This week I had the opportunity to gain a unique and interesting perspective on a call from an angle we as EMS providers don’t often get to see.
It was an “off week” from class due to Thanksgiving and I decided to use the extra time to get some of my clinical time in. Wednesday night from 2300 to 0700 I worked in the ED, and Friday morning at 0645 I was in the OR.
During my extremely busy ED shift a trauma activation came in – “gun shot wound to the head – pulseless and apenic – CPR in progress”
I knew what to expect having called in activations to this busy urban facility in the past… call in the Calvary – Trauma 1 was readied while the ambulance was en route – The docs and nurses had their stuff wired as they readied the room… who’s getting first pressure, who’s got the drug cart, who’s going to bag, who’s recording… They orchestrated the symphony before the particular piece of music arrived. The senior resident was at the head of the bed ready to conduct and all of the members of orchestra stood ready – shortly thereafter the “sheet music” arrived via gurney.
He was a large 30’s male CPR was in progress and they moved him from the gurney to the bed in no time flat. Report lasted about 10 seconds. (I had heard about these “loud and proud” reports in the trauma room, but I’ve never seen one given, it was impressive.)
Immediately after he was placed on the ED table – compressions resumed, lines were started, orders called out. Doc asked why no tube was in place, medic replied with, “jaw was clinched and we couldn’t get it”.
“Fair enough” he said as he inflated the cuff on the tube he had just dropped.
Two minutes – nothing.
“Let’s go one more round and call it.”
I climbed up on the stool next to the bed and began compressions – fast and deep, fast and deep over and over – while it shouldn’t be any different it felt like I was being graded by all the docs and nurses in the room and I wanted to be sure every single compression was as perfect as I could get it.
Two more minutes – and one of the docs says – “I have a pulse”, initial pressure was something like 60/30. Meds went in and a physical exam began.
Here’s where it started to get interesting, the patient did indeed have a “hole in his head” and a broken jaw, he also had a hole in his back and in his right bicep. ED Doc decided that the hole in his head was not due to a bullet (no palpable fracture or crepitus below the wound) but that the other two wounds were. A chest tube was inserted and 2300 cc of blood were drained from his chest – he began to stabilize and was sent up to trauma surgery.
The rest of the shift was pretty uneventful and at 0700 I called it a day.
Friday morning rolled around and I headed up to the OR, I was more than a little nervous about intubating my first actual patients. It was a slow day in surgery with only 3 cases scheduled day (a typical day sees between 20 and 30 scheduled surgeries in the 13 different OR suites). The first case however intrigued me, it was the gunshot victim I had worked in the ED.
He had been taken into trauma surgery from the ED and had the bleeding in his chest and right arm controlled, a second chest tube inserted and then was sent to SICU to stabilize before further surgery. Since he was already intubated there wasn’t much I could do, but I was allowed to observe from bedside.
They reopened his chest and after removing several handfuls of clotted blood they began to examine his lung. When the surgeon found out I was a paramedic student and that I had worked this guy in the ED he invited me to “scrub in”. What an amazing opportunity – how many of us get to not only observe but actually scrub in on a patient.
After the obligatory hand washing to your elbows, the whole dressed by the nurse twirl to get the gown on and sterile gloves I was ready. The surgeon invited me to watch over his shoulder as he showed me the damage the bullet had done to the lung tissue, he explained what he was looking for and at. It was amazing to see the lung in his hands as it inflated, if I looked at just the right angle I see the pulsating aorta as it exited through the diaphragm – this beat cadaver lab hands down.
Satisfied that he had adequately repaired the lung the doc said he was going to attempt to find and remove the bullet – “do me a favor – hold this” he said as he gestured at the retractor sticking out of the guys chest. I looked around through the safety glasses I was wearing, not seeing anyone else he would have been talking to, I pointed at myself (careful not to touch the gown) and said “me?”
I swear I could see the surgeon smile through his mask while he reassured me that I could in fact hold his retractor.
I took a firm hold and was careful to follow his instructions to the letter… he found the bullet and repaired some more damage, it was fascinating to watch. My amazed wonderment overcame any lactic acid build up in my shoulder and arm and I didn’t miss a beat. The surgeon explained to me what he was doing and why as he did it.
Once he was finished and getting ready to close I asked where the bullet had entered and what it had damaged. He invited me around to the other side of the bed and explained that the bullet had just missed the spinal cord and the aorta, and he slid his hand way into the patients chest – he lifted his hand lifted the lungs in the process and said – Here slide your hand against mine – be careful not to rip your glove there are some broken ribs back there.
Could this experience get any better? I slid my hand into the patients chest and could in fact feel the shattered ribs, the vertebral column and the pulsations of the aorta – I’m pretty sure I had that same look a kid who sees Cinderella’s castle for the first time has – It was a truly amazing experience, one I will probably never get again.
Interestingly enough even after surgery the docs weren’t sure if the hole in the patients head was due to a bullet or something else. I suppose it doesn’t really matter, and is a further illustration of how inexact our practice can be sometimes.
It also gave me perspective that most EMS providers never get – while I didn’t actually pick this guy up on the street, I did get to “follow” him from his arrival in the ED to his discharge to ICU. What an amazing experience and how fascinating to watch the treatment plan be implemented and carried out.