Monday, June 23, 2008

Quiet and Comprehension

There is a certain profundity that is expressed by silence in the face of screaming tragedy. Quiet has a potential to permeate the soul deeper than any cry could, hit harder than the fiercest blow. With somber sadness and a quiet reverence for a life gone in only a few seconds, my partner and I stood over the body of a woman who was alive and working at the machines only ten minutes ago. Now, her skull was gruesomely crushed, open and split onto the cold concrete. The factory, usually buzzing with activity and clanking machines, was totally shut down. The hundred or so workers who manned the iron from nine to five were frozen in their positions, standing in awe. Their smudged faces peeked out from yellow hardhats, betraying a contorted mixture of disbelief, shock, awe, fear, and sadness. Silently, we all stared at the result of an accident that brought the entire factory, and this woman’s young life, to an abrupt halt.

She was assisting on a large iron press, we were told in whisper. The machine exerts several tons of pressure, and through some miscommunication or some other horrific lapse, this woman was caught underneath it on a downward stroke. The result was the worst traumatic injury I have ever seen: a crushed skull and brain matter spread out in a fanning pattern. The face was an unrecognizable mash, attached loosely to a body that lay lifeless in an awkward, contorted position. We didn’t even check a pulse. There was no point.

We conducted our business under our breaths, passing word to the police officers that the patient would be presumed dead having sustained injuries incompatible with life. Firefighters wordlessly began surrounding the workstation with a large opaque tarp, shielding the entire area from the tearing eyes of her coworkers and friends. I was able to get demographic information from some of the factory management, and then quietly made my escape back to the ambulance.

My partner and I stowed our gear and climbed back into the truck. Looking at each other from driver’s seat to passenger, we couldn’t come up with anything other to say than “holy shit.” Silently, we drove back to the ambulance bay.

I’ve been to the scenes of many recent deaths. Car accidents, shootings, various cardiac arrests. Outside of health facilities there seems always to be some distraught family member or friend, loudly exclaiming their grief in either cry or yell. It used to bother me to see the faces of these anguished people, and it was usually with them – not the patient – that I empathized. For some reason or another I don’t usually find myself sympathizing with the dead. They’re gone, and in most cases there seems to be plenty of grieving going on anyways.

…But not this call. It was deathly quiet. The silence was so thick that it had to be managed, considered as its own passive obstacle like knee-high sand. We waded into that factory though oppressive quiet and took in a scene that few should have to bear witness to. We saw a hundred hard-hatted faces, watching and silent as if they were waiting for the woman to take her next breath and spring from that contortion. It was a frozen moment of time, lasting an hour, where consideration and re-consideration of events past left little room for outward emotion or cry. It was unreal.

We were brought in to talk with our supervisors who worried whether we were okay. They were extremely accommodating, asking if there was anything we wanted or needed. They said they knew that the scene was pretty gruesome, that it is tough for anybody to see a body so mangled and dead like that.

But it wasn’t the gore. It was the quiet. Seeing that person lying there frozen where she last moved herself was an extremely powerful experience that I don’t think I will soon be rid of. It was as if the clock stopped immediately after that machine banged downward, and though the area surrounding that small space shuffled and blurred in the background, our dead patient remained in sharp focus, preserved in powerful tragedy on the precipice of comprehension.

…And all we could manage to say was “holy shit.”


Gerry said...

I'm pretty sure I would have said the same thing.

Herbie said...

Didja at least go for pizza afterwards?

Zac said...

I can't imagine, man. I see stuff that's usually the person's own fault... but a horrific trauma like that? Never even makes it in to the ER.

Bernice said...

I don't even know if I would have gotten out the holy shit.

Take care of yourself.

Mastabattas said...

Your simple statement, holds more power and emits the gravity of the situation more honestly then anything else you could have said. It is authentic.

NJ EMS said...

Hi Doc I know I have not been by lately...but could you hook me
up with a prescription of Haldol?

Medix311 said...

Very powerfully written and vivid. I can't even imagine what it was like to see that. I've seen gore too, but nothing like that. Take care of yourself and take advantage of the counseling if you need it. It can really help.

Kristen said...

Don't overlook CISM, it can be a powerful tool. I still lose sleep over certain calls.

ROOKIE said...

Bad stuff man. I recently wrote a post similar on my blog. The scenes of death are hard to scratch from the mind.

Wonder Woman! said...

there's nothing that would have been able to shake the oddness... of silence... :P Wow...
(I'm a baby medic too... starting in July...)

Anonymous said...

Hi "Baby Medic". I have been following your blog for a time now and I think you are a good writer. I am originally from the East Coast; NYC. I have not kept the cert up. I NEVER thought it would up to to the THOUSANDS of dollars to get it back! I paid 1500 for the class, lol. I thought I may just have to take a "refresher class" LOL but the all mighty private organization called the NREMT gets to play G-d with everyones lives.

