I had my first ‘chest pain/difficulty breathing’ call this morning.
I hadn’t been on a call since the two brush fire calls last Monday… I haven’t writtten about them but they were quite exciting, especially the first one. I was on the first truck to the big Perkinsville brush fire and ended up actually in the brush with the fire, trying to dig firelines, spraying water, cutting burning things up with chainsaws. It was so smoky that you couldn’t see much and it was difficult to do much while trying to hold your breath and dealing with smoke stinging your eyes. It so was windy that every time you turned around, the fire had jumped over yonder into that pile of leaves.
I was at the scene for five hours. Fifty five firefighters from seven departments worked on that fire.
It was caused by an ‘illegal burn’ that jumped onto a wooded hillside. It threatened a saw mill that had been freshly rebuilt after burning to the ground last year. We did stop it before it got to the mill.
I provided some minor care for a FF who hurt his finger driving one of the engines. I improvised a finger splint by cutting up a SAM splint and following the BUFF principle… Big, Ugly, Fat, and Fluffy. Apparently the emergency room was really impressed by my handiwork… Made up for the crappy job I did on the kid’s elbow at the accident at the beginning of the month. I’m batting .500 as far as splinting goes.
Regarding the accident, I went to a debriefing at the state police barracks the other day. Apparently everyone is doing okay. Both the head-injury female and the toddler had pulmonary contusions in addition to the problems I found. They should have both gone by helicopter; next time I’ll know.
I’ve heard the dispatch radio tapes for both the EMS dispatch frequencies and the law enforcement side. They are very interesting.
Anyway, it had been a week since I’ve been on any kind of call. We were getting ready for an appraiser to come by and look at the house. My pager went off. remarked that of course, this would be the time for a medical call (i.e., one that I absolutely have to go on immediately). The dispatcher came on (usually there’s a few-second delay between the tone and the dispatch information) and announced a medical call; sixty-eight year old male, chest pain, difficulty breathing. Out I went.
I stopped at the station and grabbed the defib. A firefighter was on the scene by the time I got back in the car. I drove on over to the house, missing the driveway the first time but being quickly corrected by radio by the FF on the scene who saw me pass by.
The patient was lying down. He was text-book diaphoretic. He looked like a stone statue of himself, except that he was moving. He was clearly in a lot of pain. I tried to find a radial pulse and was unsuccessful; weak.
I started oxygen and tried to take a blood pressure. I was unable to find a blood pressure. On the second attempt, I found a 90 heart rate.
I spoke with the patient and tried to calm him. His wife was trying to help in any way she could. She and I both got a little excited when he told us that he was ‘fixing to die’. I was glad we had the defib handy; supposedly the patient will often make some remark like that before coding. He held on, though, and I was glad to see the ambulance come up the driveway.
The ambulance crew came in. They had difficulty getting vitals and finally the blood saturation monitor was able to get a pulse; it was bouncing between 25 and 150.
We could not get the cot into the room where the patient was, so we used a stair chair to get him down the hallway, around the corner, and down to where the cot was. The two firefighters on scene disassembled part of the porch to get the patient through.
We placed the patient into the ambulance. My oxygen cylinder had gone dry while working my patient (my first used cylinder) and I took it to the rig to trade it and get another rebreather mask to replace the one I had used. I watched the ambulance crew start an EKG , install an IV, and attempt to draw fluids. When they were ready to transport, I got out.
I put my gear away in my car, helped the FFs put the porch back together, then went back to the station. I replaced the AED, called the dispatch center for times and address information and filled out the paperwork.
I got home to find that I had completely missed the appraiser.
I didn’t have a chance to do a narrative of the call last Wednesday.
My brother-in-law and three of his boys were visiting. I took the morning off and took O1 skiing with Jerry and his boys. After we left the ski area, we stopped for lunch in the town where the ski mountain is.
My first responder squad does not presently have a transport license and so our transports are covered by the squad in the town with the mountain; Ludlow. A member of the Ludlow squad was having lunch in the same restaurant that we did. I have worked with this EMT-I on several calls so I said hello. This guy is a gruff sort of person and didn’t have much to say to me. I have gotten used to the idiosyncasies of the squaddies that I have been working with so I didn’t take it personally.
After a lovely lunch, we headed home. My parents had come for a visit and had gone to pick them up with O2 while O1 and I were skiing. All four of them were at the house when we arrived.
