FYI? A little too soon for an EMT student.
Friday, June 3, 2016 8:25pm
Like a film clip abruptly inserted into my real life on my drive home from work – via my windshield – I see a thick and disorganized cloud of dust the size of a small house rapidly rolling and flipping and growing just off the right side of the road. When it stops moving, the cloud hangs in the air over its path and eventual resting place. In the middle of it I can barely make out the shape of an automobile coming to rest. Upside down.
‘No! No! No! No!” I hear someone yelling. It is only after the words hit my ears that I realize it is me. I am yelling.
Then I am running down the embankment pulling on purple latex gloves and waving my arms wildly at the same time shouting over and over, “Do not flip the car over!!!” until I reached the scene.
The car is no longer upside down, it is now on its side, held in place by ten or fifteen people. All eyes are on me, and it is eerily quiet. I realize they are performing a balancing act with the car, waiting for me to follow up with what to do next.
It’s the purple gloves, I think to myself. Most first responders wear purple gloves. And I am, by default, the “first” first responder. ‘Ish.
In class I am a fifty-eight year old EMT student two thirds of the way thru the course who, just the day before, completed a 12 hour ride along on an ambulance. Who, in two and a half days, has a Division II exam that I really need to focus on and study for. Who, two days after that, has a 12 hour shift in an emergency room.
In class we learned the importance of Scene Size-up, Scene Safety, and Scene Control. And the one thing I am absolutely, 100% sure of in this very moment is that car needs to remain exactly as it is, on its side, until the fire department gets here and stabilizes it.
The silence is broken by the sound of loud moaning and movement from inside the car. Everyone tightens their grip as others join them to keep the car from rocking. Bloody arms reach out of the broken side window, which is now facing upward, grasping and clawing at the air, trying to grab a hold of something. He manages to stand up inside the car, and his face joins his arms just above the tangled door. He is covered in blood. His eyes are open wide and wild with panic. His face is a grimace of pain and fear. He has braces on his teeth, the clear kind. He is a teenage boy. He drops back into the car, too slippery and weak to climb out on his own.
In class we learned that, in a textbook scenario, you do not remove an injured patient from a motor vehicle crash until you have secured their neck with a c-spine collar, and then remove them carefully on a rigid backboard for spinal immobilization, just in case of a spinal cord injury.
Prior to that, we are to have completed our scene size-up, insured the scene is safe for ourselves, the patient, and bystanders. We try and determine MOI (mechanism of injury) or NOI (nature of illness). In this case, MOI is clearly blunt force trauma from a motor vehicle accident.
Follow that with our primary assessment in which we attempt to get as much history we can (SAMPLE OPQRST), assess their mental status (AVPU), level of consciousness (AEIOU TIPS), get vital signs (BP, HR, RR, Skin, Pupils, Breath Sounds, Sp02), and perform a physical exam (DCAP BTLS), and administer interventions as appropriate to the assessment.
However, this is not a textbook scenario, and this young man is clearly in a state of compensated shock, 100% survival mode, and remaining in the vehicle is not an option.
He appears again, somehow mustering the strength to pull his body part way up and get a knee thru the busted out window. I reach up for him and he simply falls forward towards me. Other hands reach out and grab him as well. We carry him a short but safe distance from the car, and gently lay him on the ground, supine.
He is conscious and breathing, and his chief complaint is back pain. I kneel at his head, quickly checking for any large wounds or soft spots in his skull to indicate severe trauma and find none. I carefully tilt his head back slightly to keep the airway open, and then use my knees to hold his head in this position. I ask him some questions, and he answers them correctly. He is alert and orientated. A&O x 4, which completely blows my mind.
I ask the fellow who helped me get him out of the car to take over my position at his head and to keep talking to him. To let me know right away if he stops responding to verbal cues, loses consciousness, or stops breathing. I ask bystanders to contribute any jackets or sweatshirts they may have in their cars that can substitute for blankets to help keep him warm, and hopefully prevent him from slipping into a state of decompensated shock.
