Every Time I See Her
By Joe Moore
There are things that cannot possibly match the satisfaction that you can feel when the person you have helped survive a serious injury can walk up to you and say, “Hello,” and maybe give you a hug.
It’s about 3:30 in the morning when the pager goes off for a 25 year old female who has fallen down the basement steps. The situation and the time of day suggest that there might be alcohol involved since it is a Saturday night with last call over and parties at homes commencing for those dedicated partiers that fit that age group.
One of my fellow, former paramedic study partners is the paramedic on-call, but we all respond when we are able. It’s a “y’all come” situation in this rural community because we know almost everyone by their first name, their parents and their kids and grandkids. Mark is a deputy sheriff. Bea is a registered nurse as well as a paramedic. The four of us, Mark, Bea, Bill, and I recently completed a paramedic program that kept us busy for every weekend for eighteen months. We flew in the paramedic instructors, and I was the backup instructor when the weather or other circumstances did not allow the instructors to make it to this most remote inhabited island in the Great Lakes. We all went down to Battle Creek to take the practical exam first, and then the written exam, and we all ended up licensed as paramedics. Pass rate for this class is one hundred percent.
On this particular morning, Mark would have to be wearing his law enforcement hat, so I felt that two paramedics might be needed depending upon what injuries were found for this young female patient. We have an emergency response vehicle, and Bea would be driving that. She called me on the radio as she left her house. “5740 from 5742,” she radioed.
“Go ahead, 42,” I answered, kind of groggy from sleep.
“I’m driving by your house in couple of minutes. I’ll pick you up on the way by,” Bea radioed.
“10-4,” I responded, meaning okay, and rushed to get dressed after making the mandatory trip to the bathroom. You automatically do this as you get older because it is inconvenient to have to urinate in the middle of an emergency.
After getting my winter clothing on, just enough that I wouldn’t freeze outside, but not so much that I’d sweat when inside, I walked outside and across the Kings Highway to await Bea and the 57 Echo 3 vehicle, the designation of our emergency response vehicle (ERV). It was chilly and slightly windy and wintertime. Enough said?
It wasn’t long before Bea was seen coming around the curve on the Kings Highway with the emergency lights flashing. The next thing we knew after Bea stopped to pick me up was the call from an EMT saying he was headed to the garage to pick up the ambulance. Her husband Mark was already ahead of us going to the address using his sheriff’s department car. We were headed south on the King’s Highway when Mark reported on the patient.
“The patient is at the bottom of the basement stairs. She apparently had a little too much to drink and stepped back through the doorway to the basement and went head over heels down the wooden steps to the cement basement floor. There is blood everywhere, on the steps and on the basement floor, and the patient is unconscious and not responsive. She has obviously landed on her head and has a serious head injury. The patient is breathing and has a pulse. Bring in the blue bag and the oxygen from the echo car. Drive carefully! BREAK. BREAK. 57 Alpha 2, (the designator for our ambulance), you might want to come more slowly than normal. The Kings Highway is covered with windblown ice. It is dangerous driving right now just south of the Welke Airport,” Mark stated commandingly on the radio frequency we use for emergencies.
“Thanks for the info,” the ambulance crew responded. “We’ll be a couple of extra minutes getting there, but Echo 3 is ahead of us and should be there shortly.”
“About five more minutes before we arrive,” Bea responded on the radio. “Are you holding C-spine?”
Mark said, “She’s not moving, so I don’t have to. You’ll want to come in the sliding door, Alpha 2. Echo 3, come in the front door and then come down the steps carefully. Her airway is open, and I don’t want to move her until I get some help. See you in five.”
“Clear,” Alpha 2 responded. “Clear,” Echo 3 responded.
As we pulled up the driveway to the house, we could see the kids crying through the windows and the sliding door used as the main entryway to the house with a deck in front of the door. The only tracks in the snow were obviously from the patient coming home from the bar, and the same tracks walked in by Mark. Obviously, the dad and the kids had been home, and mom had been out celebrating something. We walked toward the slider, and Bea radioed Alpha 2, “Before you try to back into the space near the basement sliding door, make sure you are in 4-wheel. The snow is about two feet deep. Luckily the county plow hasn’t made any huge pile of snow along the road. Drive right on past the house and you’ll see the light on in the basement. I can see it from the front door. Copy, Alpha 2?”