About forty minutes after we got home, my fire department pager went off, reporting a multiple vehicle accident with injuries in town. I grabbed my radio, said goodbye, and left.
Of course, I had no idea what had happened at the time. I found out how the accident had occurred by reading the news the following day.
A car with four teenagers and an eighteen-month old had been speeding north through a school zone. None of the occupants of the car had a seatbelt on; the baby was strapped into a car seat but the seat was not secured within the car.
A pickup truck with two occupants was heading south and had started to turn left across the other lane when the speeding car came up over the rise. The driver of the car slammed on the brakes and skidded fifty or so feet into the truck. The truck was thrown across the intersection and into a jeep that was waiting to turn onto the main road. The jeep was knocked about ten feet back down the side street.
As I was leaving the house, somehow I managed to switch the channel on my radio. I didn’t realize at the time, but I was hearing the dispatch channel on my pager rather than on the radio, and transmitting on the radio over a different town’s fireground frequency. As a result, no one heard me when I tried to sign on.
I drove over to the station. I could hear from the radio traffic that the accident was bad. One of the senior members of my department had happened onto the scene and established command. I could tell by his radio demeanor that the scene was stressful. I tried to call him to ask if I should come direct but he could not hear me due to my incorrect channel selection.
I grabbed my jump kit and oxygen bag and went into the station. I was the first member to arrive at the station. I threw my oxygen bag into a compartment behind the driver’s seat on engine one and put my jump kit onto the floor of the passenger side. I grabbed the AED from the station office and put that onto the truck, then went and put on my turnout gear. By the time I had my boots, pants, and coat on, another member had arrived to drive the truck. I climbed into the passenger side of the truck and we left the station, lights and siren.
As we drove to the scene, the chaotic radio communication underscored the severity of the accident. There were multiple serious injuries. There was no medical coverage on scene. The scene commander, from my department, had not heard anyone sign on and had no idea that engine one was enroute.
I’m not really sure what I thought about on the way to the scene. Usually I consider the reported situation and think about what I might find and how I should deal with it. This time, though, it was clear that the scene was way beyond anything I had dealt with before. I watched the scenery go by, listened to the radio chatter, and was otherwise pretty vacant.
We pulled up to the scene. We were the first engine to arrive and there were no ambulances yet. The town police officer was the only official on scene other than our department’s officer.
When we pulled up, I saw the first accident vehicle. I have learned that the vehicle was a green Escort wagon. At the time, I could tell it had been a car. There were pools of engine fluids around the car. I could see that there was one person on the ground outside of the car and one person apparently in the car.
I jumped out with my kit and went around the truck to get my oxygen bag. As I walked up to the car I looked around. I could see a third victim on the ground on the side of the road and a child’s car seat nearby. All of the victims had bystanders providing care.
About this time I ran into the scene commander. I said hello. I could tell that he was relieved to see me.
I threw my gear on the road and did a quick triage of the four victims I had noticed so far.
There was a young woman lying across the floor of the back seat of the car. Her head and face were bloody. Her c-spine was being held by a woman from our department. She appeared to be unconscious.
There was a young man lying on the pavement, very close to the car. His face was bloody. His head was being held by a bystander who I recognized as being a local. This patient appeared alert; his eyes were open and he was talking to the guy holding his head.
There was the young woman on the side of the road. She had several people around her, one holding her head. She was talking to the people.
There was a little kid in the car seat. He was crying. There were several people around trying to console him.
There were groceries all over the scene; I specifically remember numerous bananas and bottles of water strewn across the road. At the time I was too distracted to think about why those things were there; now I know that the truck the car hit was coming back from grocery shoping and had bags of groceries in the back.
Based on my visual triage of eyeballs and talking, I could tell that the girl in the car was the priority patient. I went back over to the car.
The firefighter holding the patient’s head told me that the patient had been verbally responsive initially but that she hadn’t been able to get any response from the patient recently. I tried talking (yelling) to the patient and confirmed the loss of verbal responsiveness; then I pinched her sternum and was able to elicit a painful response. This was not as positive a sign as verbal responsiveness but better than totally unresponsive.
I went to get the oxygen bag for this patient. As I backed away from the car, I inadvertently stepped hard on the foot of the patient on the ground outside of the car. He screamed loudly. I apologized profusely, massaged his foot for a moment, and went for the oxygen.