I can see two more people trapped part in, and part out, of the car. One is exposed from the collarbone up with a gaping head wound. The other is lying on his back, his body resting on the ground from mid chest down; the upper half disappears into the car.
In class we had not yet studied Mass Casualty Incidents (MCI’s), triage, or how to address this level of physical trauma. That was coming up next week, in Division III, the third and final part of the course. And in the interest of keeping it real, I will share with you the fact that I have struggled from day one to maintain the 80% minimum course average one must have to stay in the class. I sit at 83.45%. I completely overestimated my ability to jump back into school, (the last time I was in school Nixon was President), and completely underestimated the time, effort and study skills necessary to do well in class.
It is the written tests that are my nemesis. I am doing fine in the labs, in the scenario simulations, with the homework, with the hands on assessments, interactions and interventions.
On my 12 hour ambulance ride along my proctors, a Paramedic and an AEMT provided me with a great experience. I took vital signs, talked with patients, and radioed in a couple of hospital reports. I was given the opportunity to take the lead on a call, but it ended up being a straight transport, and the last call of the night, so I did not get to have that experience. I felt very much at home on the ambulance, and the shift exceeded my expectations. They shared their stories with me, as well as cautionary tales and words of wisdom. They gave me an outstanding Field Internship Evaluation. I sure do wish I was with them right now.
As I kneel down to get closer to the other two, I can see that they are also teenage boys.
I can see the breathing on the boy with his chest exposed. His respirations are agonal, but he is breathing. I lie on the ground and look inside the vehicle, but I cannot see anything. I put my hand on him and talk to him. No response. He is unconscious. I check his wrist for a pulse. Thready.
The other boy is unconscious as well. I check his carotid artery for a pulse. It is weak and slow. His head wound is bleeding profusely. So much blood.
One of the bystanders tells me she is also an EMT, and is going to get a compress for his head wound. “Thank God you are here. I am only a student!” I tell her, relieved to have someone with more experience on the scene with me. She returns and places the compress on the head wound. I never see or talk to her again.
I cannot get to the airway of either of them. They are trapped, in opposite directions, between the collapsed hood and the body of the car. No way to get to them, and no way to remove them from the wreckage.
“They have pulses, but there is nothing else we can do until the fire department gets here,” I state. A collective sigh of relief hangs in the air for a moment.
“There’s someone else in the car,” I hear. I turn and see yet another young teenage boy. He is very pale.
“Were you in the car, too?” I ask, stunned, but thinking he may have crawled out on his own.
“No. They are my friends. We were in a different car.” His face is all but blank with disbelief.
I stand up and look at the vehicle, really look at it for the first time. I cannot tell you which end is which. There is no way another person is in that car. It defies the laws of physics. There simply isn’t enough space left to accommodate another person.
I step to the front, or maybe rear of the vehicle, and between the broken out window and metal there is about a six inch gap, and I see him. He is
suspended upside down, unnaturally folded in half, and held there by the seat belt. He appears to be even younger than the others. He is wearing white socks, but no shoes. I wonder where his shoes went.
I reach into the car, place a hand on his leg and speak to him. He is unconscious, and I am not sure I can see any respirations. I check his wrist for a pulse. It is not warm, and it takes a second before I feel anything. I think. I wait for another beat. It eventually comes, but barely. Maybe. The next takes longer, if it is even a pulse, I am not sure. I wait for the next.
In class we learn that not having a radial pulse does not necessarily mean there is no heartbeat, only that it is not strong enough to reach the more distal points.
When the pulse doesn’t come, I push and lean into the car in an attempt to feel his chest for breathing and/or his carotid artery for a pulse. I cannot quite reach that far, but I can now see his skin tone is not right due to poor perfusion.
In class we learn about hypoxia, a condition in which the body or region of the body is deprived of an adequate oxygen supply. This can cause cyanosis, a blue-gray color of the mucous membranes and/or skin. As does Postmortem Lividity, which is when the blood stops flowing and gravity takes over. The Latin term is livor mortis, or blue death, and it can show up in as little as fifteen minutes. It is one of the five signs of irreversible death.
