This Friday during my normal shift I had a friend from my medic class riding along with us, doing 12 hours of his own ride time. The day was mostly routine, a number of ALS calls but nothing exciting. Old lady short of breath times two weeks. Early morning car crash: "I didnt see him coming!" A transfer. My friend was a little dissapointed. "Where are all the big bad calls you guys brag about here in the city," he asks.
On our way to our last call, something that sounded equally routine, we are re-routed to a shooting. Second car in. At least two shot, one in the head. I let out a yell to our rider in back "here we go!" and flip on the lights. The street is only a few minutes away. The police is already on the radio, asking how far away we are. Always a sign that call is serious.
The address is lit up ahead with flashing police lights. They form a glow into the dark sky around the whole area, a bubble upward which - we hope - will shield us from any further danger. We pass by yellow tape as an officer, holding a black tatical shotgun, waves us through.
Our patient is visible as soon as we park. Laying on his right side in the sidewalk in a pool of dark blood is a body. An EMT from another ambulance steps over him as we approach. "There are two others, shot in the back and chest." He has to shout as he speaks, the scene is smothered in yelling. "...We'll take those" he says, and points to the body on the ground. "This one is yours."
I yell back to my friend to grab the board and collar. This is going to be a scoop and go, my partner says. We get up alongside the patient and I catch myself as I almost kneel in a puddle of blood and unrecgonizble bits of organic material. The forehead looks funny. It is caved inward. The cornrows weaved into the patient's hair look distorted, following odd angles as they run through a new shape in the patient's skull. The blue and red flashing lights do nothing to help visiblity, despite everything it is still dark. The board and collar arrive, and my partner yells for the monitor. He looks at me, frowning. We both know that this patient, shot in the head, is as good as dead.
My partner reaches for a pulse at the patient's neck. His blue gloves are stained with drak red blood as he brings them back quickly. "Hes got a pluse, man." We both notice that he isnt breathing. "Lets just get him into the bus," my partner says, and we do. We slide a board under the patient and lift him up. Both arms swing limply down the sides of the board as we transfer to the stretcher.
Someone flicks on the bright overhead lights in the ambulance. Dark blood is now bright red, and the cave in the patient's forehead is now an obvious gunshot. Grey and white brain matter is visible. The patient looks like he is about 12 years old. I feel like I am looking at him for the first time. Someone says "jesus christ."
We get to work. An OPA is placed and bagging through the BVM begins. Our rider says he can feel air rushing out of the top of the kid's skull with each compression of the BVM. We attach the monitor and the combi-pads, strap the patient down, listen to lung sounds and survey the damage. The patient is in a wide complex tachycardia that the medic and us two medic students all call VT. We each yell it out in chorus as the rhythm appears on the screen. It releives me to recgonize the rhythm. Out of the chaos of the scene, the chaos of this patient, the rhyhm brings order and stability to the back of our ambulance. The patient still has pulses, too. We know what we are dealing with.
"We need to shock!" My medic says. "Get the pads on!" The pads are already on, two people say. "Well, charge them then!" We charge to 360 and again, in chorus, yell "Get clear! Get clear! Everyone clear!" The shock is delivered, the body flinches.
Blue hands stained with red reach for the neck. There are no more pulses. The monitor still looks the same. PEA. No chrous this time, it is deadened by the result. I hear a "lets go."
I jump out of the ambulance, climbing over strewn gear and a firefighter who is now giving chest compressions. Out of the bright white light and back into the blue-red night. People are standing in a semicircle around the back of the ambulance, watching. An older woman is holding two young children close to her, yelling frantically. "See why I tell you not to mess around in the streets? See what happens! Look what happens!" The children are unreactive, staring at me and the scene behind me.. I cant understand the expression on their faces. It isnt fear, it isnt shock, their eyes arent wide. They look sullen, tired. Just another shooting in the north end. Just another kid dead. More blood on the sidewalk. The older woman is screaming and crying. She must have known something different, sometime or somewhere else.
I flick my gloves off and check my hands. There is blood on my wrist where the short gloves ended, but nothing on my hands. I can drive without getting the front of the ambulance messy. I jump up into the front seat and glance into the back. It is getting calmer. The medic is going for the tube, my friend suctioning as the firefighter does rhythmic compressions. No-one is talking. The reality of this patient has envolped the small space in back, what was a frantic effort to save a life is slowly turning into a recgonition of futility. I have a job to do though. Priority one to the hospital. I get on the radios and tell everyone where we are going. C-Med, police, the company. C-Med patches me through to the hospital and I tell them we are coming:
"Enroute to your facility, ETA 2 minutes with a male young teens. Shot in the head. Traumatic arrest, was VT with a pulse, now PEA. CPR and AlS in progress. See you in 2 minutes."
I catch the end of an "okay, thanks!" yelled into the other end. I envision the microphone bieng dropped and an excited "We've got a code coming in! A shooting!" yelled to the Emergency Department. A trauma team called over the intercom. "They're two minutes out!"
They dont know that our patient is already dead.
We're out at the hospital. There are other amublance crews waiting to help at the entrance to the ER. They heard my patch over the radio and got ready to help. Their gloves are on, bright spotless blue. We wheel the patient with deliberate caution into the ED. We've been with this patient long enough to be calm. Nothing gets dropped, and the report to the trauma team is crisp. The patient is off our stretcher and onto the trauma bed. Our job is done.
The doctors look at the child on the table, frowning. The same look my medic had when we first looked at the body laying on the dark sidewalk. I hear them say "no, look at him. He's gone." A few efforts are made, and on no change of the patient's condition, the patient is pronounced dead.
It takes us over an hour to clean the ambulance. There is blood everywhere. From the patient, from bloody gloves, from soiled equipment. We spray a disenfectent on everything, wiping carefully to leave no trace behind.
I find my medic partner sitting alone in the EMS room, staring at his EKG strips and a blank run form. He looks awful. None of us have seen anything that bad before, but this was his call. It was his patient. I was there to help, as was the medic student and the firefighter, but this patient was in my partners care. The outcome rests on him. I tell him that he did a good job. Our times were great. The kid was dead anyways and we did our best. The doctors said we did a good job. All of this, positive, but my partner's expression doesnt change. He asks me about the cardioversion. "Do you think we should have shocked him?" He asks me. He's upset about missing the intubation as well.
I sit with him as he writes the run form. There were probably twenty police officers on scene. Four people in the back of the ambulance, at least 10 people in the trauma room, two of us in the EMS room, and one medic writing the run form. One of him. This patient was his. He was the paramedic, THE guy treating the patient. Despite everything and no matter everyone, there was one person making decisions for this patient during the last minutes of his life: the medic.
He sits there, hunched over the run form as he runs through the call in his mind.
To clarify out of respect of those involved with this call:
1. The medic did not "miss" the intubation. The patient was an extremely difficult (if not impossible) tube with the amount of blood involved. Constant suction was unhelpful in clearing the airway enough for intubation.
2. Defib/Cardioversion was absolutely indicated for this patient based on the assessment performed and presenting conditions of the patient. There are details left unmentioned in the above entry that support this decision.
3. The call was run VERY well considering the conditions we were under. I worry that based on this story, some readers may think poorly of those I wrote about simply because of the way the entry was written. Please refer to a newer entry, entitled "Clarification" posted on 11.26.06 for further information.