Norm Rooker | Ghosts (part 1)

Photo courtesy of Stephane Brunet (c) 2011

Ghosts (part 1) by Norm Rooker

How many of you have read Joe Connelly’s 1998 semi-fictional book ‘Bringing Out The Dead’?  Joe, a former New York City EMS paramedic, spun a very realistic tale of the dark side of EMS.  The parts they don’t tell you about, or at best maybe hint at, in First Responder, EMT & paramedic school.

Made into a movie a few years later, the story is about a burnt out paramedic, played by Nicholas Cage in the film, who is among other things, haunted by his own personal EMS ghost. A former patient, a young female asthma patient, that he was unable to save.  Our exhausted and extremely crispy but still striving to do his best medic keeps spying her out of the corner of his eye in various crowd or street scenes as he responds to calls.

If you haven’t read the book or seen the movie I won’t spoil it for you. But the fact is that most any medic, firefighter, law enforcement officer or ED worker with more than a few months of experience will tell you, if they trust you and are being honest with themselves, that they each have their own “ghosts”.

Those calls or patients that have jarred us or have an emotional impact on us.  The ones you could do nothing for.  The ones if you could have just done this or that differently, a little quicker or maybe just that elusive “something else” that the outcome might have been different.

The one that the VCR/DVR in your head keeps playing over & over again. Or years later will suddenly replay out of the blue triggered by a seemingly innocuous event.

One of the minor disadvantages of a career spanning almost 39 years as an EMT, Paramedic, Firefighter, Rescue Specialist & what not, is that like most of you, I have had more than a ghost or two in my life.

Former patients and/or calls.  Sometimes not even my call but one that happened to someone I knew.  My mind would obsess about how I would have handled that call, that situation.

For instance, back in the late 80’s several friends of mine responded to one of those freak, once in a career, type calls. The call and the patient’s death haunted/danced in & out of my dreams for almost 18 years.  Mainly because at that time I wouldn’t have done anything different than they did. And great medic that I liked to believe I was at that time, I would have come up with the same tragic outcome had this call been mine.

My mind & subconscious chewed on this rescue problem for almost 2 decades until I finally worked out both how to have correctly and realistically identified that patient’s unique predicament and how I would have then run treatment and rescue/extrication with a real chance of success.

The story.  A mother was driving a carload of kids to an after school event.  They were on the highway and heard a loud thump from the bottom of the car & simultaneously the mother felt a burning sensation in the back of her neck at the base and a sudden weakness.

She was able to safely decelerate and pull her car off to the shoulder of the highway.  One of her kids used her cell phone, this was back in the late 80’s when not everyone had one, and called 911.

My friends were on the first responding engine and ambulance.  On their arrival they got the kids out of the car and safely in the care of a police officer.

Their physical assessment revealed a conscious & awake woman c/o of a sudden onset of a dull burning sensation at the base of her neck with full body weakness.  Physical exam was unremarkable except for a lump/deformity with no point tenderness just to the right of her spinal column at the C7/T1 level.  No medical history to speak of, no RX or drug allergies and normal vital signs except for a slightly elevated pulse.

At a loss for the cause of the sudden onset but noting the deformity the woman was placed in c-spine precautions including a c-collar and KED, Kendrick Extrication Device.  Just like many of us would have done.

The problem came when they attempted to extricate her from the driver’s seat out onto the backboard.  This wasn’t any, “Ma’am, can you swing your legs around and have seat on our backboard.” type extrication.  This was the full blown deal.

They went to lift her up to swing her torso around in preparation to laying her flat on the backboard when she let a little moan and died.  One of my friends said the closest way he could describe it was like a cartoon where the color just drained out of her from the top down.

They also discovered they were encountering resistance from her hips, so they lifted her a little higher and discovered there was something sticking out of her.

It was only after they angled her head out of the driver’s door and lifted her almost 3 feet into the air that they discovered the problem.  Rebar.

The California Highway Patrol accident reconstruction team discovered that a 6 foot piece of rebar had fallen off a vehicle and was laying on the highway.  The woman’s car had driven over it at just the wrong angle that the rebar bounced off the pavement and penetrated up through the floor of the car, the driver’s seat and into the driver.

It was one of those freak billion-to-one accidents.  But that didn’t change the shock, horror and frustration for my friends who had a patient that was alive when they got to her and during their actions to “help”, died in their arms.

They ran the code but it was one of those “Humpty Dumpty” type of resuscitations.  The kind where all the King’s horses and all the King’s medics couldn’t put Humpty Dumpty back together again.

This wasn’t even my call.  I never met this woman.  I have no idea what she looked like or even whether she was a good mother and/or wife or not.

But still, I obsessed on the incident.  This could just as easily could have been my call and I am pretty darn sure that I would have taken the exact same actions with the same tragic results.