In class they tell us that if a patient dies, you must be honest and clear with family members and/or friends at the scene. You must be compassionate, but you must use the terms “dead” or “died.” That it is not to anyone’s benefit and can be confusing to use ambiguous terms like, “He is no longer with us,” or “He is in a much better place.” We are to answer any questions they may have for us, and if appropriate, allow family and friends to approach and grieve their loved one.
In this moment, however, it would be inappropriate and completely out of my scope to share my finding with the friend or bystanders. I am not a doctor, and I could be wrong.
The first to arrive is a sheriff. I meet up with him on his way down the hill and tell him what I know as he makes his way to the scene: Four victims total. One, a teenage boy, was removed from the vehicle, is A&O x 4, and is on the ground supine with his head and neck being immobilized. There are two other teenage boys, both unconscious with weak pulses, partially trapped in the car. That the other is a young boy, possibly a teenager, completely trapped inside the vehicle with no radial pulse, no signs of respiration, and appears to be cyanotic.
The officer takes inventory of the scene as another sheriff car rolls up. The arriving officer asks him, “Who do we need?”
“We need everyone,” is his reply.
Lights and sirens arrive. More sheriffs. Police. Firefighters. Ambulances. A Critical Care Helicopter lands nearby. They all descended upon the scene and it is immediately a beehive of productive and purposeful activity, executed with military precision.
Some of the firefighters secure the vehicle with blocks and straps while others wait with tools at the ready to beginning taking the car apart in order to get the patients out so paramedics can begin working on them.
Other paramedics are already working on the boy who we got out of the car. He is being secured to a rigid backboard, c-spine collar in place.
The police are clearing the scene of bystanders and contacting Caltrans about shutting down the 267 both ways and making a safe landing place for another critical care helicopter.
They let me stay on the scene, and I help them carry the boy on the rigid backboard up the hill to the road, and then transfer him on to the gurney to be loaded into the ambulance for transport.
I make my way back down the hill. It is getting dark, and difficult to see, even with all the flashing lights that seem to go on forever up on the road. However, lighting is now set up at the scene, so I carefully and slowly make my way down the hill towards it.
One of the boys has been removed from the wreckage, and first responders are working on him from every angle. A few cops and firefighters are standing by, and I join them.
”Day off?” one of them asks me.
“No, I am only an EMT student.” I answer.
“Is this your ride along?” he asks, surprised.
“This is my drive home from work,” I tell him. “I just finished my ride along yesterday, and it was nothing like this.”
I pull off my bloody gloves and realize I have no proper place to dispose of them.
“Just toss them on the ground. This whole scene will get cleaned up later,” he lets me know.
“Ok. Thanks.” I toss the dirty gloves and pull on a clean pair.
“This is a bad one.” He shakes his head, and then adds reassuringly, “They’re not all like this.” He gives me a comforting smile, says goodnight, and then disappears up the hill.
The boy on the ground is receiving CPR, a paramedic with BVM (Bag-valve mask) is providing positive pressure ventilation, an AED (Automated External Defibrillator) is attached to him. The paramedic has me move the monitor closer to him. One of the critical care paramedics announces the drill is ready.
In class we have learned how to perform CPR.
We have learned how and when to use a nasal cannula to deliver supplemental oxygen.
We have learned about basic airway adjuncts: When and how to insert a NPA (nasopharyngeal airway), and an OPA (oropharyngeal airway).
We have learned how to use a BVM and an AED.
We have learned everything, and then some, about the ABC’s. Airway. Breathing. Circulation. As EMT’s we are to be, at the very least, airway masters. Airway ninjas. Because life, literally, depends on it.
But a drill?
As the CPR is interrupted so they can intubate him, I can see he has a NPAand an OPA inserted. Moments later I am handed an IV bag to hold up as they continue to work. They never stop moving, and are performing life saving skills far beyond my scope, let alone comprehension. Always in communication with each other, and updating each other about the patient’s condition with each intervention.
“I have a pulse,” one of them announces while palpating the carotid artery.
They continue to work to stabilize the patient, and he is then airlifted away.
