Horrors in the emergency room: Exsanguination 101

ViewsHound passes along ideas for us to write about for those times when our creative juices are stopped up. One that caught my eye was entitled "Horrors in the emergency room."

I rode an ambulance for almost 20 years in a rural county in Georgia that has no hospital. Our normal in-transit time to the hospital was most often a half-hour or so.

I'll probably tell y'all about some of that one day, but right now they asked specifically about the ER, and they wanted "horror stories." Well, I'll give you one, but you most likely ain't gonna like it.

I'm not going to tell you where I worked but I will tell you that we served four different hospitals, depending on the severity and nature of the problem, the distances involved and the patient's preference if he was conscious, alert and oriented.

I just retired at the end of 2009 and, at that time, we were seeing the results of seat belt use and air bags. Fatalities and serious injuries in car crashes are becoming much less commonplace than once they were. The one, though, of which I am about to speak, was back before air bags and in a time when few wore seat belts.

There are, in this county, some particularly winding roads and they are places with which we, the EMS, are intimately familiar.

It was on one such road, a few hours after midnight, about the time the bars close, when two vehicles ran together, nose-to-nose at perhaps 65 miles-per-hour. There was a bunch of smashing and mashing and tangling of metal and glass. One guy had done gone to the light by the time we got there and he wasn't coming back. There was another guy bad hurt. An older gentleman.

He was pretty well messed up but at least he was alive. He had some broken bones and a lot of bruising and bleeding but our most immediate concern was that one of his external jugular veins was pretty much sliced in two.

Now if you have a serious wound to an arm or leg, we can pretty much stop the bleeding by covering it with a mess of gauze pads and then wrapping it tightly enough to let blood flow through the injured extremity but not out of the hole. Eventually it will stop. You can even do the same with the abdomen or thorax, even with the head. The neck is quite another matter. The idea of putting a tourniquet around a neck may not be the best idea that's ever happened. The same is true of wrapping a neck tightly with gauze. It's generally a good thing if blood can get to the brain and air can get to the lungs. You probably don't want to cut those things off.

The external jugulars run up and down on either side of the neck. They vary in size but they're big. When one gets severed, you've got a mess. Your patient is FTD (Fixin' To Die) or "Headed to the light."

Most every ambulance carries two people, a paramedic and an EMT. The paramedic normally deals with the patient while the EMT drives. Sometimes though, you need two people in the back so you grab a deputy or firefighter and tell them to "drive like the wind." That's what we did this time.

We covered that wound with about four inches of gauze to start with and one of us held it in place while the other one dealt with all the other problems.

Once we knew what we had, we called the closest ER and told them what we were bringing, what we were doing and when we'd get there. Then we rode, hanging on for dear life, and adding layer after layer of gauze to that wound.

We got there and they were waiting for us at the door, all gowned and gloved. We went through the outside and inside doors and wheeled the patient into the first trauma room.

About six nurses and a doc were in there with us. They went to work while we recited everything we knew, crisply and clearly so everyone would know what they had to deal with.

The doc immediately ordered O-negative blood and told a nurse to call the surgeon on call and get him to get up and come in.

Once everything was all set up, the doc started to uncover the wound so he could get a look. I had already told him that the external jugular was severed but, if he could, he needed to see it for himself. The only repair for that is surgery so, if he takes my word for it, he's got to have an operating room and a whole team to support the surgeon who is coming in. He would look awfully foolish if they did all that and discovered in the OR that it was a superficial laceration that the ER doc could have fixed. As things now stood, the surgeon could be cancelled and everything would be ok if it was a false alarm.

He very gently pulled layer after bloody layer of gauze off and dropped it into a bucket. He got within an inch of the wound and blood began to ooze through the gauze. He stopped and said that was as far as he would go until the blood bank brought the blood. He had a nurse dial the blood bank and hand him the phone. When he got an answer, he asked when we would be getting the blood. He listened for a minute and then he threw the phone down on the floor, smashing it to pieces.

Turns out the bank couldn't release the blood until Doctor X got there in person with the key and he was at a party and would "come in before too long."

Okay. It is what it is. The bleeding is pretty well stopped. The IV fluids have gotten the patient's pressure to at least a minimally acceptable level. The man is breathing 100% oxygen. Nothing for anyone to do except to wait.

