The MacMedic

I really slept poorly yesterday, I’m not sure why but as tired as I was when I went to bed I was up every hour or so for a few minutes, just long enough make sure that I would wake up in the afternoon feeling anything but refreshed. The ED was neither slow nor busy, just steady with a patients that were there for either complaints that were vague in nature and required prying with heavy tools to get enough information out of the patient to treat them properly or complaints that could have easily waited until another time or had waited so long that you were left wondering why this was an emergency now.

I just hope today’s sleep is better than yesterdays.

It looked like another boring day by lunchtime and the early afternoon didn’t make me believe any different. The only ALS call we did by 1700 was an allergic reaction that my partner worked up and transported with.

We had just settled in to finish up paperwork after her transport when one of the fire departments was toned for an accident at a small airport about five or six miles south of us. Since the airport is on a main road the natural assumption was that it was a car accident. Moments later tones, including ours, started dropping for the same incident. Two engine companies, a rescue, an additional ambulance, a foam unit, and us were all dispatched at the same time. When we tried to sign on the radio traffic on the air was incredible and after a few seconds we realized that this was not a traffic accident we were going to in the “traditional” sense of the word but rather a small plane crash.

Listening carefully we were able to determine that a small plane had veered sharply off the grass runway during takeoff and slammed into a hanger. Even knowing as little about aviation as I did I could make an educated guess that this was going to be a high velocity impact and had huge potential for serious injuries. Initial reports were two serious injuries, both patients had been dragged from the plane by witnesses who felt that the plane would burst into flames at any second (people watch way too much TV).

We arrived right behind the mutual aid ambulance from the neighbouring towns fire department. They had two paramedics on board so we knew that no matter what we would have adequate ALS resources available for the two patients. When we pulled up to the scene we were directed to the ambulance that had been first on scene. Inside I found the crew working on an elderly female who was responsive to painful stimuli with non-purposeful movement. She had been the restrained passenger in the front seat of a light aircraft which was reported to have dipped a wing during takeoff causing a wheel to hit the ground hard and caused the plane to turn to that side, travel another 100 yards across the taxiway and slam into a hanger. The damage to the plane was extensive with the entire nose having been sheered off and the rest of the fuselage deformed at the leading edge of the wings. I never got close enough to see the inside of the plane but since it appeared to be quite old I could safely assume that it had very limited safety equipment in it and the interior damage would be extensive as well.

The patient that I was presented with was already collared, longboarded, had one IV established and oxygen via non-rebreather mask and a nasopharyngeal airway already in place. She had an obvious deformity to the left side of her head with heavy bleeding and some crepitus. Blood was coming from her ears at a moderate rate and when it dropped onto the stretcher sheet it had a yellow halo around it making me suspicious that it contained cerebrospinal fluid and that the patient had a more serious skull fracture that what was already evident. Her face was unstable on the left side and her left eye was bloody with an unclear pupil, on my cursory exam I couldn’t tell if she had an actual injury to the globe of the eye or not and even if she did it would not be the highest priority injury she had. What concerned me more at her head was the fact that her jaw was clenched shut and that we were unable to adequately clear secretions out of her airway.

Her neck seemed stable with no palpable deformities, JVD, or tracheal deviation. Except for a diagonal bruise that ran from her right shoulder and down across her chest to the left side of her ribs her chest exam was better than I expected. Her breath sounds seemed just slightly more diminished on the right side but not so much as to make me extremely concerned. Her abdomen was soft and flat with no evidence of bruising or deformity.

Although her pelvis and shoulder girdle appeared stable she had an obvious fracture to her wrist and her lower leg on opposite sides.

During the 2 minutes it took me to do my assessment her pulse ox had fallen into the high eighties and I was very concerned about her airway. We tried to suction as much out of her airway as we could but her jaw was tightly clenched and while we could get some of the secretions out of her cheeks the majority of the airway obstruction stuff was deeper in and well beyond our reach. She clearly needed to be intubated and there was absolutely no way that was going to happen with her clenched jaw. Nasally intubating her was not even an option, I had very little doubt that she had a significant skull fracture and the risk of doing further harm was too great for that. All we could do was manage her airway as best we could, assist her ventilations, and head for the hospital as rapidly as we could. If RSI had been an option I would have stood a better chance of effectively managing her airway but that was not an option.

I had called the ED on the phone when we arrived to give them the heads up that they would be getting two significant trauma patients in within thirty minutes and while we were transporting I called them again to give a 30 second update and ask if they could call for a helicopter to come to the ED for transport to a trauma center. I would have called the helicopter to the scene but none of the four aircraft that we could use are within anything less than a 25 minute ETA. It made more sense to head for the ED for stabilization and management of the difficult airway and fly her out from there.

One of the many things that I am adjusting to is the fact that I have no trauma center nearby, the nearest is a level 3 center that would be almost 45 minutes from the scene. A level 2 or level 1 trauma center would be more than an hour by ground. For an area with a reasonable population the fact that there is no trauma center readily available is just mind boggling.

I was happy to see that the ED staff had taken the lead time I had given them to get all the resources they had available activated and waiting. Adequate staff were present to do full trauma workups on both patients simultaneously. Thirty minutes later two aircraft landed in quick succession to transport both patients to Boston where they could get the definitive treatment that they needed. In the time that I had been out of the room my patient had been paralyzed and intubated, had a chest tube put it, a CT scan which showed multiple head bleeds, several skull fractures including a basal skull fracture and blowout fractures of the top of her eye sockets and a fracture of her first cervical vertebrea. Although her vital signs looked better after the intubation and the chest tube she was still looking very, very unstable and I had a feeling that her prognosis was extremely poor.

It took quite a while to actually finish the paperwork in its entirety and after that a single cancelled call interrupted the night leaving me free to sleep as best as I can at work for the rest of the night.

I got a somewhat pleasant surprise when I got in to work last night. Not only would I not be spending the entire 12 hours in triage, I wouldn’t be spending any time there at all. It seems one of the nurses had injured herself and was on light duty and triage was pretty much the only light duty assignment available.

The night itself was extremely busy in the beginning and calmed down quite nicely by midnight. The evening might have been better if the ED physician working was one of the speedier ones. The doc that was working is one of the slowest I have ever seen. Thorough, but slow.

Since I have been working 36 out of the last 48 hours I am looking forward to getting some good and uninterrupted sleep this morning.

If I had to pick one word to describe this shift it would have to be “boring”. My partner and I spent 24 hours here, were dispatched to five calls, actually got off of the hospital campus twice and only saw and one of thise. That one patient who ended up being downgraded to the Intermediate ambulance who had already corrected his hypoglycemia and was totally capable of taking him the 6 minutes down the road to the nearest hospital.

We both could have stayed home and it would have made absolutely no difference.