Population: 485

by Michael Perry

  So. Is your patient getting air? No? What must you do to change this? Change the position of her head? Put a tube in his throat? Blow air into her lungs? Got that taken care of? Now let’s check circulation. Does your patient have a pulse? No? Has someone started chest compressions? Is it time to fire up the defibrillator? Perhaps you walked into the little old man’s apartment and he said hello. You have just completed your most primary assessment. The fact that he is upright and talking tells you his ABCs are up and running. You will need to assess the quality of his ABCs, but at the very least they are present.

  From ABC, the algorithm bifurcates. The bifurcations fill entire textbooks. If the patient is unconscious, you go left. If the patient is conscious, you go right. Are you dealing with a medical problem (turn left) or trauma (turn right)? You just keep working your way through the maze. At every intersection, you read the sign and turn accordingly. In general, you work from head to toe, a quick once-over the first time, to find and treat life-threatening injuries. If you find bad things of magnitude—a sucking chest wound, massive external hemorrhage—you stick your finger in the dike (cover the chest wound, control the bleeding) and get rolling. “Load and go” it’s called, or “scoop ’n’ scoot.” If the patient is stable, or if transport time allows, you perform a secondary assessment, running head to toe again, with more attention to detail. You’ll be checking for more subtle signs of trouble: the little bruises tucked behind the ears that indicate a basilar skull fracture, clear drainage from the ears that may be spinal fluid, swollen ankles indicative of congestive heart failure. Throughout the algorithm, priorities rule. See the motorcyclist with a leg like a pretzel? Ignore the leg—find out if he is breathing. Check to see that his trachea is in line, not squashed to one side by a leaking lung. The most garish problem is not always the most deadly. And through it all, remember: If at any point along the algorithm your patient crashes, you don’t panic. You just move your little game piece back to square one, to ABC, and begin again. Air goes in and out, blood goes ’round and ’round.

  I pulled mostly weekend shifts at Silver Star. Weekdays were covered by full-timers working in teams of two. When the full-timers rotated through weekend coverage, they split and paired up with a part-timer. One pair worked “first out” on Saturday, and the other pair worked “first out” on Sunday. Being “first out” meant you had to be at headquarters. Working “second out” meant you could go about your business in town, but you had to carry a pager and be able to make it to headquarters in under ten minutes to cover any call that might come in while the first-out team was in the field. This arrangement meant that even as a part-timer working weekends only, you were putting in a forty-eight-hour week. The calls and experience accumulated quickly.

  I pulled most of my shifts with Jacques. You learned to stay on your toes with Jacques. He had a brilliant mind but was plainly bent. He used to sit around the little apartment starting intravenous lines on himself. For the practice, he said. He favored the veins in his feet. He read voraciously and was a martial arts maven. One minute he would be ruminating aloud on the restorative powers of meditation, and the next he would be doing the splits, or he’d have you facedown on the floor, rubbing carpet burns into your nose as he demonstrated some new submission hold. You learned to step through doors cautiously, because you never knew when he would have his throwing knives out. He set mousetraps in the coffee filters and rousted Baz by rolling firecrackers under the bathroom door. Returning from a call at three A.M., he wound down by hitting golf balls across the highway. Looking for a quick and easy way to gather worms for fishing, he wrapped copper rods around the defibrillator pads, then stuck the rods in the dirt. He’d charge the defibrillator to 360 joules, hit the double triggers, and shortly, nightcrawlers emerged from the earth. He rarely settled, due in no small part to the fact that he frequently worked a cigarette, a wad of chew, and a can of Mountain Dew simultaneously. He was bent, but he was fearless, and one of the best medics I’ve ever run with. We made call after call that first couple of years. He became my gonzo sensei.