I brought the oxygen bag to the car. I pulled a cervical collar out of the bag and prepared it for the patient in the car. It was a style of collar I was unused to despite the fact that I had it in my bag; it took me some time to figure out how to set it up. I switched c-spine with the firefighter in the car for a moment; the FF was in a very uncomfortable position and wanted to reposition so that she could better hold the patient’s head. After she readjusted and took back control of the c-spine, I placed the collar on the patient and then started high-flow oxygen. Oxygen never hurts and can be lifesaving in situations where oxygenation has been compromised. This patient looked like a head injury so oxygen was the best intervention I could provide on scene.
Around this time, another fire department officer came up and asked if I wanted a helicopter. I told her I wasn’t able to make that decision but to please expedite the ambulance and to have the ambulance staff make the medevac call. She said the ambulance was coming as fast as possible, and did I maybe want the helicopter on standby? I agreed that medevac standby was a good idea.
I made sure the firefighter in the car was okay with her situation and went to retriage. At this point, there were only three obvious additional victims. As per my previous visual assessment, all three had patent airways and no life-threatening bleeding. Based on my continuing assessment, the three were a toss-up for priority.
I stopped and looked at the young man on the pavement, the guy I had stepped on. I apologized again and asked him what his issues were. He had lower spinal pain. I did a quick head-to-toe exam and found no obvious serious injuries. I reached underneath him and palpated his spine, finding no deformities but finding point tenderness in the lumbar spinal area. The patient had some major scalp lacerations but was not heavily bleeding. I would have put this patient on oxygen but my setup was supplying the priority patient in the car. There wasn’t much further to do for this patient before transport.
Around this time, the administrator from the nearby elementary school came up to me and asked if I needed anything. I asked her to try to find blankets for all of the patients.
Finally the first ambulance arrived from the professional squad that serves our town. I met the EMTs at the car and we perfomed a rapid extrication for the young woman in the car. I helped them strap up the back board and then went off to work other patients.
By this time a second ambulance had arrived from the nearby large town. This crew started boarding my second patient so I went over to look at the little kid.
The kid was strapped into a car seat. He was a cute blond boy, very upset. At first glance, there were no obvious injuries, although there was a small amount of bleeding from the nose and mouth. I looked at his face and noticed that his left eye was squinting. The kid was crying for his mom. Although I did not know the kid, I felt that his reaction was age-appropriate and not indicative of altered mental status.
An EMT-I from the local large town had arrived and apparently taken control of this patient. The I-tech seemed a little stunned and at a loss; he knew the boy and seemed momentarily incapacitated. I helped hold c-spine on the little kid while we worked out how to improvise better support. The boy was clutching a small Pooh bear, so I sang the Pooh song and tried to block the sun from the boy’s eyes. I was cognizant that the boy was terrified and that two firefighter/EMTs were not a calming influence despite the singing. The boy tried to pull my hands off his head; he was not happy about the immobilization. This was my lowest point during the call; for a moment I thought I was going to cry but I managed to put it away and regain my working attitude.
The school administrator came by again and I asked her to get some towels. She came back with the towels and we rolled them up and taped them into the car seat around the boy’s head to act as spinal immobilization. By this time, the kid had developed the largest forehead contusion that I had ever seen and was getting sleepy. The I-tech decided the kid needed immediate transport and scooped up the seat. We took the kid over to the second ambulance and the paramedic got in with the kid. I went back to work more patients.
Around this time the third ambulance arrived, I think… I’m not sure, since I never consciously saw the third unit or its crew.
Things started to slow down around this point. I was alerted to the fifth passenger from the car; a young man standing off to the side holding his arm. I went over and assessed him. His elbow was very painful and apparently broken. I checked his spine and it appeared clear. I listened to his lungs and they were clear. The first ambulance had not left yet so I went over to find a frac-pack; a bag containing splints for fractures. There was one EMT-I in back with my first patient, speaking with the local hospital by radio. He asked me about the number and types of injuries and I gave him my best estimate. He told me where to find the frac-pack and I rooted through some of the cabinets on the side of the rig. I couldn’t find the frac-pack so I decided to splint with Sam splints; flexible rolled alumiunum splints.