It took almost 18 years of chewing all aspects of this call over in my mind.  Both conscious and subconscious before I had worked out all the pieces to have maybe, MAYBE, run this call with a different outcome.

I will tell you that the very first thing I did/changed was to start being more consistent in applying that wildland fire safety rule “Look up, look down, look all around” to my patient assessments.

As humans we pretty much look at, view our world and surroundings at eye level.  That looking down for clues/evidence, especially like we see now on TV shows like CSI is a learned or trained behavior, not one that comes naturally to most of us.

The same holds true for looking up.  For overhead obstructions, safety issues like something dangling on a wire or a thread above us.  Everything from a FF waiting in ambush to dump a bucket of water on you as you pass by to IEDs, Improvised Explosive Devices to overhead obstructions prior to swinging an axe or raising a ladder.

Shortly after this accident I incorporated feeling under the patient’s car seat as part of my assessment.  Especially when I had a situation/presentation that wasn’t adding up. While I have never found a patient impaled by rebar, from time to time I have found some clues to my patient’s presentation/predicament at that moment.

That was the easy part. The next challenge was to figure out how to extricate a similarly trapped/impaled patient safely and get them to the hospital alive enough to give the trauma surgeons a viable chance at saving this unfortunate individual.

Being a rescue specialist, I was already teaching structural collapse rescue at the time, I chewed on the extrication side of the problem.  How to stabilize the rebar and cut it between the seat and the floor of the car without jarring or shaking it so badly as to further cause internal injuries to the patient?

How to remove the roof of the car, disconnect the seat from the car and lift the patient and seat as a unit and lay it down on a backboard?  How to secure the seat and patient to the backboard, supporting their legs and the sides so that they had a stable ride to the hospital immobilized in the same position we found them only laying on their, the car seat’s, back? This included how to realistically build up a support for her legs so they didn’t just dangle or flop about.

She was one of my motivations for taking the NFPA, National Fire Protection Association, approved Basic and Advanced Vehicle Extrication courses.

In the meantime, once extricated, how would I go about “packaging” her for transport and what treatments, effective treatments would need to be rendered?  And while all of this sounds good on paper and in my head, I also had to figure out how to communicate the situation to first my fellow medics and FFs on scene so they would accept my proposed plan of action and secondly the receiving hospital so that they would have the appropriate resources ready when we or the air ambulance hit the door.

When I had worked all this out, I was finally able to say goodbye to this woman’s ghost. A second-hand ghost at that as she wasn’t really mine to begin with but rather had become mine via adoption.

This unknown woman was neither the first or final “ghost” of my career.  My first “ghost” came into my life Thanksgiving Eve 1975.  I was 19 and had been an EMT for just over two years.  Most of my experience up to then was either as the medical (cadet) sergeant on a not very active ground search & rescue team or as an EMT for a redneck “mom & pop” private ambulance service that almost exclusively did routine transfers.

Anyway, it was Thanksgiving Eve and I was sharing my first bachelor pad with three good friends I had known since grade school, Boy Scouts and the Civil Air Patrol.  We had all been cadets in the same CAP Squadron that ran a “ranger” team.  It was that CAP affiliation and timing that allowed two of us to have been selected to be part of the second pilot EMT class run in the State of Connecticut over the summer of ‘73 between my junior and senior year of high school.

All four of us have since gone on to careers in emergency service.  Brett and Fred in law enforcement, myself as a paramedic/FF/rescue specialist and Dick as a FF, and ultimately Battalion Chief for the Washington DC Fire & EMS Dept.  Indeed Dick ran part of the roof operations in the battle to save the Pentagon on the night of September 11th.

But that all was in the future. Going back to that Thanksgiving Eve evening, we were just four 18- and 19-year-olds, one in the Army, two going to school full-time and me working full-time as an EMT for Northern Virginia Ambulance Service.

The company, as an early Christmas present, had just issued all of us windbreakers with the company name on the front and back.  Being young and unbelievably proud of what I did, I of course wore that windbreaker on and off duty.

Remember, this was a bachelor pad.  Decorated in second hand and yard sale furniture.  The bunk bed that my brother and I had shared when our ages were both in the lower single digits was disassembled and was now two of the beds for our apartment. The center of decoration for our living room was a combination TV set and high fidelity stereo and an 8-foot wooden bar that one of us had come across at a yard sale and just knew that we had to have.

We weren’t slobs, but we sure weren’t what you would call neat-nicks either.  Brett, who was active duty with the 3rd Division “Old Guard” artillery battery had a waiver to live off-base with us.  For some reason Brett got it into his head after dinner that Wednesday evening, we were going to clean/police the place up for the holiday.

For an even stranger reason, that seemed like a good idea to me as well and the two of us set into it with the gusto and enthusiasm of youth.

