WARNING: Graphic.

I had to get up early at my paid squad to go see a patient at a local nursing home. As a result, I was a little tired. I was relaxing in the day room waiting for dinner when the radio crackled to life.

“Fire department, stand by for tone.”

I sat up and rubbed my face, waited for the tones. I was expecting yet another miscellaneous elderly issue at an extended care facility. The weekend had been full of them.

The tones played. I stood up and moseyed towards the apparatus floor. The Twins and Lt. Toadstool wandered into the dayroom as the tones finished.

“Fire department, please respond to 722 Valencia Street for a possible suicide. Police department is in route.”

That got everyone’s attention. One of the twins was my partner for the day; he and I ran to the ambulance. He pushed the button for the apparatus door while I got the truck started and turned on the lights. He jumped in and we took off. As we pulled out, my partner flipped on the siren and notified dispatch that we were in route.

We drove to the location. Along the way, dispatch called and told us that police were on scene and that the scene was safe. Just as we started to worry that we had gone too far, we saw the police car ahead, jutting out into the road from a driveway on the left. We pulled up into the left lane in front of the house. I called us off on scene as my partner jumped out and grabbed the first-in bag.

A cop was coming up a walkway around the side of the house. A path was shoveled in the snow. He said the the patient was ‘back there’, shot in the head. We went quickly down the path. A set of stairs went up to a deck behind the house and several paths led off through the snow to the woods in the back of the house. We didn’t see anything.

I ran back up the short distance to the cop to clarify the location. The patient was on the deck. As I turned to run back, I saw the forestry truck arrive with Toadstool and the second twin.

Returning to my partner, we ran up the stairs to the deck. There was a a body laying on its back on the deck; it had been obscured by furniture from our previous vantage point on the ground. There was no gun in evidence; the police officer had removed it to ensure the scene was secure.

The patient was breathing, quickly but shallowly. They were pale. Their jaw was clenched.

There was a bloody mess on the side of the patient’s head towards us. The head lay in a large pile of thick blood and other material. Stepping around the patient, I could see that there was damage to the other side of the head, as well; the entry wound. The patient’s eyes were closed.

I started working on airway. From the clenched jaw, I knew that there was little point in trying to put in an oral airway. I opened the first-in bag and pulled out the nasopharangeal airways. I found the right size by comparing the rubber tubes between the patient’s nostril and earlobe. Finding one I liked, I removed the wrapper and slathered lubricating jelly on it, then slid it into the patient’s left nostril. The patient did not react.

I got a non-rebreather mask out of the first-in bag. Toadstool took the tank out of the first-in bag and dialed-in the flow rate while I took the wrapper off the mask and uncoiled the tubing. As I stuck the end of the tubing onto the regulator, I realized that the patient really needed to be bagged and said so to Toadstool. He agreed. I handed him the non-rebreather mask. He put the mask on the patient while I got a bag-valve-mask out of the first-in bag and shucked and assembled it. As soon as it was ready, I switched out the tubing on the regulator from the non-rebreather mask to the bag-valve-mask. Toadstool took his mask off of the patient’s face and I started huffing some breaths into the patient with the BVM. The patient didn’t resist the breaths.

This patient was not a candidate for our best airway tool, the Combitube, for several reasons. Their jaw was clenched, eliminating access to their oropharynx and trachea. Second, they might well have had a gag reflex. In the the absence of a paramedic, we couldn’t solve either of these problems in the field. Finally, a Combitube is outside of our scope of practice except in case of respiratory arrest. They clearly needed intubation, though; their Glascow Coma Scale score was three, the minimum value, in a scale of three to fifteen.

Toadstool was on the radio with dispatch and our hospital. The helicopter could not fly for at least thirty minutes due to weather considerations. Should we take the patient directly to the trauma center, an additional twenty or twenty-five minutes away? The hospital suggested that we should come to them given that the patient was not intubated and they’d get the helicopter to come down for the patient when it could fly.

Meanwhile, the twins were wrapping the patient’s head in a big trauma dressing with gauze rolls. There was blood and stuff everywhere. Toadstool and I had a quick consultation and decided that the guy was going to have to be moved on a backboard due to the porch steps and the width of the shoveled portion of the walkway. I handed off the BVM and ran up to the truck and grabbed a backboard and straps then returned to the porch. We put a collar on the patient and rolled them onto the board. By this time, several other firefighters and the chief had arrived. I figured there were enough resources to care for the patient so I went out to the truck to prepare for the patient.

I got out several large bags of saline, hung them, and attached IV tubing. The patient was going to need a lot of fluid replacement. I also prepared the cardiac monitor; I put electrodes on the leads and unfurled all of the cords; three cables for the ECG leads, one for the SPO2 lead, one for the blood pressure cuff. I laid all of the lines out along the counter so they could be grabbed in any sequence without tangling.

The cop popped his head into the back of the truck and said the team working the patient needed head blocks. I got out and pulled a set of blocks out of the external cabinet and handed them to the officer. He took off down the walkway and I got back in the truck. I got out a bunch of large IV catheters and a pair of saline flushes and J loops. I assembled the flushes to the J loops and flushed them. As I was finishing this, the cop appeared again and said that they were bringing the patient and needed the stretcher out and ready. I jumped out and pulled the stretcher, moved it down towards the walkway, collapsed it to the lowest configuration, undid the straps, and removed the pillow and blankets. I took the blankets and pillow back to the truck and climbed back in as the team of firefighters appeared with the patient on the backboard. I finished the last of my preparation while they strapped the patient onto the stretcher. They pushed the stretcher into the back of the ambulance and I guided the head of the stretcher into the locking mechanism.

The twins and Toadstool climbed into the bus. The chief hopped into the driver’s seat and we got under way. On the way, I tried to start an IV. I couldn’t find any suitable veins. I tried several spots that I thought should have yielded results but was not able to get vascular access. As I was poking around, the twins and Toadstool were getting the patient on the monitor and assessing vital signs. The patient seized for a minute or two.

We pulled up at the hospital and wheeled the patient into the trauma room. The staff was ready; there was a PA, a respiratory therapist, a doctor, and two nurses, all in gowns. We quickly moved the patient on the backboard from the stretcher to the trauma room bed and the staff got to work.

Everyone was busy so I hung around to help. The staff placed IV lines and pushed various medications. We got the patient’s clothes off with scissors; we removed the collar and head bandaging for better airway access. They placed a foley catheter. We placed AED pads in case the patient coded. I held cricoid pressure during several intubation attempts and then auscultated for epigastric sounds to verify tube placement. After the third attempt was successful, I held the tube in place for several minutes until the late-arriving on-call anesthesiologist had a moment to secure it. Meanwhile the patient became diaphoretic; very wet.

After about thirty minutes, the helicopter arrived; we could hear the machine flying low over the hospital. In a few moments, the flight medics arrived in the trauma room and started to get an update on the patient’s condition from the PA and move the patient from the hospital systems onto their own mobile equipment. That took a few minutes; then they wheeled the patient out of the room and out to the helicopter.

I stayed in the trauma room. I took my gloves off and carefully washed my hands, arms, watchband, and scissors. I realized I was really hungry.