I went back over to my current patient, stopping to rifle through someone’s jump kit for a Sam splint. I did a poor job of splinting the guy’s elbow with the Sam splint and a found pillow (left on the side of the road by the first ambulance crew when they put the boarded patient on the stretcher). Then I took a set of vitals. Conveniently, a bystander in OR scrubs was standing with the patient and I enlisted her to take ongoing heart rates and respiration rates on this patient. The patient was getting shocky so I retrieved my oxygen bag and started him on oxygen by nasal cannula.
After the departure of the three ambulances with the four most serious patients, I was again the only EMT on scene. The scene commander asked me to assess the three occupants of the other two vehicles. I left my current patient in the care of the bystanders and went over and assessed the other people. One of the people in the truck had a stiff neck and the driver of the third vehicle had a scraped knee; I advised them to go to the hospital.
There were no local ambulances left to be called and Ludlow had eventually been toned for this accident. The Ludlow rig arrived with two volunteers including the guy I had seen at lunch. He reassessed my broken-elbow patient and decided that the patient needed spinal precautions based on the mechanism of injury and other injuries in the vehicle. The patient was initially resistant but the EMT-I was able to explain the risk in such a way the the teenager eventually agreed to the medical necessity.
I helped with the takedown and backboarding. The Ludlow EMT-I needed an additional EMT for patient care (as his partner was driving) and he pointed to me and stated that I was going with him. I asked a fire department officer to bring my gear back to the station and climbed into the ambulance.
I worked the clipboard and oxygen and took vitals under the direction of the EMT-I as we drove to the hospital. The local hospital was maxxed out from our priority patients so we were directed to a hospital about fifteen miles away. The patient was very uncomfortable on the ride as his elbow was unstable. I spent much of the ride holding his elbow in both of my hands and trying to find the joint angle that was most comfortable for the patient.
We arrived at the hospital and transferred care to the emergency department. We changed the linens, then left. On the way back to my station we stopped and got a soda. While we were in the store, the gruff EMT-I told me that I had done a good job. I took that to be an extreme compliment based on my previous relationship with him.
The ambulance dropped me at my station on their way back to Ludlow. I went in and filled out the paperwork describing my assessments and the care I provided. As I finished, engine one returned with my gear. The Ludlow ambulance had replaced my oxygen delivery supplies and collar, so I repacked my stuff. Various FFs returning congratulated me on my performance, which meant a lot to me.
Then I went home.
In retrospect, there were a few aspects of patient care that I provided that I was unhappy with. I stepped on a patient, I should have closely assessed the child earlier and called the helicopter for that patient, and I should have started immobilization on the fifth car passenger as soon as I realized he had been in the car.
Rabid and O1 were at a restaurant earlier today and overheard a teenager discussing the accident with her parents. My priority patient is off the ventilator and talking with friends by telephone. Another patient, I assume my second patient, is paralyzed for now. The car with the unbelted baby and four unbelted teenagers was traveling almost seventy through the 25 mph school zone.
While I have spent time analyzing my performance, I haven’t had any PTSD symptoms, and I don’t think I will. I think I provided very good care, especially considering that I was virtually by myself at the beginning and in a situation way more serious than any I had been in previously except in training. Even in training, I was part of a group of EMTs whenever I dealt with any hard calls.
I’m pretty happy with the outcome; I’m feeling less of an EMT poseur and more of an asset to the community.
I had a pretty nice Easter, all in all. This morning, my youngest boy (‘O2’) and I drove my parents to the airport in Manchester, about two hours away. We practiced using the escalator at length; up, down, up, down. Repeat. Then we drove home, stopping once to change our diaper and once for a french fry extravaganza.
When we got home, we took a nap while and our oldest boy (‘O1’) went for a walk. O2 and I tried to nap together but we eventually ended up in separate cribs.
After about an hour of sleep, I woke up to the pager. There was a brush fire in our part of town. The brush fire had been a controlled burn that had jumped to grass and was now threatening to enter the woods.
I listened to the turnout but could not respond since I was ‘PIC’ – Parent In Charge. Our department was having a hard time getting people together due to the holiday. People were freaking out on the radio about the minimal manpower and the proximity of the fire to the woods. Eventually a number of local towns were toned out.
After a while I took the baby monitor and went over to the meadow. and O1 were there and I explained to Heather what was going on. She took over the monitor and I ran back up the drive, grabbed the car, and drove over to the station. It appeared that two of the engines had left in a hurry so I closed the bay doors, then grabbed my turnout gear and left the station.
