last week, we were requested on a scene flight 14 miles west of our base. reported to be a head on crash involving two vehicles at high speed, the pagers went off just as the sun was beginning to set. like every other call, we checked weather, accepted the mission, packed up our Oneg blood and went out to the aircraft .
as i did my walk-around, i mentally went over some of the possibilities of injury mechanisms, interventions and little time saving tricks to minimize our on-scene time and get us in the air towards a trauma center.
we pre-flighted and lifted with eyes out, and i shortly thereafter turned my attention towards calculating rapid sequence intubation medication dosing for a 180 pound individual. shortly, we arrived over the scene and started our recon orbits. below were two cars, front ends heavily damaged, one up on its right side.
we put down in the roadway and hot unloaded out stretcher and gear, and walked past the two vehicles. i noticed the panoramic sunroof was open in the car which was tipped up on its right side and down in the ditch there was a mess of trampled grass, mud and medical debris.
our patient was in the back of the ambulance so we entered to find an alert, oriented to person/place/time teenage boy who was muddy, scraped/bloody but otherwise appeared unscathed. report was given to us by EMS as follows:
“17MC unrestrained driver traveling approximately 50 mph crossed center line and struck vehicle off-center/head-on, causing his car to be flipped up on the right side. victim was thrown about interior and ejected through sunroof into ditch. found supine and initially unconscious by witnesses and a sheriff’s deputy. remembered the events leading up to the accident. initial EMS findings: GCS 14 | 128/50 | 48 sinus brady | 14 clear non/labored | 99% O2 sat room air.” collared/LBB/packaged prior to our arrival and two large bore peripheral IV’s were running wide along with a NRB @ 15LPM before we even climbed into the ambulance.
our primary and secondary exams revealed a very athletic young man complaining of mid/lower back pain, some sternal discomfort without dyspnea, right hand/wrist deformity/swelling and a few soft tissue lacerations involving his right side. no major injuries detected, and scored 15 on our glasgow exam twice over.
my partner and i were both feeling pretty good about this kid given the circumstances of the accident, tremendous energy transfer, no safety belt usage and ejection with positive loss of consciousness. one of the scene paramedics confided to us he was the local high school starting quarterback and as i was weighing for a second whether or not he was right handed, the patient looked up into my eyes and asked the question:
“am i going to die?”
my mind immediately flashed back to my formative days as a paramedic on the east coast, working in an urban system where we ran from sunup to…well, sunup. along the way, i met the most colorful characters – including the regulars - which made up the fabric of my shift life.
one of those people was brankho, a second generation eastern european who worked in the shipyards of the far east side almost 35 years. built like a brick shithouse – but a gentle soul – he was on the dark side of his 60′s when i first encountered him short of breath outside a shipbuilders union hall. over the next three years, i learned that he drank heavily, was hypertensive, had asbestosis, almost never saw the doctor and suffered from what i perceived to be virtually omnipresent kidney stones.
it was the kidney stones passing that caused us to encounter brankho the most. our medic unit would run at least twice a month to either his residence or the union hall for a sick person/abdominal pain call. inevitably, he would be intoxicated to some degree and in a great deal of pain. for four years we would manage his pain with morphine in the field and transport him about eight minutes to the nearest hospital, since he would frequently be too intoxicated to refuse transport.
on a still august night with the humidity and temperature both around 85, i had barely began to enjoy the air conditioning of the day room at our station after a long day of running the streets when the house tones rang for severe abdominal pain at brankho’s home address. usually, i would just look at the clock and block out an hour to complete this predictable run, but i found myself annoyed. three shifts ago, i had just taken him in for kidney stones and figured we wouldn’t be hearing from him for a couple weeks.
strangely, he wasn’t on the front stoop of his neatly manicured shotgun bungalow when we pulled up. the front door was cracked and, mercifully, the air conditioner was on full blast inside. brankho was in the bathroom slumped against the wall, boxers down around his ankles – diaphoretic, pale short of breath per normal and complaining of severe bilateral flank pain extending down into his genitals. a quick BP showed 240/110 and i looked over into the open toliet bowl and saw some concentrated urine streaked with blood. in clipped phrases, he conveyed to me that he was voiding to pass a kidney stone and just passed out.
my partner and i each locked an armpit and assisted brahnko to his feet. i could instantly tell that he had been drinking, but he didn’t seem intoxicated. we assisted him a few woozy steps towards the stretcher and his visible pain seemed to be worse than i ever remembered. i wondered if his ureter was obstructed.
when we were one step away from the stretcher, brankho’s knees buckled. in a practiced dance move, my partner and i managed to spin brankho around and plant his ass squarely on the cot. i wrestled his upper body while felicia managed his legs into the accepted position. the back of the cot came up to semi-fowlers. we clicked the seatbelts, and i was just about to pull away when brankho lazily waved his hand across mine and looked me in the eyes, raspily asking the question:
“am i going to die?”
and as i started to answer brahnko that he would not die, his eyes rolled up with a quick burst of seizure activity. ten seconds later he was still, apneic and pulseless.
felicia called for engine 61 and an ems supervisor. we flew out to the ambulance with CPR in progress and started working brankho – monitor, IV, tube.
his intial rhythm was PEA and continued on that way for nearly 15 minutes until the complexes got wider. and then we were almost to the hospital and it looked like asystole. we tried everything at our disposal, even pacing, when we witnessed the line go flat (because it was still acceptable in those days).
brankho died.
upon autopsy, cause of death was determined to be catastrophic dissection of an existing abdominal aortic aneurysm. i was devastated that somehow, i had missed this.
from day one, i never believed that i could save every ill or injured person that emergency medical services brought me into contact with. but i have never been quite able to hear the question “am i going to die?” from any patient without suddenly being taken back to that night in august nearly fifteen years ago.
i finally answered my patient in the ambulance (after what probably seemed like an eternity to him) by saying on the outside he looked fine, but that i couldn’t see what was going on inside his head and body after being thrown from a car at high speed. he seemed satisfied with my reassurance, but probably wondered if i was suffering from vapor lock since it took me almost a full fifteen seconds to process his question, flashback and answer it. i know my flight nurse gave me one of those “wtf? that was lame…you glassy-eyed freak.” looks.
we flew our football star to the crystal palace for trauma evaluation. his throwing hand and wrist turned out to be OK. but he had multiple spine fractures, a cardiac contusion, bilateral pulmonary contusions and abdominal organ injuries. he required surgical intervention and was discharged from the hospital at post-operative day #10.