A nurse added a bunch of new gauze to the wound and taped it down securely with wide tape.

I went out to the ambulance where my partner was trying to clean up the blood. In a case like this, that is a major problem. I grabbed some towels and started helping. After a few minutes I gathered up a bunch of bloody towels and went in to get some clean ones. As I went by the trauma room, I looked through the window in the door. Nobody but the patient. I stepped inside and looked. Blood was flowing from beneath the tape, running down onto the plastic mattress.

I grabbed a bunch of gauze, piled it on and did the best I could to get it temporarily stopped, then I took off to find a nurse.

Nobody at the nurse's station. I started going from room to room. Finally I saw a nurse coming out of the break room, ran and grabbed her and told her what was going on. We both went to the trauma room and she started redressing.

I asked her where everybody was. "Oh —— is retiring and we're having her going away party in the break room."

I went back out, put my bloody towels in a decontamination bin and got a bunch of new ones. Back out to the truck.

We cleaned and wiped and sprayed and wiped and cleaned some more.

Almost done. I gathered up the trash and bloody towels. Back into the ER.

Nobody in the room.

I stepped inside. Same thing. Again I got it stopped.

I headed to the break room, burst in and let everybody within earshot understand exactly what the situation was and how I felt about it. Several of them, mad as hornets, came out and headed for the room.

I went again to dispose of my stuff. As I headed out the door, I heard the loudspeaker. "CODE RED, CODE RED, TRAUMA ONE. CODE RED, TRAUMA ONE."

I went out to the truck. My partner finished cleaning while I wrote up the report. I went back inside to find the doc and get his signature. Nobody would look me in the eye. I found the doc, he signed my report without looking at it or me and I put a copy in the bin.

As I walked out, I looked into the room. He was, of course, still there, covered entirely by a sheet. His life's blood was in a pool on the floor.

We got in the truck and went back to quarters to be ready for the next one.

Be assured, this matter was not done in secret. It was thoroughly investigated. The doctor, the head nurse and the nurses involved were interviewed and appropriate action was taken. Stuff happens. No one has been a paramedic or an ER doc for more than a very few years without doing something stupid and, perhaps, killing someone or, at least, failing to save their lives. It is the nature of the work.

The Coroner's report? "Patient exsanguinated secondary to a neck wound sustained in a high-speed motor vehicle accident."

Case closed.

Hey, it's just a routine surgery—no big deal

Sometimes even the most careful of us will overlook the obvious.

Stuff happens as we age and, eventually, most of us will require surgery of one sort or another. I have had my share. I've had enough that I pretty well know the drill.

And that's where the problem lies. Hiding in that drill.

You go in, take off your clothes, put on their silly gown and lie down on the bed.

Eventually someone will come in with a bunch of forms for you to sign. This one says that things sometimes don't go the way we hoped. Sign here. This one says that sometimes some pretty ugly things can happen. Sign here. Terrible things could conceivably happen. Sign. Awful, terrible things will almost certainly happen and you will probably die on the table. Sign here.

Thank you, have a lovely day.

A nurse sticks his or her head around the curtain. "Doctor Bumfuzzle will be here in just a few minutes."

Three hours later you will be told that the good doctor has been held up but will be along as soon as his blood alcohol level comes down.

Finally he shows up, bustles in through the curtains, picks up the chart, looks at it, says, "Hmmm. Hmm. Uhm-Hmm." He puts it down, looks at you. BIG smile. "Well, are we about ready? We probably won't see each other again until it's over. Do you have any questions? Good. You just lie back and be comfortable. Piece of cake."

Exit the doctor.

You wait for about an hour or two and the curtain parts again. A very handsome gentleman with a big smile and an air of confidence steps in. "Hi. I'm Doctor Hugglewump. I'll be your anesthesiologist today. Do you have any questions? Is there anything I need to know? Good. Now I'm going to give you a little something to make you sleepy. You just start counting backwards from one-hundred."

He injects stuff into your IV. You start to count. "One-hun... Snork."

Later you wake up — if nothing really bad happens. And you go from there. You feel all warm and fuzzy and comfy and in about four hours you will begin to cry and scream and beg for another pill.