I drove over to the scene and parked on the road near a number of mutual aid trucks. Our trucks were up a hill on a driveway and the several mutual aid trucks from surrounding towns were down on the road. The mutual aid firefighters had set up a portable pond which they were filling. Large hose lines snaked into the 2500 gallon plastic pond from several pumpers and another large line ran up the driveway to where our trucks were pumping the water into a number of woodland fire hoses. These smaller lines ran up into the forest where several crews of firefighters clad in yellow and green brush suits were working.
I threw my keys under the front seat and exchanged my fleece jacket and low shoes for my turnout gear, then grabbed my jump kit and oxygen bag and went up the hill to where our trucks were located. I got to the top of the hill and said hello to the FFs who were manning the pump controls on our two on-scene trucks, engines one and three. Then I threw my first aid gear on the the hood of engine one, removed my bunker coat, and went to find the chief to offer to help.
As I surveyed the scene, I could tell that things were pretty much under control. Near the engines was a partially burned pile of pine debris that had clearly been the original burn pile. Several hundred square feet of grasslands were blackened and smoking, and the fire had clearly gone into the woods. Several crews were working in the woods while another crew was hosing down the original burn pile.
While I was getting my bearings, the chief of the other fire service in town came by with a civilian. The civilian had soot on his face and looked red and exhausted. The chief remarked to my chief that the civilian needed medical attention as soon as the ambulance arrived. My chief said that his EMT was on scene and would look him over. The other chief noticed me at that point and turned the civilian over to me.
Other than the soot and red skin, the man looked okay to me. I asked him what was going on and he told me that he was having cramps. I asked him to follow me over to a dirt bank on the other side of engine one, where we would be out of the way and things would be a little less noisy. He followed me over and I had him sit down. I made a very quick initial assessment; I looked into his mouth and nose and took his pulse.
His nose seemed clear of soot but his mouth contained some black residue. His heart rate was tachycardic; 150 beats/minute. I told him that I wanted him to rest for a few minutes and have some oxygen and water. I set him up with a non-rebreather mask and told him to huff on it. He seemed resistant at first but I explained the relationship between his heart rate and his current oxygenation and he understood. I continued my assessment, taking his blood pressure and asking him a number of questions about his activities preceeding his cramps. It turned out that he had been one of the people doing the controlled burn. Since the burn had escaped, he had been working flat out for over an hour to try to get the fire under control. He had not had any hydration in that time and he had been breathing a lot of smoke.
I took his pulse again and it had dropped to 110. I figured we were on the right track. I left him sitting with the oxygen cylinder and went to find water for him to drink.
Despite the eight or so trucks on scene representing four departments, there was no drinking water to be had. Around this time the standby ambulance arrived. I walked down to meet it and said hello to the two EMTs; an EMT-I and another EMT-B with whom I am familiar from previous calls. I explained the situation to them and they walked the short distance up the hill to where my patient was sitting. They did a short assessment and then invited the patient to go down the hill to the ambulance. I secured my oxygen gear and followed.
When I arrived at the rig I asked if I could observe; the two EMTs readily agreed and I climbed in. The EMTs listened to lung sounds and started pulse-oximetry. The pulse-oximeter is a device that clips onto the patient’s finger and measures the heart rate and the oxygen saturation of the blood. The patient’s O2-sat was a little low so they continued the oxygen therapy and started taking down the patient’s identifying information. I realized that there wasn’t going to be much more to see and so thanked the EMTs, said goodby to the patient, and left the rig. I knew from my own limited experience that the patient would not need to be transported.
I floated around for a while. I put my gear back in order and and made sure that our FFs were healthy. I eventually returned to the ambulance after the patient had left and picked up a replacement non-rebreather mask for my oxygen bag. The professional EMTs were very positive and said that my assessment and interventions were right on, but that they were seeing me entirely too often recently (four calls in a little over a week, including the mass casualty incident on Wednesday).
I went back and made myself available as labor to the department. They set me up with a hose, wetting down the burn area perimeter. I spent about thirty minutes spraying water into the grass, and then foam onto the burn pile.
We finally secured, picked up, and left the scene. We went back to the station and rolled hoses and cleaned gear. I got home about two hours after I left. , O1, O2, and I took a walk over to the meadow and enjoyed the last of the sun.
It was an entirely pleasant way to spend Easter; lots of family time, a nap, some non-critical patient care, and playing with hoses.