While all of this was going on, the other boy was removed from the car, stabilized, and airlifted as well.
“What about the other boy?” I ask a fireman standing next to me. Actually, there are several firemen around the car armed with specialized equipment and tools to use on the vehicle. I realize the fourth boy, the one who appeared to be the youngest, the one who had no pulse, is still in the car. He didn’t have a chance; he was dead before they even arrived.
“We’re going to get him out now.” he replies.
In class we learn how firefighters dismantle a vehicle around the person trapped inside. We become familiar with words like “extrication” and “disentanglement.” What we don’t learn, and what they cannot possibly teach- let alone prepare you for – is how it feels to touch the body of a dying kid trapped inside a mangled automobile and not be able to do a damn thing about it. And I can assure you that, as much as you can feel life running through a body, you can absolutely feel life not running through a body.
As the fire department begins to dismantle the car, I say goodnight, and walk up the hill. This is something I do not need to see. One of the firefighters at the top asks me how I am doing. I may have spoken to him earlier, I am not sure.
“I think I’m doing alright,” I answer, though I haven’t given it much thought.
“First time you lost someone?” he asks.
“Yeah, “I answer, and it sinks in a little more.
“It’s rough the first time someone dies on you. Not to say it ever gets easy, but the first one is pretty bad.” He pauses. “Make sure you talk to somebody.”
“I have class on Monday. I can talk to my teacher then I guess.” After all, it is only two and a half days away.
“You’re a student?” He, too, is surprised.
“Yes. Two-thirds of the way through the course. I have my Division II Exam on Monday,” I explain.
“You might want to talk to someone before that,” he says as he pats down his jacket looking for something. “I’m sorry, I don’t have a card on me. I’m just coming onto shift,” he explains.
We chat for a few more minutes. He shares with me the importance of not trying to handle this on my own. That is very important to talk with other EMS personnel. He cannot stress it enough, and assures me there are ways to cope. I tell him that I understand, and that I will.
I walk over to my truck, and head home. I get about a mile or two down the road before being overcome with the need to pull over and take deep breaths. It is dark. Quiet. No more flashing lights or radio chatter. I look at my watch. 9:40pm. Seventy five minutes. All of this took place in a little over an hour.
My adrenaline driven “I am an EMT student” persona gives way to the fact that I am a mom with three boys age 10, 18 and 19 years old. I think about those family’s getting calls tonight. I think of the family of the boy who died at the scene hearing the words, “I’m sorry, there was nothing we could do.” About the boys who were transported by critical care helicopters, one of whom they worked on tirelessly to get a heartbeat back. About the boy who we got out of the car.
My heart aches. Literally and figuratively. It feels like someone is pressing down on my chest. My throat is tight and swallowing is difficult. The pressure behind my eyes is painful, but I won’t let it out. I must get home. I must turn my truck back on and drive. Deep breaths.
In class we learn about Critical Incident Stress Management (CISM), which consists of two different approaches: Critical Incident Stress Debriefing, and Critical Incident Defusing. This is designed to help EMS personnel deal with on the job stress reactions such as Acute Stress Reaction, Delayed Stress Reaction (aka PTSD), and Cumulative Stress Reaction. “Some of the top sources of stress for the EMT include having to respond instantly, making life-and-death decisions, fearing serious errors, dealing with dying people and grieving relatives, and being responsible for someone’s life.” Check. Check. Check. Check. And check.
I focus on nothing but the road, and driving it safely. I get behind an eighteen wheeler and follow it to my exit. My emotions are pushing and pulling at me, and I can physically feel it. I beg them to hold off, to let me get home safe.
I take my exit and immediately realize, with absolute certainty that I cannot go home. Whatever fortitude I had managed to muster up to this moment would disappear the second I opened my mouth to speak. What words could I possibly use to describe the raw emotion that was currently living behind my eyes, in my throat, under what felt like a brick sitting on my chest, and in the vivid, full color images that will now forever be a part of my memories. I have no reference point for this.
I drive aimlessly for a few minutes, then decide that I need to go to my school. I need to go to the ambulance garage, which operates 24 hours a day, where I went for my ride along. I have driven to school and back probably 50 times. I sure wish I could remember how to get there. I google map it.