THE US IS IN A PARAMEDIC CRISIS (FACT). Rural medics are important too because I want a good one there if I get hemmed up rock climbing or riding my dirt bike! Most of rural America is looing paramedics and "intermediates" dont have the hours in training necessary (small amount of clinicals). The intermediates also dont get to use their skills very much as I PRN'ed for a rural service (F 8P- M 6A in college) and the entire service only got like 20 tubes a year to share with 8 medics! I had the entire station to myself because after 4PM everyone went home and took calls out of their house!

I only see a few people/orginizations to blame for this "paramedic crisis".

The U.S. Government needs to look at the NREMT when states bitch and moan that they loose all their rural medics to the city or once in awhile the reverse after city burn-out. I know 5 other people in my shoes that just need to learn some of the newer stuff like how to use a lifepack 12, lol. We did have RSI so we are not THAT old, but cath lab alert, "fahgetaboutit".

First of all I wanted to tell you that your site has helped give me a jump on some of the newer things in EMS, thank you!

I think I became a medic in my early 20's and am now 33. Maybe at 22.

I am commenting on your "tube situation". I remember working for a service that had a 'life-pack 2'. It was in a BIG METAL BOX! It was a boat anchor. This is 1995 folks. The thing did work and they did not break (only broke your back). The only good thing about it was that if you dropped it down a flight of stairs in a 'walk-up' building; nothng happened to it! When I moved out to the midwest they were still using them. When NYC-EMS (now FDNY EMS) had life-pack 5's we all got by making due and doctors did not give us much crap. What you went through was BS. I would have gotten fired that day I am sure because I would have told the guy off. Look at old episodes of Emergency and you will see what many used to work with! Now I have to learn a few new things.

We had no capnography. Those color changing plug-ins are severely unreliable. They started out costing a fortune and you sometimes had to open 2 of em.

Since I have been a non-certified PA for a General Surgeon for 2 years that doctor in your ER did NOT CONSIDER SPONTANEOUS PNEUMOTHORAX OF A PROLONGED CARDIAC ARREST! As soon as I read your story that was the first thing that came to my mind.

I copied you blog and took it when I had dinner with my old boos; now fried as he as gone into retirement. He learned long ago that paramedics make better PA's beause of our training and we have good hand eye cordination! I only had one 'dizzy spell' in the OR and that was the first time I had to squeeze a certain something out of a certain sack, lol. After that I got adusted to the nether regions. To digress, you may like working as a paramedic PA for a doctor.

When I brough your story to dinner the FIRST thing he said to me was why did the ER doc, IF he was board certified, not at least do a bi-lateral needle decompression and put a tube in?

I agree with all the other comments that the doctor owes you an appology. I would talk to your shift supervisor and word it as the doctor is embarassing your private service. it is the truth. He demeaned you in front of other nursing staff and now they may deny orders you may need for a life/pain saving event (I know there are still SOME call-in orders).

Use google and type in "bi lateral pneumothorax" cardiac arrest-- and show the sup. the articles. I would tell him the doc is making your paramedics look incompetant when, in fact, it is HE that needs an ATLS refresher! I know that I have broken plenty of ribs in my tenure!

You are so lucky to have capnography and I have been looking for your old link "capnography for paramedics" because I forgot to bookmark it. Can you please put it up again.

I can't even begin to count how many tubes the hospital staff pulled out moving the patient over to their cot despite the fact that we would put a collar on them to prevent that!

I wish I had a capno strip to wave in front of them like my "I did not fuck the patient up; YOU DID flag"!

If I had $100 for ever tube that was either yanked out by a nurse or a volunteer first responder I would have the cash to pay for a new class! TECHNOLOGY IS AMAZING! I hope one of you out there can direct me to that site.

Anyhow---- These memories of smashed faces will dissapear as you get on in life/medicine. The medics that live and breathe "post stress debreifings" are the ones who fall apart. If I went to all of those offerings I would have had no personal time! Maybe they are useful ON OCCASION; but there are some very overly emotional people in this profession; I am sure everyone reading this knows some.

The one thing you said in a post is that EMS is a SERIOUS TRAP. In a way, getting out of EMS has put me in a better situation then being in.

If you honestly want to be a doctor; like I still do, since you are younger than me, I would consider taking out a student loan and going to a good local state school and paramedic PRN *don't loose your cert*

I am now contemplating taking the MCAT next year (since my grades sucked when I was trying to paramedic and take things like 5 cr trig based physics) I have to spend a year re-taking my sciences at a community college since my transcript looks like a roller coaster! I had to drop trig based physics and that is they EASY one; many take calc based physics but it took all I could to pull off a C+ in Calc (5cr) because I was up all night and taking the class at 8AM, just like you, in uniform.