“Clear,” Alpha 2 responded.
I was carrying the blue bag, which is our jump bag with a little bit of everything needed on an emergency scene in one bag, and the oxygen green bag that had a tank of oxygen, oxygen masks and canulas, and oral and nasal pharyngeal airways. As soon as the slider opened, Mark said, “Down here in the basement.”
Bea said, as we descended the stairs, “You do the airway and breathing, and I do the assessment, okay?”
I answered, “Whatever you say, Bea. You take the lead, and I’ll do whatever you want me to do.”
On the scene of an emergency there needs to be one person in charge directing the other helpers, so that the needs of the patient get completed quickly and efficiently. Someone needs to coordinate the treatment, and it makes more sense for the person doing the assessment to be the person in charge.
Once at the bottom of the steps, Mark almost immediately said, “We are going to have to move her fairly soon. Her airway is being compromised now.”
“Joe, hold c-spine, and Mark and I will do the log roll,” Bea said. “We roll her onto her back on the count of three. Everybody ready?” She looked up as we both nodded. “Here we go. One….TWO….THREE.”
The patient had been laying on her chest with her head turned to the side. There was a pool of blood around her head, and I was glad that I had my gloves on as both gloves got blood on them as I straightened the patient’s neck as they rolled the patient. Her neck was now in anatomical position, and I was sliding my knees up to hold her head in this position. I used my gloved hands to open her airway by putting my fingers behind her jaw near the TMJ, just behind the earlobe, near the place where the jaw connects to the skull. Just as we finished the log roll, the ambulance sent by on the road. We could see it through the sliding door.
Mark said over the radio, “We’re gonna need c-collars and a backboard in here ASAP.”
“Roger, as soon as we back the ambulance in and get off the road,” Alpha 2 responded.
Bea reported, “We have bruising behind both ears, and bruising around the eyes. This appears to be a severe head injury. Unfortunately, we are probably going to be dealing with swelling inside the skull, so we better be prepared for it. Joe, let’s get a BVM ready in case we need it, and oxygen by non-re-breather at fifteen liters per minute right away.”
I dragged the oxygen bag over next to me and got the mask and the oxygen out of the green bag. I filled the reservoir and placed the mask on the patient observing the patient’s chest rise and got a respiratory rate for Bea.
“I’ve got a blood pressure of 150 over 88, and a pulse of 80,” Bea said.
I jumped in with, “Respirations of 20 and normal depth.”
Bea continued, “I don’t find any other injury other than bruises and abrasions from the fall, so we’ve got a severe head injury to deal with, but we can’t rule out cervical injury either, so we’ll fully immobilize her on the long backboard.”
“CRAP!” I yelled out. The patient began seizing and posturing. This type of seizure was the contracting of the muscles of the arms and the upper body including the face. Her mouth was clamped shut, and she quit breathing. The words that tried to come out of my mouth were not acceptable for any writing. I grabbed the mask off her face, unhooked the oxygen line from the mask, and grabbed the bag-valve-mask or BVM for short. I grabbed an oropharyngeal airway, one that goes in the mouth, but I couldn’t get the mouth open enough to get it to go in.
Before I got a chance to begin to ventilate the patient, she began vomiting with what we call projectile vomiting. The vomit was shooting out of her mouth, and I had to lean back to keep it from hitting me in the face. I had vomit on my legs along with the blood from the floor. Luckily, the ambulance crew was ready to come in. They had taken one look through the sliding glass door, seen the vomiting, and grabbed the suction machine along with the cervical collars and the backboard. We were all pretty busy at that moment and someone forgot to close the door for a couple of minutes and we all began to shudder and shake. Was it the cold or was it a reaction to the situation?