Once inside, I recognize one of the girls behind the counter from the other night. I start to speak, but some unexpected sound comes out, and the tears start in earnest. I close my mouth and hold up one finger to indicate I need a minute. Deep breaths. Deep breaths.
There are two paramedics just ending their shift putting things away. I state my need to talk with someone, and then walked back outside to my truck. The garage is a huge, bright space and I needed to be… less lit up. The night is my friend. The night can deemphasize and soften the edges of my vulnerability, which I do not do well.
The two paramedics come out and talk with me, and are soon joined by a shift supervisor. They all listen patiently and compassionately as I blubber my way through the night’s events, sharing as much detail as I can. Possibly repeating things more than once, as it is so surreal, only saying it out loud confirms that it really happened. They collectively reaffirm what the firefighter said, which is to talk about it with other first responders. That it is important to go about your daily routine. To not let it consume you. There are people here to help you find your coping mechanism. They suggested I talk to my teacher before class Monday and share it with him.
In class on Monday, which is two and a half days away, I have my Division II Exam. I managed to pass my Division I Exam by the skin of my teeth. You must score 80% or more on the exam to move forward to the next division. If you score between 70% and 79% you can immediately retest, and if you get over 80% you can stay in the class. I got a 76.25%, retested, scored above 80%, and was allowed to move to Division II. You do not get to apply anything beyond 80% to your class average, regardless of your retest score, which is completely fair, and I was thrilled to be able to continue on.
For my Division II Exam I have been studying religiously, taking practice quizzes, making flash cards to help improve my weak points, and staying focused. As mentioned earlier, the book learning/memorizing is my Achilles heel. However, I felt ready this time, and still had a couple of evenings after work to study.
The Next Day – Saturday June 4, 2016
I didn’t sleep much at all last night. Too many images and emotions to process, acknowledge, and figure out just what in the hell to do with. I am determined to go about my routine as advised by everyone I have talked to. And I get it. I feel like if I stop, if I give pause to all that is in my head right now, I will get lost in it.
Like everything else unpleasant in life, it is the passing of time that eases our minds and bodies and provides relief and perspective. The twelve hours that have passed offer me nothing. I go to work. I drive past the accident site. It occurs to me that I will be driving past it twice a day, five days a week, for work.
I attempt to study in my down time, but am having trouble staying focused.
Sunday, June 5, 2016
On the way to work I see a gathering at the site of the accident. Family and friends having a memorial. I pull over and get out of my truck, but remain at the top of the hill. I don’t want to disrupt them, I just want to pay my respects, say a silent prayer for the family, and be on my way. I notice there are two white crosses in the ground.
A girl with a baby gets out of a car parked by mine. I think I recognize here from the other night, she was one of the friends in the other car.
“How are the boys?” I ask her.
She tells me that a second boy died that night thirty minutes after they got him to the hospital. The other two are in critical condition, and the one who we got out of the car is expected to recover.
A few people make their way up the hill. One of the boys I definitely recognized as the one who informed me there was someone else in the car. Right behind him, with the look of complete loss and confusion in their eyes, could only be the parents of one of the boys who died. The boy I recognized thanked me for my help. I told them I was sorry for their loss.
I make a quick, but polite, exit. I have nothing to offer in the way of comfort or an explanation, and I don’t belong here. The pain of losing a child is something I cannot begin to imagine, and pray I never experience.
I get to work, attempt to study in my down time, but am having trouble staying focused.
Monday June 6, 2016
I make arrangements to meet my teacher before class. I share the story, with more detail this time, and he listens. He, too, stresses the importance of talking about this. Of finding my coping mechanisms. He lets me know he is available to talk to anytime. He asks me if think I may be uncomfortable with the upcoming topics, or if I felt I need time away from class. I tell him I don’t think that will be necessary.
I ask him about the drill. He explains that it is used for a procedure called Intraosseous Infusion, in which a hole is drilled into the leg bone just below the knee cap to provide a non-collapsible entry point directly into the bone marrow to provide fluids and medications when an IV is not possible. Damn.