Remember how you got here? Your family doc said, "We better have this looked at." You went to Doctor Bumfuzzle and he said, "Oh my, I don't think I've ever seen one this bad before. I'm afraid we're going to have to go in. I can do it Wednesday. Show up at the hospital at 4:00 a.m. Don't eat or drink anything after 8:00 p.m. Just come in the front door and they'll show you where to go. Any questions? Good. Wednesday."

You went home, got on the internet and Googled Doctor Bumfuzzle. You learned everything about him from his first pet's name to what size briefs he wears. You know his win/loss stats and all kinds of other stuff. Nothing really bad. Okay. But, just in case, you talk to some of his patients. They tell you he's great. You feel more at ease. You're in good hands.

Now, let's pull back and think about this for a second. What is the worst that Bumfuzzle can do? The absolute worst?

It's your shoulder. He is going to do a simple laparoscopic repair to your rotator cuff. He could really kind of mess that shoulder up. He could damage a nerve and you would never be able to use that arm again. He could get clumsy and it would never work right. He could even work on the wrong shoulder.

That's about it.

Now… Remember that other guy? Doctor Hugglewump? The one you never heard of before? The one you met 47 seconds before he knocked your cute little pink butt slam out? What could he possibly do to you?

Well, for starters, he could turn you into a vegetable. Maybe a nice cabbage or a cauliflower? Or he could just mess your mind up a little to where you can't remember your name for 17 minutes at a time.

Or he could kill you.

Or, he could give you a drug that paralyses you, and knocks you out for the operation — but it doesn't really knock you out. You're paralysed and can't even roll your eyeballs to let somebody know that you can see and hear and FEEL everything. EVERYTHING. You can't see it because he's off to the side but you can hear the scalpel bite into the skin and fat and flesh and you can feel every single movement as it cuts. And you can feel the laparoscope as he jams it in. No problem, he doesn't have to pussyfoot around about it. Just shove it on in. I mean, after all, you can't feel anything, right?

Need I say more?

My friend, don't worry about the guy who's going to fix your hernia, or take out your gall bladder. Worry about that handsome smiling confident looking guy. The one with the syringe behind his back.

If you're going to check somebody out, start with him.

About as bad as bad can be

One thing that always used to really bother me when I was a working paramedic was the people that would approach me in the coffee shop, with their eyes bright and their cheeks flushed, and want me to tell them what was the worst thing I had ever seen.

My answer was, I've seen people die. Does it get worse than that?

I remember a wreck, some few years back, where we had a lot of patients and could not spend time on trying to bring dead folk back to life. Sometimes we have to make that choice. It's called "triage." I covered two of them, laying in the median, with a sheet.

Later in the call, when I was climbing out of an ambulance with blood from head to toe, I looked up to see two by-standers holding up the corner of that sheet and staring at the bodies. When I started walking towards them, they walked away. When they looked back and saw that I was still coming, they ran to their car and left. It was a wise choice.

I have walked down railroad tracks, picking up a kidney here, a brain there, and putting them in plastic bags. One of my early calls was to a lovely old lady whose entire face had been ripped loose and was hanging down on her chest.

You want the worst? I'll give you two that wake me up at night and break my heart again as soon as I think they're gone.

Now, this is a small community. A lot of people know me. A lot of people have followed my adventures over the radio for years. And everybody seems to follow all the gossip.

Just a word to those local folk. When I write about the EMS, you may think you know the call of which I'm speaking. You are wrong. In every case, I find a way to camouflage it in such a way that I can always show the judge how you are mistaken. You would be surprised how often calls are almost identical. I may, therefore combine calls. I may start out with a wreck where a mother, rather than have her child in a seat, holds him in her lap and crushes the life out of him when there is a wreck that left the back seat and the car seat safe as houses - and then start treating a child who got the same way in a whole entirely different incident. I'm giving you the cold unvarnished truth, but my mama didn't raise no ordinary fool.

There was a woman who had a small child, just barely a toddler. She drove all over and, as a matter of some kind of sick principle, refused to use a car seat. I believe she may have taken a little nip to kind of ward off the cold sometimes. Or maybe it was a big one. I don't know.

One day, with the baby in the front seat, she decided to run head-on into another vehicle.

When I got there, the infant became mine. I've always wished that it had not.

We got the child into the ambulance. There was clearly little chance this child could survive. Any one of several injuries had every right to be fatal but you do what you can do and pray for the best.