Suctioning of the airway was difficult through clenched teeth, but we got the airway clear, and began ventilating the patient with 100% oxygen. As quickly as the projectile vomiting began, it was over in less than two minutes, I’m sure, but it seemed to go on forever. We began cutting away the vomit-covered blouse, wiped the patient’s skin off including her arms, so we could get another set of vital signs.
Now the respirations were absent without the ventilations. The pulse was decreasing, now down to 60. The blood pressure was going up with the top number up to 190 and bottom number is now 84. Bea said, “This looks like Cushing’s Triad. We need to get this patient fully immobilized on the backboard and get moving.”
Mark said, “That’s a good plan, but the local aircraft are not flying now. Look outside. We’re in the middle of a blizzard.” On the radio, Mark said, “Central Dispatch, 1597.”
Central Dispatch responded, “Go ahead, 1597.”
“Can you contact the Coast Guard for me, please? We have a severe head injury patient here on the island. The local flight service can’t fly, and the flying service out of Traverse City will not come in the dark. We need a medivac for this patient ASAP,” Mark stated.
While Mark continued the communication with Central Dispatch, USCG Soo St. Marie, and USCG Cleveland, we continued the ventilations and backboarded the patient in preparation for transport. Our patient had headblocks on either side of her head. Her head was strapped down to the board. We had crossed the straps by going over one shoulder, across the chest to the opposite hip, placed a waist strap and two leg straps on the patient to hold her down to the backboard.
Bea started an IV, but only hooked up a saline lock. This patient didn’t need fluids that might raise the blood pressure and the intracranial pressure in her head as well. We were almost ready to load the patient onto the cot.
James, our first responder/firefighter, brought in the ambulance cot with help from another fireman, Tom. They had come to help us out in case we needed it, and, with all the snow and the blizzard, we needed it. The patient was loaded onto the ambulance cot by lifting the backboard and placing the backboard on the cot. The patient was strapped to the ambulance cot, and my only job was to continue to ventilate the patient with the BVM. The firemen and the other EMS people carried the equipment out to the ambulance and then helped get the ambulance cot through the snow to load it into the back of the ambulance.
I had to work around them and be careful to keep up my ventilations throughout the loading process. I climbed into the ambulance and stayed at the patient’s head to keep up the ventilations because the patient was still not breathing on her own. They loaded the patient and the cot quite quickly and closed the back doors of the ambulance to keep out the snow and the cold. Bea jumped into the ambulance in the back with the patient and me, and we needed the four wheel drive to get out onto the roadway. Once again Bea took vital signs, but they had not changed for the better. I kept ventilating the patient as we made a very slow trip to the Township Airport.
We heard Mark communicating with Central Dispatch first, then he switched frequencies and we couldn’t hear him anymore. Bea continued monitoring the status of the patient. Bea hooked her up to the cardiac monitor, and did a 12-lead EKG. Vitals still remained in the same range as previously. No major changes, no improvements. The slow trip out to the Township Airport was fairly uneventful. Mark called Bea and gave her a number to call to talk to the USCG Flight Surgeon, and Bea gave the report to the Flight Surgeon, who immediately authorized the flight based upon that report. You see, this truly was a life-threatening emergency; there were no commercial air transport operators capable of flying in this blizzard; and the only hope this 25 year old female had of survival was to get to definitive care hospital with a neurologist standing by.
Once we had arrived at the Township Airport, there wasn’t anything else to do. Our medical control did not authorize any other treatments. All we could do was continue ventilating the patient with the BVM and await the Coast Guard helicopter. Mark stopped by and said that the helicopter was on its way from Traverse City. He told us to turn the radio over to the Coast Guard frequency, channel 21, and we could hear his communications to the helicopter. Bea gave me a break on the ventilations, so I could make a trip to the bathroom at the terminal building.
When I stepped outside the ambulance to walk to the terminal building, I noted that the wind was really howling, probably gusting to 35 miles per hour or more, and the blizzard was in full force. The wind was out of the west, and I noticed I was getting chilly on my walk. Remember, I had dressed for a winter evening, but was not prepared for the wind blowing right through my dress pants and into the collar of my jacket. It was downright nasty outside. I did my duty inside the airport terminal building, washed my hand, put on new gloves, the extra ones I took with me, and walked back to the back of the ambulance and climbed in. Bea immediately said, “Joe, I need you to reach up into the cupboard right above the EMT seat that you were sitting in, and reach us both a couple of boxes of juice. This ventilating of the patient is quite tiring, and we both could use some sugar for energy and to help warm us up.”