A couple hours later we had the place ready to receive our parents should they drop in to visit.  The last task left to do before we called it a night was to take out the trash.

It was a cold November evening so we both donned jackets, me of course in my NVAS windbreaker.  As we carried the trash down to the dumpster we heard a horrific crash.  Our apartment happened to be alongside Interstate 95 by an exit/on ramp.

Photograph courtesy of Stéphane Brunet

We both saw the fireball from the wreck rising up above the tree line along the edge of the highway.  I gave my trash to Brett and ran towards the fence.  By the time I finished clambering over the 8-foot chain link fence and barbed wire fence the first arriving fire engine and ambulance were on scene.

As I came down on my feet and turned to the wreck I saw the fire fighters restraining a man with badly burned arms fighting to get back to the burning vehicle.  I heard two sets of shrieking screams coming from the fully involved vehicle and a child’s small voice calling from the back of an otherwise empty ambulance.

I asked the firefighters if they needed a hand and they directed me to the back of their ambulance.  I climbed in the open back doors to find a young boy, maybe 8 or 9 laying on the gurney with probably 60% second & third degree burns, mostly to the right side of his body.

It was just the two of us back there.  I looked around and grabbed a bottle of sterile water and began pouring it on his burns.  I still remember how the water steamed and rose off of him.  And the smell.  That unique smell of burnt hair and flesh.

I didn’t’ have any trauma shears on me.  I was a young EMS newbie/geek, but even back then I didn’t carry trauma shears on me when I was off duty.

So I found the OB kit, pulled out the scalpel and began cutting this kid’s burnt clothing off him as best I could.  I used the sterile sheet and dressings from the OB kit to cover this young man’s burns and then continued to cool with bottle after bottle of sterile water.

And it was not like this youngster was screaming or writhing in pain.   Just the opposite, he was lying quite still and speaking in a clear, English accented voice inquiring “Please sir, can you tell me how my mother and sister are?”

Blessedly, the way the ambulance was facing and the sounds of the fire engine in pump mode as the firefighters worked to put the car fire out were drowning out the death cries of two of his closest family members and the mourning wails/keening of his badly burnt father who was being treated/restrained in a second ambulance that had arrived on scene after I had initiated taking care of this young man.

I learned later that the father, a counselor officer for an Eastern European country had just brought his family over to the US that very week and he had been showing them the beauty of the Virginia countryside.  He was driving them back to their new living quarters when a drunk driver accelerated up the on-ramp and rear-ended their vehicle causing it to explode.

The father received his burns pulling his son out of the burning vehicle and was trying to go back to attempt to save his wife or daughter when I clambered over the fence and joined in the response.

I rode into the hospital with the FF/paramedic crew, assisting them as they started IVs administered MS, morphine, and all the time trying to find new ways to avoid answering this young boy’s inquires into the status of his mother and sister.

Afterwards the fire crew thanked me and gave me a lift back to my apartment complex.  I worked on the ambulance Thanksgiving Day and then went home on Black Friday to spend the rest of the holidays with my family.

All the time still hearing this young boy’s calmly questioning voice in my head.  Well that and the anguished cries of his dad and the death screams of his mother and sister.

I realized later, much later that this boy was in shock.  That he wasn’t feeling the pain, yet, of his severe injuries that looked and smelled so bad to me.  This young man became one of my driving motivations to become a paramedic so that I could do more than just fake my way through treating him and just pouring water.

I learned this young man succumbed to his injuries a week later. It was because of him that I made it a point to learn all I could about burns, burn injuries and the best way to aggressively, but not overly aggressively treat them. Burn injuries became one of the first subjects I taught/lectured on in various EMT and paramedic training programs.  When I broke out onto the national speaking/lecture circuit, this was also one of the first talks I marketed.

Even now, sharing his story with you over three decades later I still hear his voice in my head.  His spirit doesn’t “haunt” me.  Rather it motivates me.

And continues to do so.  Even though I am in the autumn of my EMS/rescue career I still pursue how to take care of these patients better.  One of the many items on my “bucket” list is to take the ABLS, Advanced Burn Life Support course.

(EMS treatment pearl for those burn patients who are in pain.  If all you have for treatment is Fentanyl or Morphine but medical control is being stingy in allowing you to administer it. You know, following the cardiac/pulmonary edema algorithm for the administration of MS rather than the one for burns/trauma,  “Start with 2-4 mg MS and call back in 10 minutes if you think the patient needs more.”

First of all, don’t wait 10 minutes and when you call back in, stand near your still loudly screaming/shrieking/moaning patient and after making a request for an additional MS order, tell them to hold on a minute while you move out of the vehicle/into another room as you can’t hear their response over the patient’s cries of pain.

Pretty sure that they will become much more liberal in the amount and frequency of MS they will allow you to administer.)