I have forty minutes before class starts, and I decide to do some last minute studying. I am having trouble staying focused. I am retaining nothing. I am remembering very little. Everything I read takes me back to the images of those boys in the car, so I close my book and put away my flash cards.
In class the exams have been passed out and the room is silent, save for the sound of #2 pencils scratching on scantron sheets. I read the questions over and over again. They may as well have been written in Greek.
“You know this! You fucking know this!”I scream in my head. “Snap out of it. Focus.” I take deep breaths. I go through the exam, answering the questions I can first, and then go back to the beginning to try and answer the rest. I am struggling to access information that I know lives in my brain, but all I can come up with is bits and pieces I cannot put together
I am staring at the blank spaces on the pages that are provided for me to write in the correct answers. They do not come. When I find myself staring at a picture of the female reproductive system, and I second guess myself about what part is the ovaries, uterus, fallopian tubes, and vagina… I know I am sunk. I have owned and operated one for over 50 years, and if I can’t get that clear in my head right now, I don’t have a chance with the rest of the questions.
With only minutes left on the clock, I close my exam, walk to the front of the room, place the test and scantron on the desk and exit. I join the other students, who have also completed their exam, in the hallway. They are discussing and comparing different questions and answers.
“How do you think you did?” I was asked.
“I don’t know. It was pretty brutal,” I say.
“Right!? Way more difficult that the Division I Exam,” someone states. They all agree and go back to discussing the exam. I listen.
I stay for the second half of the class, which is a non-mandatory lecture. I stay because I am clearly in denial of just how badly I did on the exam. I stay because I am not ready to accept failing. I stay because I do not want this to be the end of my EMT education.
That night, on the news, they state that the boy pronounced dead at the scene was the driver of the vehicle. He was fifteen years old. The other boy who died that night at the hospital was sixteen years old. The other two, who are in intensive care, are also sixteen years old. That alcohol or drugs are not suspected to be a factor in this accident.
Tuesday, June 7, 2016
I receive my exam grade. 68.75%. Damn. Just like that, I am dropped from the class.
At this point I have to ask myself some very important, and very real, questions:
- Had I not come across the scene of that accident and gone about my studies as planned over the weekend, do I think I would have – at the very least – scored over 70% and been able to retest?
Answer: Oh, hell yes, I do.
- Had I not come across the scene of that accident and gone about my studies as planned over the weekend and received the 68.75% and been dropped from the class would I be able to accept that?
Answer: Yes. Because as much as I would have been disappointed, and as much as I loved this class, I have learned – the very, very hard way – to listen to and trust the Universe. And not in a pathetic or passive way, but because I have had my ass handed to me too many times when I have ignored the obvious signs and red flags thrown my way and pushed and pushed for something that was simply not meant to happen. As a result, it has had to go to Biblical proportions to get my attention. Not again, thank you very much.
Equally, had I gotten to the scene of the accident and panicked, or not known what to do or how to do it because I blanked out like I did on the written test, or if I had done more harm than good, then I would have quit the course myself before even taking the exam.
But I didn’t do any of those things. I had my mettle tested, and I passed the real life exam. Yes, I fell short on the written exam, but I am going to cut myself some slack, all things considered.
So, I will start all over. I will take the EMT entrance exam again, just like I did three months ago.
Update, Wednesday, June 22, 2016
On my way to work I see a third cross has been added to the original two at the memorial on the side of the road. My stomach sinks. Three teenagers out of four died as a result of that accident nineteen days ago.
I also found out I passed the entrance exam, which I really needed for my piece of mind, as well as a definitive sign – via The Universe – of weather I should continue with EMT school, or not. Seriously, I threw down the gauntlet; Pass = Continue. Fail = Let it go.
There is another class starting in January 2017, perfect time for me. I figure I can read my book a few times over by then, giving me plenty of time to study and become confident and comfortable with all the information.
So, wish me luck, and if you need me I will be over here reading my 1,398 page Prehospital Emergency Care textbook. 10th edition. No big deal.