Boy, I didn’t have to be asked twice to do that. I had forgotten that Bea had some issues related to blood sugar, but I didn’t mind getting a little moisture into my somewhat dry mouth. The nervous system has a tendency to do some really interesting things to an EMS responder when the “fight or flight system” is activated. When required to keep up this level of care for longer periods of time, it can be quite taxing on the body. Bea let me drink my juice before she turned the ventilation requirements of our patient back to me.
I’m not sure of the timing of the rest of this, but I do remember continuing to ventilate the patient. I remember the Coast Guard helicopter landing in the blizzard, and I remember the moving of the patient into the helicopter by sliding the backboard off of the ambulance cot and handing the ventilation of the patient over to the EMT swimmer on the helicopter. I remember the helicopter taking off, and the sigh of relief that I felt that I was no longer responsible for the life of this 25 year old female patient with a severe head injury.
All of a sudden, Mark is calling us on the radio as we were heading away from the Township Airport in the Echo car. “57 Echo 3, from 1597. Return immediately to the airport.”
“Copy that traffic, 1597, what’s up?” Bea asked over the radio.
“I’ll tell you when you get here,” Mark answered and seemed to be quite secretive.
We weren’t that far away from the airport, so turning around and returning to the airport wasn’t taking very long. We were pulling in the driveway as we noticed the Coast Guard helicopter returning to the Township Airport. We pulled in as the helicopter began its descent down the runway in the blizzard. We pulled up to the terminal building and went in since we could see Mark inside the building
I walked into the building first and said, “So, Mark, what’s the mystery about? Why were you so secretive?”
Mark responded, “This shouldn’t go out over the radio. The Coast Guard swimmer is not comfortable ventilating the patient. He’s not used to doing this for any length of time, and he doesn’t want to be responsible for the patient’s dying. The pilot called me on the Coast Guard channel and asked that we send someone with the patient. Bea, you have to work at the medical center in the morning. I can’t leave with a felony arrest pending for tomorrow. So, guess what, Joe? You will be flying with the patient.”
I just stood there, and my mouth must have been hanging open because Bea said, “Joe, don’t stand there with your mouth hanging open; close your mouth and answer the question I asked you. Are you okay with continuing to ventilate the patient during the flight over to Harbor Springs?”
Mark interrupted, “They’re not going to Harbor Springs. The hospital has cleared the parking lot closest to the Emergency Room (ER). The helicopter is going to land in the parking lot right at the hospital. They’ll have cars with lights on to mark the landing zone. Once the helicopter lands and shuts down, and ambulance will pull up and pick up the patient to drive her up to the ER door. Joe, you can turn the patient over to the paramedic in the ambulance. Oh, and, by the way, the swimmer is NOT an EMT. He’s only a first responder. He’s going to stay here on the island while you fly over with the patient.”
Well, if you think my blood pressure had been high enough before this new information was provided to me, you would have been really surprised if anyone had taken the time to take it at that very moment. My brain was working so fast. My adrenaline level had just increased with a huge dump into my blood vessels. I ran quickly to the ambulance, looking for the jacket that I knew was there. I also found two knitted winter hats in the same outside compartment along with some nice warm insulated gloves. I also went into the rig and got two blankets. I had no sooner grabbed these things than the helicopter taxied up to the tarmac in front of the terminal building, but this time the rotors did not shut down.
Out jumped another crew member who ran over to the terminal building. He said, “We need to get your paramedic on board the helicopter right away. The weather is getting worse, and we have to get moving.”
I stepped up with my warm fire jacket on and with one of the knitted winter hats on my head and with the insulated gloves, and started for the door. “Let’s go,” I said.
“What’s the other hat for?” Bea asked.