The way you do this is to forget that it's a child, forget that it's a person, catalog the injuries and sort them into their proper order. Than you take one and fix it. Then you go to the next one. They're not a patient, they are a series of injuries for you to fix.

You prioritize the problems.

Airway, breathing, circulation.

Your immediate goal is to get oxygen to the brain. If the airway is closed, there will be no breathing, if there is no breathing, there will be no oxygen in the blood, if the heart can't get oxygenated blood to the brain, the patient will die.

Get the airway open. Get them breathing, or breathe for them. Get the heart pumping blood to the brain or pump it yourself. If the blood is running out of them, stop the leak.

The first problem was the airway. The child wasn't breathing and clearly could not breathe because the airway was severely damaged. Looking into the mouth, all you could see was torn meat and tiny little baby teeth down at the opening of the trachea.

I grabbed a laryngoscope, close to the smallest blade we had, and a similar sized endotracheal tube. I turned the tiny light on and started. First I positioned the child in as neutral a position as possible with my partner holding the tiny head so that we would not damage the little spine. Then, holding the tiny jaw open, I tried to sort out the torn tissue to find my way to the epiglottis and the trachea it protects. Hard to see because of all the blood but suctioning the blood didn't help that much – it came back as fast as we suctioned it away. Just keep trying.

I knew where it should be but it was such a mess, and everything so tiny, it was very, very hard. Finally I found the epiglottis and got my blade under it, lifting gently so I could see the trachea – and I saw it. Squashed closed. Okay, got to do something. I tried a lot of stuff and nothing worked.

Maybe, if I could just get the tiny tip of that tiny tube just barely into the opening, I could use the tube itself to do the job.

I tried and tried. I kept losing the whole thing and having to go back and start over. I needed to open that thing so I could look in and pass the tube between the vocal chords.

Finally I gave up on seeing anything and just tried to do it by feel, but that didn't work either. I could get it in a little ways and then it would hang.

This isn't working. I cradled the baby in my arms and made sure that, if somehow something could get through, it would be pure oxygen. My partner drove like a crazy person as hard as that truck would go, which was, back before they governed them down, well over a hundred.

One of us talked to the ER by radio and they were waiting. They snatched the ambulance door open and we all took off for the first treatment room.

I laid the baby on the cot and they took over. I told the doc what we had done and what all I had seen: the torn tissue, the teeny tiny bitty teeth. Then he, and an anesthesiologist he had called in to help, went to work.

I went outside, sat on the ground and cried. I had seen paramedics do that in that spot. And the docs too. It was not uncommon. There was this little corner there, kind of out of the way.

It wasn't very long before the doc came out. He put his hand on my shoulder. He told me that there was nothing I could have done. Those little teeth weren't teeth – they were bitty little vertebrae. The spine had been ripped from the brain, and the reason I couldn't push the tube in blindly was that the trachea had been ripped in two.

The mother? Nothing much. And what did they do to her? Nothing. "She's suffered enough poor thing."

I'm sorry. I don't think so.

I will say no further on the subject except to say that I found a lady psychiatrist who patched me up enough that I could pretend to be okay. Except maybe during the nights. And whenever the sun was up.

Now, as to the other one: It should go much faster.

We were called to a mobile home out in the woods for something. I don't remember what. The trailer was full of younguns and the patient was in the back bedroom. The place reeked of poverty.

We went into the bedroom, examined the patient and determined that the problem was not life threatening. The mother elected not to have us take the child to the ER. My partner went outside and started writing up a report for the mother to sign. I gathered up our stuff and started out.

A little girl, maybe six, maybe even seven, had been beside me the whole time from the first step inside. She was still there. She was wearing a little dress, not very clean lookin. She had pretty brown hair. She kept looking up at me with big soft clear beautiful eyes. Just before we made it to the door, she wrapped her little under-fed arms around my thigh, looked up at me and asked, "Would you please be my daddy?"

Okay. You tell me. Which one of these two calls was the worst? If you had to take one of them yourself, which would it be? The psychiatrist lady? She couldn't make a choice. Give it a try.

Sleep well tonight. You needn't worry yourself over these matters. Don't worry, I'll take care of that. Me, and a lot more like me in ambulances all around the country and the world.

God help us all.