What do the dead say?

You know how you hear people always say, "it was a miracle I survived" following a tornado or other "act of god" that destroys their town? But what do the dead say? For instance, remember when that awful tornado outbreak hit Indiana this year, and that baby they called the "miracle baby" (Angel Babcock) was flung out of her home and 300 yards through the air was found alive? She didn't. She died a week later. I didn't see the towns, nay, the nations prayers answered then. How about the huddled family's in the attics of the lower 9th ward during hurricane Katrina who drowned? You can bet they were praying and calling on god to save them. Many did not survive, and the dead were not asked their opinion on gods divine providence. Sometimes everyone calls on god to be saved, as in a doomed aircraft with its wings stripped off plunging into a New York crowded neighborhood. All dead, and even the innocent watching TV in their homes died. No prayers were answered then. A firefighter sifting through the wreckage found a man burnt to a crisp clutching his infant child in a protective embrace. No one ever talks about those unanswered prayers. I can recall people "thanking god" that the crash occurred when most were at work and not in their homes. Never mind the ones that were. They must've some how earned their grim ticket to the nether world. The spotlight and the focus of attention is always when someone seemingly escapes death and they call it a miracle. If it is mentioned, it's excused as "gods will." A divine excuse for the invisible man.

It was a pleasant Wednesday afternoon when I beheld another fine example of gods will in action. A elderly couple who had been happily married for 38 years were on their way home when the husband, who was driving, experienced a massive grand mal seizure. Uncontrolled spasms forced his right foot hard onto accelerator and the vehicle raced wildly through a suburban neighborhood. The wife, a frail women in her 70's tried desperately to pull her husbands leg off the accelerator and hit the brake pedal to no avail. The outcome was as anyone could predict, a catastrophic crash that sent the car in "Dukes of Hazard" fashion leaping across a yard and straight into the brick wall of a house. Half the roof composed of 2x6's, shingles, and plywood came down hard on the driver's side, and the veneer of brick tumbled across the hood and windshield. The dash was pushed in and onto the occupants trapping them completely. The horrific scene sent neighbors frantically calling 911, while one went and held the hand of the old woman to reassure her that rescue was on the way. Covered in blood herself, she repeatedly told bystanders to "please help my husband." No one could reach the husband who was buried under roof, brick, and wood. He was still alive though, his moaning could be heard beneath the rubble. The woman's elbow was sticking through the passenger window was split open with forearm long bones sticking out in all directions and the muscle meat hung out in grisly fashion. Only one neighbor had the strength to stomach the scene enough to hold her hand to reassure her. "They're coming," the good Samaritan said.

Firefighters were the first to arrive as their station was just two blocks from the accident. Dispatch activated our unit and gave us the details shortly thereafter. I could hear some of the details from the on scene firefighters as my partner battled the drivers who refused to yield to our sirens. We received the usual slew of indignant looks at inconveniencing their trips to Wally world. The firefighters were unloading and setting up the compressors/hydraulics that would power their extrication equipment and lift bags and letting us know by radio how many victims we had, and a preliminary assessment to how bad they were. Bottom line.....bad. I reached between the seats and snatched a pair of latex gloves to wear, and I pulled from the dash my utility belt and its arsenal of shears, mag lights, and tourniquets. Like Batman, I felt ready to scale a building, or in this case save some people dying. Scaling a building seemed vastly easier in hindsight. When we finally arrived I could see two firefighters running towards a car that was buried by a brick wall and a elderly woman on a back board out on the front lawn. It's never a good indicator to see firefighters "running" around at the scene of accident. It's always deadly serious when you see that sorta behavior from trained professionals. I could see the old woman was awake and able to talk and the most obvious injury being her right elbow which as described earlier was split wide open. The hemorrhage of a open compound fracture had already completed itself and all bleeding appeared arrested. As on scene commander I had to triage these two and see which was the most serious, and a talking victim is a good sign so I moved on to the crushed car to see how far the firefighters had progressed in their extrication. Two firefighters were on top of the roof with jaws and cutters while another was crawled up in the back seat providing c-spine support to the male occupant. "I need to get out of here, get me out of here! I can't breathe!" yelled the old man. "I'm dying," he said. We call these expressions in EMS, "feelings of impending doom," and it's one of the most ominous statements you can hear from your pt's. When a person says "they're dying," they usually are.