  Jacques took me to my first full-blown trauma. A woman and a man on a motorcycle lost it on a curve. The woman got flung ahead of the cycle, wound up wrapped belly-first around a pine tree. The bike followed her into the tree, crashing into her back. Her kidneys and liver were lacerated. She was in imminent danger of bleeding out. She had severe head injuries and was unconscious, but her gag reflex was still intact, and she wouldn’t tolerate an oral airway. The last thing you want to do is jam an airway down someone’s throat and make them puke. If they aspirate the vomit—breathe it in, literally—you suddenly have a patient with a compromised airway. The first responders already had her in a neck collar and strapped to a backboard, so we didn’t linger. As Jacques hit the siren and struck out for the hospital twenty minutes away, I looked at the woman under the bright cot lights and realized I was in it for real. I taped sandbags around her head to increase the stability of her neck. Then I got busy with the secondary survey, and began accumulating follow-up vital signs, taking her pulse and blood pressure every few minutes, rechecking her breathing, looking for signs of shock. It is critical to recognize shock early, and our instructors drilled us on the signs: rapid pulse, rapid respirations, falling blood pressure. Then they added a grim little coda: by the time these signs begin to show, your patient may be past retrieving. So you do what you can. Keep the patient warm, deliver oxygen, drive fast. Start an intravenous line if your license allows—ours did not at the time. We did have the woman in a pair of military anti-shock trousers. These are essentially inflatable pants. Like much of the EMS repertoire, they were developed during the Vietnam War. Theoretically, inflation of the pants forces blood out of the legs and lower abdomen to the more vital areas of the chest and head. MAST trousers have fallen from favor in recent years. We still carry them, but we rarely receive permission to inflate them when we radio the emergency room doc for orders. I no longer recall if we received permission to inflate that evening. I just remember that about five minutes out, the woman began to seize and puke, and for the rest of the ride, I was consumed with the maintenance of our old friends, A and B.

  The seizure came first. The woman’s entire body stiffened, even as her eyes stared blankly at the ceiling. As soon as the seizure passed, the puking began. And for a second or two there, I was terrified. I thought surely the woman would choke and die, a pathetic irony in the face of all her other life-threatening injuries. Strapped down on her back, she was in the worst possible position. I grabbed the suction unit, but her teeth were clenched. The puke (a burgundy syrup—we later placed it as red wine and crackers) burbled up through her teeth and lips and spilled over into her open eyes. Realizing I had to act immediately, I flipped the entire backboard up on its left side. The straps and sandbags held the woman in place, and I kept one hand on the underside of her head to further support her neck. The puke rolled out of her mouth and down my arm. I got the backboard propped and swept the suction across her mouth. Using a technique we learned in class, I crossed my fingers and tried to pry her jaws apart, but it was futile. I still remember looking up through the little communicating passageway and out the windshield, dipping my head, desperate to get a glimpse of the hospital as we hammered into town and down the boulevard. I kept suctioning and trying the finger technique, and finally got the woman’s teeth open just enough to admit the suction tip. When we pulled into the ambulance bay, I remember hands reaching in to help us debark, I remember being a little breathless giving report, and six months later, when I heard the woman was finally walking out of the hospital, I remember thinking that in all the madness, with all the critical things going on, the greatest lifesaving action I made on her behalf involved the diversion of throw-up using the principles of gravity. “You did well out there,” said Jacques, in a rare serious moment. It was all that mattered.

  From ABC on, the rescue trade is big on mnemonics. The idea, I suppose, is to help you recall assessments and procedure
s under pressure. Textbook authors and instructors bury you in the things: OPQRST = Onset, Provokes, Quality, Radiates, Severity, Time. DCAP = Deformities, Contusions, Abrasions, Penetrations. SAMPLE = Signs/Symptoms, Allergies, Medications, Past Pertinent history, Last oral intake, Events preceding. CUPS = Critical CPR, Unstable, Potentially unstable, Stable. Notice how the last two mnemonics sometimes assign the bold letter to two words simultaneously, while in other cases, the letter matches only the first word. Excusable to a point, but turn the mnemonics crowd loose, and things quickly get out of hand. ABC becomes ABCDEFGHI: Airway; Breathing; Circulation; Deformity; Expose; Fahrenheit (temperature); EKG, pulse oximetry, vital signs; Head-to-toe exam; Interventions, Inspect back. Okay through E, I guess, but the Fahrenheit thing is a little sketchy. Then, to squeeze in EKG, we completely ignore E and K, highlighting G. And since P and V are too far down the alphabetical line, pulse oximetry and vital signs are tacked on to EKG like a cheap porch. His for head, you’re on your own recalling “to toe exam.” And finally, “I,” presented in classic double-assignation form.