“For the patient’s head, and the blankets are to help keep the patient warm,” I said.
The crew member put a set of headphones on my head to protect my ears, and Mark and Bea gave me the thumbs up sign as we headed out toward the helicopter.
I had to duck down and come in from the right direction to get to the helicopter, but that wasn’t so difficult with the crew member showing me the way. We managed to get close to the open door, and the swimmer jumped out quickly. I climbed in putting one blanket on the deck where I was going to sit. I immediately gave the patient a ventilation, and then quickly put the hat over the top of her head. I gave another ventilation and then covered her up with the blanket. The crew member who had shown me the way to get to the aircraft gave me a thumbs up and closed the door to the outside blizzard. I continued to ventilate the patient, but I leaned down and began talking to the patient.
Yes, she was unconscious. Yes, she was not breathing on her own. Yes, it was really noisy inside the helicopter. Yes, I’m sure the other crew members were thinking that I was crazy. I wasn’t talking quietly. I raised my voice, so that it would have seemed to anyone else not in this noisy environment would have thought that I was yelling.
I began talking about the mother’s husband, using his name, and about how worried he was about her. I talked about how frightened her children were. I used their names and talked about how great the youngest one was in singing during his music class. I talked about how wonderful the entire family was. I talked for about ten minutes on an off bringing up the Christmas program that her children would be in.
Then……ALL OF A SUDDEN… It happened. Don’t ask me how or why, because I can’t answer you. The next time I went to ventilate the patient, she started BREATHING ON HER OWN. I yelled at the top of my voice, “SHE’S BREATHING!” Every crew member in the helicopter looked at me like I was crazy, but sure enough, this mother and wife had decided to breathe on her own. I know that I sat there staring at this severely head injured patient, and I was just mesmerized by the simple fact that she was breathing on her own. I continued to stare at her and watch her breathing. I continued to talk to her about her relatives, her husband and her children, and the next thing I know, the crew member, I think he was the engineer, showed me his index finger and was pointing downward.
I took a moment to look out the window of the helicopter to see the cars. There were two of them on each side of a rectangular area below us with their lights pointed in toward the empty parking lot area. I think I really let out a huge sigh of relief right then. At the corner of the rectangle was an ambulance with the emergency lights flashing. Down we went slowly, so slowly that it seemed like we were moving in slow motion. I watched the patient breathe and never felt the helicopter touch down on the ground.
Even the patient’s breathing seemed to be in slow motion. Then with a cold blast of air, the door to the helicopter was slammed open, and my slow motion changed into a flurry of activity. We unloaded the patient from the helicopter using the backboard, and placed her on the ambulance cot. I was amazed that the ambulance was so far away from the helicopter, but this was not a usual situation and meeting a Coast Guard helicopter and turning a patient over to another paramedic in a parking lot in the middle of a blizzard was not part of anyone’s experience. Obviously, the parking lot had been plowed with the snow pushed up into high banks. The cars with their lights pointing in towards us weren’t bothersome at all. They provided the bright lights from the side while the parking lot lights provided the light from above.
As we pushed the ambulance cot quickly across the parking lot to the ambulance, the paramedic asked me, “When did the patient start breathing on her own.” We loaded the patient into the ambulance, and the doors were closed, so we could talk in a normal level of voice.
I answered, “About halfway across the lake. The breathing has been regular since she started breathing without assistance. I have a patient report from the island with vital signs from before we left the island. It’s impossible to get vital signs in the helicopter. She fell down a set of steps, head over heel, and landed on her head on a basement floor. She had classic signs of Cushing’s Triad, but seems to have improved in the respiration department. I’d get her vital signs right away to see how they compare.”
“Will you be coming up to the ER with us?” the mainland paramedic asked.
“No, I’m getting a ride home on that helicopter, and they aren’t going to wait very long,” I said. “Do you need any further information from me?”
“No, we’ll take it from here. Safe travels home,” the mainland paramedic said.