The man's scalp was avulsed from the forehead back leaving his entire skull cap exposed and a pool of blood down the top of his shirt. Another pool equally ominous was one that gathered in his groin, and it was near impossible to tell where that one was coming from with him so wedge under the dash. His appearance was pale and clammy, each breath with intense effort, and eyes that demanded merciful exemption from the pain. Divine mercy was inconveniently absent on this day. Being unable to do more than slide an oxygen mask over his face I backed away to allow the firefighters who were wearing thick protective bunker gear their chance at getting in and opening the cockpit with jaws and cutters. A mix of painful screams, the pop of glass, and crunch of metal echoed between the two houses as I hurried to load the old woman out on the grass into the back of our ambulance. I had my partner setup an IV and get a set of preliminary vitals while I radioed a helicopter and a additional unit in for assistance. Naturally the radios weren't working particularly well that day and I struggled to relay what resources were needed to dispatch and the responding unit. In between repeating my radio requests I saw the firefighters pull the man out from the crumbled car and onto a backboard. The man was non to happy with being layed flat on a spine board given that it was making his effort at breathing worse. But it had to be done or risk paralysis. I came over to give the man a good stare and a focused assurance that he would make it to a hospital alive if he would just following our instructions. With great reluctance he submitted to a supine position and we continued our care with great haste. I shredded his clothes from his body trying to find where all these pools of blood were coming from. The man was for all practical purposes "descalped" so I knew where one pool was from. The other was found from where his left femur had snapped and perforated the inside of his thigh, and his pelvis was loose and unstable. His genitalia was pooling with blood from the pelvic cavity. Another critical finding was an easily identifiable flail segment across the right chest wall paradoxically moving in and out with each labored breath. We're taught to stabilize a flail segment with a sandbag or 1000ml bag of saline taped across it, a treatment easier said than done. Electing to go with an bag of IV fluid we attempted to tape it across the flail segment only to fight wet and cold sweaty skin and tape that wouldn't....well, tape. Desperate ingenuity had us taping from one end of the backboard to the other across the whole fluid bag. The old man's breathing failed to improve.

The man was now inside the ambulance fighting to breathe while his wife gripped my leg and implored, "please don't let my husband die." Not feeling particularly assured I offered assurances that "we'll do everything we can for him." I had a bad feeling though. I had my EMT get us en route to the LZ (landing zone) as these two were headed to a trauma center. One of the firefighter's rode with us to assist me since it's not easy managing two critical pt's by myself. I had the firefighter hold the man's arm out at length while I stuck a large bore needle into it searching for a vein that was now flat from lack of blood. Rural bumpy roads, the awkward angle of the units tight confines, and inadequate lighting made the IV attempt a fat chance in hell of happening. Pulling it out I elected to go with a smaller gauge catheter as it just wasn't happening with a 16g. Veins tend to flatten out at the peripheral when in shock so I searched along the man's neck looking for some juicy jugulars. Finding one was the easy part the other was in positioning oneself in the well of the unit's side door while crouching in the shadows of the captains chair and the stretcher to achieve the angle of optimum penetration. By some trickery of skill and luck the IV flowed after achieving a good flash. I began dumping fluids into the man's body while moving on to start an IV on the old woman. Compared to the husband she was relatively easy. IV's are great and all but they're not blood and these two needed blood transfusion in order to survive. We raced to the LZ and the inbound trauma team and watched the golden hour narrow like the closing fist of death. Still, the woman gripped my leg and repeated her demand. "Don't let my husband die."

The man's blood pressure was critically low, his heart racing to keep up with dwindling blood reserves, and his breathing unrelieved with the stabilization of his flail. Something else was terribly wrong. I listened to his breath sounds straining to listen over the motor of the ambulance, the sirens imploring the eye rolling public to move out of the way, and the clacking made by a loose cabinet door. Breath sounds were clearly diminished on the left, and I knew that probably meant he had a pneumothorax/or hemothorax that was progressing to a tension pneumo. I hadn't decompressed anyone in some time and in those instances the outcomes were not at all good. Something had to be done so I reached into our IV kit and pulled out a 14 gauge catheter dreading what would come next. I cut one finger off a latex glove and thread the catheter through this forming a device called a "flutter valve." Since we don't have chest tubes this was the next best thing, that next though was a far departure from a medical tube sutured into the chest wall, its placement confirmed with x-ray, and attached to a 3 chambered vacuum device. "Please don't let my husband die," the woman said again as she grew chill with a morbid clamminess. Her blood pressure becoming dangerously low too. Hating to be a paramedic for a brief second, I stuck the needle between the ribs as we're taught to and felt the latex flutter with air and blood. It was working to the best of its capability to relieve tension in the chest and allow the man to breath, but it was anything but efficient and tolerable. The man was in deep profound shock and was muttering intelligibly. We were still ten minutes from the LZ, and at a moment every paramedic dreads, the moment when you realize your pt is quickly circling-the-drain, paying the final coin to the boatman, and leaving the flesh. His blood pressure could not be maintained. His groin swollen the size of a basket ball and his face turning ghostly white. Pupils dilating and breath shallow. The firefighter attempted to distract the wife with fake assurances while I made ready to intubate the man and begin working a trauma code. A code that has only one type of ending, one final resting place, the morgue. If you die from lack of blood, you're dead. IV fluids don't transport oxygen, and only a surgeon can open you up and repair the internal damage. "Please don't let my husband die," wailed the woman while imploring the god almighty once more. God wasn't listening, or if he was, felt differently about whether this man should live or not. Arriving at the LZ we vainly hurried to pull our dead body out and do compressions to the helicopter. Epinephrine and amiodarone were doing their tricks to the heart, but neither drug would miraculously replace blood that was now pooled in his gut and groin. The man's heart flipped and fluttered like a unprimed heart until it could take no more and simply ceased doing anything at all. Probably somewhere in the skies over South MS. Another helicopter was tied up elsewhere so I was forced to race the wife up to the trauma center by ambulance battling her own blood loss. Divine providence seemed to be with her as she maintained consciousness even at a awfully low pressure of 50/30. Pale and clammy herself, and tilted in trendelenburg she found herself under the surgeon's blade at the end of the "golden hour." Our unit's innards looked like a murder scene and stains on my uniform in places I could not reach.

What do the dead say, I wondered. Certainly no explanation from the almighty.