  This stuff just doesn’t work for me. I can never get the initials to cohere. In my head, the letters Ping-Pong off one another, triggering a parade of words and associations. P—was that for Previous, or Potential, or Pills, or Primary complaint? M—Medications? Or Meals? The letters skitter and simply won’t stand still. In high school, we were required to memorize the twelve pairs of cranial nerves: olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, vestibulocochlear, glossopharyngeal, vagus, spinal accessory, hypoglossal. Our science teacher, who favored “auditory” over “vestibulocochlear,” recommended we associate them with the phrase, “On Old Olympic Towering Tops A Finn And German Viewed Some Hops.” This phrase has worked fine for generations of students, and I encounter emergency-room physicians and physical therapists who employ it daily, but I could never summon it completely. I would try, and what I would get was the image of a guy with a big belly and knobby knees, wearing lederhosen and peering downhill at a field of barley. The Finn never made the scene. Furthermore, some instructors favor accessory nerve over spinal accessory nerve. Their Finn and German view not Some hops, but A hop. Another source disposes with the Finn altogether: “On Old Olympus Towering Tops A Famous Vocal German Viewed Some Hops.” I see Helmut Kohl yodeling over wheat fields. And what if I could remember one of these phrases? How to sort those first three Os? And the Ts—is it trochlear, trigeminal or trigeminal, trochlear? Kenneth Saladin, author of Anatomy and Physiology: The Unity of Form and Function, proposes “OLd OPie OCcasionally TRies TRIGonometry And Feels VEry GLOomy VAGUe And HYPOactive.” As in, OL- factory, OPtic, OCulomotor, TRochlear, TRIGeminal, Abducens, Facial, VEstibulocochlear, GLOssopharyngeal, VAGUs, Accessory, HYPOglossal.

  I do believe the alphabet soup that fills my head just went bad.

  The trouble is, this is one of those areas, like religion or spinach, where the folks who think you need it keep piling it on. That mnemonic didn’t work? Here are sixteen more! I beg them to stop. I am, I want to say, “A Free-Associating Ruminator. Terribly Scatter-Brained. Usually, Mnemonics Bring Little Enduring Relief.” A FARTS BUMBLER. Try to remember that, you mnemonics pushers.

  Not all of the terminology and mnemonics I learned in those early days were officially sanctioned. A patient whose condition was deteriorating was often said to be “circling the drain.” An unresponsive patient whose EKG was as flat as a certain western state was said to be exhibiting “the Nebraska sign.” Sometimes you walked into a scene and declared the patient “DRT”—dead right there. DRT patients often presented with “the Q sign.” You’ll get the idea if you draw a smiley face, replacing the smiley mouth with a capital Q.

  There was a bluffness to those early years. We were, for the most part, young men in uniform, learning to operate coolly at the nexus of dramatic events. I quickly grew to love the art of cutting through the chaos, to thrive on the idea of applying my knowledge in the field, often without the benefit of bright lights or flat surfaces. I loved stepping out of the front of the ambulance into the teeth of the wind, plunging into the deep snow on the median, the scene lights pushing my shadow ahead of me down to the upended pickup with the guy trapped inside, knowing Jacques was right behind me, and that somehow we would find a way to get to the guy, to package and remove him, to get him safely into a place with sterile sheets and delicate lifesaving tools. Our work environment ranged from dangerous to goofy—one call you are trying to figure out how to safely move a woman impaled on a fence post, the next you are jumping up on the toilet every time your partner charges the defibrillator and yells, “Clear!”

  What you are given is a series of opportunities to prove your ingenuity and gumption. Rescue work is like jazz. Improvisation based on fundamentals. Protection of the cervical spine is a number-one priority, so we learn to take and maintain immediate manual stabilization, put on c-collars, and immobilize patients as completely as possible before moving them. In class, back in the high-school library, we practiced placing each other in a KED (Kendrick Extrication Device), a sort of wraparound splint designed to immobilize patients from the base of the spine to the top of the head. The protocol is very specific regarding positioning of the device, and the seven different straps are to be applied in a set order. We rehearsed over and over for the national test, in which we applied the KED to a person sitting calmly on a wooden chair in the middle of an open room. Then you’re upside down in a king cab, your patient is hanging from his seat belt, his head cranked over at an impossible angle, and suddenly your usual tools are worthless. And so, using your head, your hands, and maybe some towel rolls, you find a way to pluck the guy while still adhering to the primary principles of protecting the patient from further injury. You are riffing on a basic chord structure. I was explaining this to a friend once, how the presentation of our patients often requires us to improvise in the field. I brought up the jazz allusion, and he did me one better, putting it in terms of golf. “What you’re saying,” he said, “is you gotta play it where it lies.”

