be heard over Jimmy and the sirens.

“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)…”

“Lines?” she wants to know. “Cardiac rhythm?”

“Fourteen gauge, running a bolus now. Sinus brady on the monitor. 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.”

At Small Town ER, Babs greets us with a wry smile that quickly changes to concern with my handoff report. I can see her thoughts, like a cartoon balloon over her head:

Shit. What are we supposed to do with this kid? He needs to be in a big hospital.

I really didn’t think he’d make it this far, I answer with thoughts of my own. Otherwise I’d have called another bird. If he makes it, it’s because Matt gave him a chance.

I can hear Jimmy howling his displeasure in the suture room as I complete my report. Moonlighting Paramedic is working him up, using the version of tender loving care that MP uses for belligerent drunks. One long stream of profanity is cut off by a piercing screech.

That must have been the Foley catheter. Go get him, MP.

Bodie and I finish cleaning the rig, clear from the hospital and send Medic Two back to their station. By the time we settle onto the couch, it’s close to four am, and we’re both still too keyed up to sleep. American Pie is playing on cable, and we sit and watch numbly without laughing.

All the kids look so damned young.

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