I hadn’t noticed that the crew member from the helicopter was standing outside the ambulance waiting for me. When I stepped out of the rig, he said, “We need to go right now. We have to get you back to the island, pick up our swimmer, and we need to get back to Traverse City. Fuel is the issue. We have a reserve, but we’re getting close to the ‘must go now’ point. So, LET’S GO.”
Obviously, I made it back to the island that night. I felt every single bump on the flight back, but the flight over with the patient, even though I know I did it, is only partially in my memory. The flight back is completely there. I was warmed by the extra clothing. I was warmed by the smiles of the crew. They were very happy to have successfully completed another emergency medical evacuation. I was warmed by the feelings of success. The crew plugged me into their intercom system on the way back, and I was able to hear their comments as well as see the smiles. I felt the rise of the helicopter on take off and the landing as well as the little bumps caused by the blizzard and the touch down at the Township Airport. What an amazing, totally amazing experience!
On arrival on the island, I literally jumped out of the door and was directed away from the helicopter. The swimmer was waiting and came out of the terminal, and the quick exchange took place. No sooner was the door closed on the helicopter, it took off straight up and disappeared into the blizzard.
Mark was waiting in the sheriff’s car at the airport, and I jumped in. He said, “All the clean-up is done. The run report is done. Bea did the report on the computer. Everyone chipped in, and we have been done for what seemed like an hour. I’ll take you to the garage where you can take a shower, and then I’ll drop you off at home, so you can get a couple hours of sleep before you have to go to school. Do you know how bad you smell and look?”
I told him about the miracle of the breathing, and he just looked at me and said, “It just must be her night.”
I responded, “She certainly made my night a lot better.”
We talked about the highlights of the run and the things that we did to contribute to the run. It was a debriefing in the best possible situation, with a friend and fellow paramedic on the same ambulance run. I got my shower, put on some old clothes he had brought along, and got back in his car. He dropped me off. I went to bed, and I was a little groggy in my middle school classroom the next day.
Ten days later, I was taking my wife off the island for a medical appointment, and we decided to stop by the hospital to check on this 25 year old mother and wife. When we arrived at the nurse’s desk, the intensive care room nurse would not let us see the patient. We could not get any information about the status of my former patient. As we were getting ready to leave, the patient’s mother stood in the middle of the hallway to block our exit. “Turn around,” she ordered us.
We walked back to the ICU nurse’s station, and she said to the nurse there, “This is one of the paramedics that saved my daughter’s life. Please provide him with the information that he wants.”
Wow, between the sobs and tears caused by that statement, I asked the current condition of the neighbor, friend, and parent that I had helped get to definitive care. The nurse began, “It’s too early to make a prognosis, the outcome of the head injury. Currently, she is intubated and on the ventilator. She is not responding to any outside stimulation other than painful stimuli. She is sedated. You are here at the right time. I can let you in to see her in a couple of minutes.”
“We’ll be waiting in the waiting room,” I answered.
As we walked away, the ICU nurse said, “You did an excellent job keeping the swelling of the brain down before she got here. You must have done excellent ventilations, and it helped that the patient was somewhat hypothermic when she arrived. We are currently maintaining her body temperature at the same temperature as when she arrived. Good job! You must have a great EMS team on the island.”
I smiled and said, “Yes, ma’am, yes we do!”
I got to see the patient without actually touching her, but just seeing her was all that I needed. She was still alive and being taken care of by an excellent team. We hugged the mom and left the hospital to go to our appointments.
Literally months later…..
Mark called me on the phone and sounded excited, “Bea saw our head injury patient at the ER in Charlevoix. She was coming from the rehabilitation facility for some tests. She is talking, and she is walking, although it’s more of a shuffle than a regular walk, but, not only is she alive, she talked to Bea and thanked her. She told Bea to tell all of us a huge thank-you to the entire EMS crew for their efforts.
This patient is back on the island now, and every time I see her, I am reminded of the reason for doing emergency medical services in this rural community. Sometimes, we can make a difference between life and death, and this was one of those times. Other times, we can help our patients feel more comfortable, maybe by just holding a hand while they are transported. Every time I see her, the “Hello” and the hug we give each other really means something more than just a nonchalant greeting.