  Jacques, of course, was never afraid to improvise. We went to an inservice one day in which an instructor showed us a rapid-extrication technique called a horse-collar. You take a blanket, twist it into a long roll, drape it across the back of the victim’s neck, bring the ends around, and cross them in front of the neck beneath the chin, and then pass the blanket ends back under the victim’s armpits, so they stick out like wings. You grab the ends like handles. The roll is supposed to cradle the patient’s neck as you lug him to safety. The instructor repeatedly stressed that this was strictly a last-resort technique, to be used only when the patient was in imminent danger.

  Three A.M. the next morning. Jacques and I are staring at a drunk guy in a Yugo. The wheels are down, but he has rolled the thing once or twice. All the corners are rounded off. We are on an overpass. The wind is cutting straight through, driving sleet into our eyes. It’s a struggle, getting the c-collar and KED on, and the guy is cussing us the whole time. By the time we’re done, my hands are numb with cold. Finally, everything is in place. The KED comes fitted with handles, and Jacques and I each grab one. “One, two, three…go!” We move the guy about six inches and can get him no further. Turns out the Yugo has pancaked just enough so that the KED is too tall to fit out the door frame, and it has become wedged. Now the guy is really cussing us. We are alone. No fire trucks with equipment to cut through the door frame. I’m standing there trying to figure out what to do next when I hear the ambulance door slam. I look back, and here comes Jacques. His arms are outstretched, and he is twirling a blanket, spinning it into a long roll. “Umm, Jacques, do you think…?”

  “Get the cot,” he says, leaning into the car. Pop, pop, pop… there go the KED straps.

  I can’t bear to watch. I get the cot, already rehearsing what I’ll say in the deposition. Behind me, I hear more drunken cussing, and a thwack! as the discarded KED hits the concrete. I roll the cot up just as Jacques
drags the guy, cussing and gargling, from the car and drapes him over the cot. On the way to the hospital, I quickly check to see if the man can move his arms and feet. Everything checks out. Up front, Jacques is whistling.

  There were always the calls, though, that pulled you back. The ones you couldn’t laugh off. On a gray morning just after dawn, Phil and I answered two consecutive pages, the first for a wounded cop, and the second for the man who shot him. From a fundamental standpoint, everything went well. The cop had been shot through the upper chest. I got my IV lines in, and Phil controlled the sucking chest wound. The cop kept telling us how much it hurt, and when he couldn’t talk, he squeezed my hand. We were deeply relieved when we delivered him alive. He was on his way to surgery when we got the page for the shooter. The shooter had tried to blow his brains out, but had succeeded only in lifting away half his skull. The right side of his brain was completely exposed and perfectly intact. His EKG squiggled out and flattened as we pulled into the ambulance garage. The ER doc stuck his head in, took one look, and shook his head. Then he told us the cop had died in surgery. We were dumbfounded. Driving back to headquarters through the morning rush, I remember irrationally wishing to flag down each and every car, to look each driver in the eye, and say, “Do you realize what has happened this morning?” Ten years later, I called Phil, and he says the image he retains is the cop’s gun belt on the bloody ambulance floor, the buckle open, the holster empty. On a sunny afternoon, Jacques and I transported a one-legged, three-hundred-pound man back to his home from the hospital. He was in his seventies. He wore a trim fedora and held his head with dignity, but he was weak and pale, and said he didn’t think he was ready to return home. It was all Jacques and I could do to slide the man from the cot to his bed. His wife hovered in the background. She weighed maybe ninety pounds and was visibly shaken at the prospect of caring for him. Back in the rig, Jacques shook his head, and we talked of what it must be like to exist on such a fragile cusp. Another night, I helped a homeless alcoholic get to his feet from the doorway of the hardware store where he had collapsed. He was dirty and smelly. After I got him settled on the cot, he rummaged around in his pocket, pulled out a little black plastic comb and began combing his hair straight forward with slow, deliberate strokes. I was reminded of the way a toddler pushes a comb, trying to look grown up. It was this sad, noble little effort at tidying up. I watched, and my heart broke.