Monday, April 12, 2010

To Code or Not to Code

To code or not to code, that is the question. Per my protocols and most teachings for EMTs and paramedics across the US, trauma deaths are just that, deaths. If someone is the victim of trauma and their heart and breathing has stopped there is somewhere around a 99.99% chance they cannot be resuscitated. At least that's what the studies say. The story I am going to tell though is about a woman who beat the odds.

It was an extremely busy day. We were on the way back from our third trip out of town and countless 911 calls. It was pouring down rain, and I mean dumping. Right at dark, around 19:30 hours my partner ambulance for the day got toned to an MVA almost near our north county line, this is a 45 minute drive with the lights on.

The short report sounded bad and there was two patients so we went in route too. It took us 50 minutes to get on scene and the whole time we are hearing reports of power pole on top of vehicle, can't shut down power, one patient is unconscious and can't reach her, etc. Sounded like a bonified grinder.

We arrive on scene to find four volunteer fire agencies(with multiple rigs and personnel) and my other medic unit all staged a little away from the accident. A large 70s pickup had gone head-on with a power pole and the pole had smashed the roof of the truck almost flat to the dash. The mechanism of injury was very significant. The other ambulance crew gave me a briefing, explaining that the wires were still hot and for some reason the power company had not turned them off yet.

So we waited, and waited, and waited. During this time the driver, who was entrapped woke up and began yelling at us.

"Help me! HELP! I think my girlfriend's dead. HELP!" And then he would reach up and grab those high voltage power lines. We kept yelling at him to let go and put his hands down but he only listened for a minute then did it again. It was still pouring down rain and despite my good jacket I was soaked through and evening turned into night.

Finally we received word that the lines were shut down and we could proceed. The other crew took the driver and I went to the passenger. It took the hydraulic spreaders to open her door, and the roof was caved in over the top of the windowsill area on the door. After popping the door I saw the patient was in bad shape. Her crotch was on the floorboard area with one leg going straight up past her head and the other lodged in the dash. Her head rested against the seat where ones booty would normally go. It was very dark so I couldn't get a proper assessment inside the truck so I made the judgement call of life over limb and had someone help me get her out quickly and onto a backboard.

Once outside the truck I could see that her skin was gray, she had no pulses and no spontaneous respiration. Per my protocols I could have called her right then and she would have been a statistic in the trauma studies. However, I had a really gun ho group of EMTs and they all grabbed the backboard and ran her to my ambulance. I hopped in the back and saw that my brilliant, EMT-IV partner had set up the monitor, two full IV setups, and all my intubation equipment.

My partner hooked her up to the EKG while I dropped a quick tube, no gag, no vocal chord movement, so I didn't need my induction meds. Went in easy. About then my partner look at me and says "Heart rate's 40!"

I said "No, PEA at 40 get ready to do CPR." By that time I noticed I had poor bag valve mask compliance and only the left side of her chest was rising. She had a tension pneumo-thorax, or a collapsed lung that had built up pressure and was stopping her heart from beating. I grabbed the iodine and a 12g needle and performed an emergency needle decompression. The amount of air that shot out the end of the catheter was more then I've ever seen before or since. But the patient's color immediately started improving and the bag valve mask compliance was easier as well.

"Ok, heart rates in the 120s now." My partner informed me. I checked a pulse and sure enough she had bounding pulses with that. I told my partner to get up front and not to spare the ponies. We couldn't get a helicopter because of the rain so we transported 45 minutes to our local hospital.

On my head to toe I found the patient had contusions to left anterior chest, bilateral femur fractures, bilateral tib/fib fractures and multiple cuts and bruises. The patient was flown to a trauma center later and she recovered nearly completely. Albeit after a lot of physical therapy and time in the hospital.

Would I have worked her if not for the EMTs? Who's to say. I was with in my right to call her, she met the criteria for Traumatic Death In The Field. I will say that from that day out I have looked at each situation very carefully and if there seemed to be any chance at all I go for the gold.


Anonymous said...

Great story Ben-Ilove reading these--G.questeOnie

canoehead_ said...

Right on, you did a GREAT job. And thanks for writing it out for us rubberneckers.