There are of course other “ghosts” in my life/career but I will save sharing some of their tales for the second part of this essay.  I promise to follow up with it in the next month or two.  Until then stay safe, and as my friend Hal first said to me many years ago, always strive to do your best to practice Big Medicine.

Photograph courtesy of Stéphane Brunet

 

Renewing terror and other tricks of mass evacuation

by Hal Newman

It’s been a long while since this happened however it seems the story continues to have a serious impact on those with whom it’s shared.

And that’s interesting in and of itself in that several colleagues have approached me recently because they’ve heard this story presented at conferences by folks other than me claiming it as their own.

Except, of course, for the part where the presenters accept responsibility for making fateful decisions because in their telling of my story this happened to ‘someone they know’ or ‘an unnamed colleague’ and they proceed to dis’ him for his lack of knowledge about their community.

I was actually very familiar with the community I served.

I was the director of Cote Saint-Luc EMS in January of 1998. The City of Cote Saint-Luc was an interesting place to lead a team of emergency medical services providers. There was a very high percentage of the population who were 65 years of age and older and embedded within that considerable slice was a large community of Holocaust survivors.

Our EMS department was innovative in its outreach efforts and in its expanded scope of service that made it more of a psycho-social service than a purely emergency medical services organization.

On January 5 the freezing rain storm began to take a toll on the power grid. At 05h00 on the morning of January 6th, dispatch began to become inundated with calls for assistance. There were reports from Hydro-Quebec that some 700,000 households were without power in a large swath of southern Quebec.

On January 6 we realized evacuations were likely to become a necessity. At 11h35 we received the first of what would be many calls for medical verifications. A 75-year-old man was on a home oxygen system and plans were made for his eventual evacuation.

We were sliding further into crisis. Our calls were multiplying while available resources were shrinking. People were finding it difficult if not impossible to find a hotel room anywhere in Montreal.

From crisis we went directly into the abyss. No need to pass Go. I called for assistance from the provincial government to assist with establishing shelters for the thousands of senior citizens and medically fragile residents we were evacuating from dark, frigid, carbon-monoxide-intensive apartment buildings.

You could not measure the depth of my despair when I realized no help was coming. That feeling of profound isolation was almost immediately replaced by the realization that we would have to take care of ourselves – no cavalry would be riding over the hill to come to our rescue.

On January 7 at 10h42 our crews began the assessment of a 10-floor seniors residence. At 10h46 the transport of the first 16 evacuees from the building begins. They taken to a shelter established at City Hall. The fire department is called to the scene to ventilate the building after fumes from the emergency generators circulate throughout the hallways.

On January 8, Hydro Quebec reported 950,000 households are without power.

I made mistakes.

We had many senior-centric highrise or multi-building facilities that had to be evacuated. Given the sheer number of evacuations and the limited humans available to carry out the task, we drafted police officers to assist with these mass evacuations.

As police officers, many in tactical or bulked-up gear due to the extreme weather conditions, went door-to-door in the darkened hallways, hundreds of Holocaust survivors flashed back to a time of forced evacuations and transport to the death camps.

When bubbies and zaidies* scream.

We had, of course, unintentionally made matters worse by providing the police officers with instructions to residents to gather their essentials into a bag as quickly as possible and then make their way to the lobby where they would be loaded into buses for the ride to the shelters.

At the shelters we had the standard line-up check-in procedure. The first round of evacuations resulted in dozens of cases of severe mental trauma and more than a few syncopal episodes.

When the plans failed, we adjusted.

We adjusted by having our medics accompany the police officers on their evacuation rounds, softened the approach, used as much light as could be hauled around, brought social workers into the mix on the buses and altered the check-in procedure to include large round tables where a social worker and a medic were assigned to each table to help residents acclimate to their new surroundings.

It became more like a last-minute social gathering. Thank goodness.

On January 10th, Hydro Quebec reported 1.4 million households without power. Water had to be boiled prior to consumption.

On January 11th, the army arrived with more than 11,000 soldiers on the ground. The Abbruzzesse Family had power in their kitchen in Montreal North. Huge trays of wonderful Italian dishes were transported across the city to feed our crews. Smaller army. Just as appreciated.

I remember a satellite phone conversation with someone at an agency considering lending us a hand during the disaster. We were evacuating another 100 or so seniors from a nursing home at the time. The gentleman on the phone said they might be willing to send someone to better assess the gravity of the situation. Right at that moment a large piece of ice dropped off the top of a 20-floor building and hit a parked car on the street behind me. There was a large crash. The man on the phone exclaimed, ‘What was that?!’

My reply, ‘Hell just froze over, sir.’

Be well. Practice big medicine.

Hal

*Bubby and Zaidie are the yiddush words for Grandmother and Grandfather respectively.