Every state has a pell grant (free money) which is usually around 5-6K. You can take the rest out in a stafford loan.

I pray you get out of this sand-trap we all love and hate at the same time and become one of the "cool docs" that everyone loves. The ones that take you asside and let you learn stuff like central lines (which we used to have in our protocols till people lost their skills.....there was a period of no CVP/no IO gun since IJ's wound up as Internal Carotdid's and Femoral V's wound up as Inguinal Canal "internal spermadic cord lines".

THANKS FOR THE COOL BLOG AND MY RANT! Please keep us old cats refreshed so that we can go back to work a little smarter! Maybe explain some 12-lead cardiology on the strips you put up.

If you or any of your dedicated readers either know of any GREAT medic classes affiliated with a traua center that takes student loans OR knows where that site is "capnography for paramedics" please email me.
(everyone bungles it up, it is all lower case and I am not a "boi"). It is( I U B B I O 5 ) in lower case at THANKS GUYS/GALS and if you can email me any good educational stuff like 12-lead learning please give me an email! EVERYONE HAVE SAFE TOURS WHILE ON DUTY AND OFF! E-

fiznat said...


Thanks for the compliments and comments! To answer some of your questions, the ETCO2 for paramedics blog can be found here It is written by Peter Canning, a coworker of mine who writes another popular EMS blog entitled Streetwatch (

As far as 12 lead stuff, honestly the best thing I can suggest is to pick up a copy of Dale Dubin's book Rapid Interpretation of EKGs. It is probably the simplest and most effective way to learn these things, and the book even gets into some fairly detailed stuff that we don't use often but is still useful. Well worth the 20 bucks or so. I'll try to do some more explanations of the 12 leads I post but in the past I've shied away from that because I don't want to presume to know more than my readers on those subjects. I am, after all, a "baby" medic still...

I did consider the pneumo with that cardiac arrest patient, but then again I re-checked the lung sounds several times during my care and heard full and equal breath sounds bilaterally throughout. I don't know what the doc's problem was with that, but it all worked out in the end because I had (thankfully) taken care to obtain objective proof of my tube placement with the ETCO2. I'm not going to push the issue of looking for an apology from this doctor. Everyone at that hospital knows me well enough and I'm not worried that this single event would tarnish my reputation significantly. Even the nurses were rolling their eyes during the whole thing, so I don't really feel the need to push the issue. I'll prove my worth again (hopefully! haha) with my next patient.

I'm doing my best to move on from this stuff as you have. Currently finishing up a few more classes and I'll be ready to take the MCAT/apply to school early next year. Until then, I don't mind learning a few more lessons in the ambulance as well.

Again, thanks for your comments!

VA FireMedic said...

i've seen some pretty messed up shit...but that defiantly tops it all. take care of yourself bro, that will probably live with you your entire life. the humor of it all is that while i was reading it all i could say was "holy shit", and then i saw your reaction was quite the same as mine

artillerywifecq said...

holy shit is right, i wouldn't know what to say. I hope I never see anything like that. I love this post, its very well written and powerful. WOW!

Tim said...

Baby Medic, thank you for sharing. Your writing is so vivid and authentic, you are a truly gifted clinician and writer. Your humility only further emphasizes your gifting as a paramedic. As a fairly new medic myself your blog is always an inspiration to further educate myself and remain compassionate, I genuinely appreciate your insights. Keep up the good work!

Anonymous said...

Very powerful and insightful writing,I actually had to stop reading after I read what happened to the woman and consider the silence,the shock and the fan shaped pattern. It created such a vivid picture in my head.
Makes me glad that I only work in the hospital,I don't think I could manage that.

Coach said...

One of my first ever calls, back in the 70s, was of an older man who fell off a wall on a construction site. Later, now working for a professional ambulance service, one of my first calls was of a man whose head was crushed between his forklift and the door jamb.

Unfortunately, I could go on and on....

No one told me that these images would never leave me. No one warned me that the adrenaline rush would give way to the impregnated images in my brain. No one told me.

Last week I went to the 30th anniversary celebration of Life Flight, in Portland. I was hired on their 10th anniversary. What a wave of emotion that brought back.

No one told me.

Coach said...

PS: This was a very articulate, and well written post!

Anonymous said...


I've been reading your blog as I'm interested in becoming an emt, but currently I'm a millwright who works on the type of machines involved in this incident.

In my country (Canada), the labor laws are such that an accident like this is an impossible occurance. The only way for such a thing to happen would be to intentionally circumvent safe guards. In my country, this women's supervisor would be personally liable for a $50thousand dollar fine and six months in prison.

This is the legacy of the Bush years.