The Least of My Brothers

Instant

CHAPTER 1

…..FOR WHOM THE BELL TOLLS

They say the adrenalin is killing me slowly. For now, it’s getting me up and running from a sound sleep. It’s 1:05 AM and I don’t want to move this fast. After twelve years I still put on one boot at a time while I confront the nightmare of waking up.

Engine 73, Squad 6, traffic collision at 8500 Sunset, cross of La Cienega.

Sheriffs at scene reporting multiple injuries.

The dispatcher’s detached tone carries no hint of the content of his words. The Sheriffs are reporting it’s a bad one: my body releases another shot of the killing stuff. I don’t have to drive, so I hit the En route button to shut off the incessant beeping of the Mobile Data Terminal in the squad before the high pitch chirping disintegrates my brain; then I start putting on my rubber gloves as the bay door sounds like it’s rolling up into my head. We pull out into the night with the red lights churning above. My partner flips on the siren along with a controlled kamikaze mind set and we start weaving through cars driven by dazed zombies who are a second of bad luck away from their own grinding catastrophe. Neither my partner nor I have said a word. I wonder if that’s because he feels like shit. I know I do. I must have been in a phase of deep sleep, but I got dressed and into the squad- so far so good.

Time to start my procedure, my calming mantra. The imagination is no match for the possible injuries in an auto accident so I do an ordered assessment of an imaginary patient. This serves the function of getting my head out of my ass and on to the coming test. I watch the red lights play off the shop windows and cars we pass- that’s part of the ritual too; it also shields me from the rage Norm is experiencing as he negotiates his way around drivers on cell phones, drivers with their car stereos turned up and drivers who appear to be sailing in the Bahamas. The ritual focuses without numbing or leaving me hyper- a common state of paramedics brain dead on arrival at the scene.

Suddenly the radio interrupts our individual reveries: Squad 6 from Engine 73. What’s your E.T.A.?

Two to three minutes, are my first spoken words.

The Engine 73 captain, already on scene, repeats, Two to three with distinct distress in his voice.

This is not a good sign and calls for another shot of adrenalin even before we nearly hit a car whose driver has chosen to stop in front of us rather than pull over. Norm utters his first words - Scum sucking, bottom dwelling shit head.

I catch a glimpse of the frightened driver as we pass by. I think he felt your anger.

Norm smiles, breaking his inscrutable Japanese exterior.

Things click up a notch as we start approaching the traffic backed up from the accident ahead and are forced to pull across the double line into oncoming traffic. I lose count of the number of times I stop breathing: I have never gotten used to this game of chicken with oncoming cars. I’m fully awake now.

I finally see two badly distorted cars silhouetted by the lights from flares and emergency vehicles. The front of a BMW is melted to the front of a late model Firebird at a 120 degree angle. The BMW made it to the firewall of the Firebird: not a good sign for mechanism of injury. Harmless white steam coming from under the hood of the BMW takes on a red tint from the flares. A one inch protector hose line from Engine 73 lies unattended at the front of the Firebird. Right now, almost everyone on scene knows more than we do. I press the On Scene button on the Mobile Data Terminal. We’re going to be in charge of this mess in about thirty seconds so we have some anxious catching up to do.

I should explain at his point that neither my partner nor I give a rat’s ass about what the system thinks of our performance. There isn’t enough left of the system. We worry about the judgement that can haunt you for a lifetime, the conviction that comes from remembering that we’re riding with Anita Baker. Her voice will be our judgement later.

Norm and I meet at the paramedic equipment compartment of our squad and start pulling out the initial equipment we think we are going to need. It’s not an optimistic assessment. As we walk toward the cars we see some good news approaching us in the form of Ed Barnsdale, an excellent paramedic working overtime on Engine 73. He’s amazingly awake and cheerful considering the circumstances.

You guys weren’t asleep were you? I was watching soft porn on cable channel. Cable is great. Without breaking his verbal stride, Ed shifts to his initial assessment. Unless the woman in the Bmer has a deceleration injury, she’s only got facial lacerations from flying glass. Her asshole boyfriend has something wrong with his shoulder but seems more concerned with his car than anything else. The other car is a can of worms; I don’t think any of them were wearing seat belts but we can’t get into the car to check them out. I don’t like the looks of the two in the front seat and I can’t really get a good look at the two in the back. The passenger side of the windshield is cracked and the driver looks like shit.

Norm and I are looking into the Firebird and agree with Ed. Just then the captain comes up to us. He’s amped and sweating from trying to get the doors of the Firebird open. Neither door will come open: too much body damage. We’re going to need your jaws.

I nod my approval. Norm and I are both figuring out how to organize this. We can feel the clock ticking on the people in the Firebird. Norm says quietly to me, Ed can take the Bmer and the first ambulance?

Yeah. Norm just kick-started the plan.

Norm turns to Ed and hands him his clip board with the MICU forms. Take anything you need out of our squad and handle the two in the Bmer. You got the first ambulance.

The captain, the engineer and the remaining fireman are busy getting the heavy jaws equipment off our squad. While I’m figuring the best way to get myself into the car, Norm decides to roll our engine. We need some fuckin help, he says as we walk back to the squad. I take out a crow bar, a chisel and a hay hook to pull the front windshield out. It’s already been cracked by the female passenger’s head. Walking back to the car, I hear Norm: L.A. Dispatch from Squad 6, roll Engine 6 and two more ambulances. A brief pleasure passes as I picture the Engine 6 crew being awakened. As we stumbled out of bed when the call came in, one of the Engine 6 firemen had muttered: Don’t wake us up when you come back. What goes around comes around.

Two minutes later, I’m kneeling on the hood of the Firebird, sweating in the cool night air, with shards of glass imbedded in my pants. A sheriff with arms the size of my thighs comes over.

Need a hand?.

I hand him the chisel and crow bar. He makes short work of the window molding and pulls out the rest of the front window as easily as dislocating an arm from its socket.

I decide to go through the window feet first. They don’t give training on how to enter a car through a broken window; probably because there is no good way. I can feel a small piece of glass that we didn’t get out making a tear from the upper leg to the butt of my pants. Inside the car, it looks like a concussion grenade went off. While I take off my leather gloves with fine glass imbedded in them, I see the driver look at me. It’s the look of someone who thinks he may die and doesn’t want to. It’s a look that varies from face to face but has a common theme. The girl next to him is wearing a mini-skirt that would be sexy if it wasn’t covered in blood coming from her mouth. Her lower lip is hanging to the rest of her mouth by a few corner attachments. I never worry about the blood I can see unless it’s spurting out.

In the perverted light that makes it into the car I can barely see the couple in the back seat. The guy in the rear catches my eye. Mister, please, you got to get us out of here. I don’t think I can move my legs. In addition to telling me that he may have a spinal injury, I now know he has a good airway and an alert mental status. The girl next to him is lying in the fetal position whimpering.

I touch her shoulder while shining my small flash light on her. Does anything hurt.

Yeah, my whole fuckin body. When are you assholes going to get us out of here?

I ignore her attitude, knowing that it comes from fear. We can’t open the doors to the car and we have to get you out very carefully. Now where do you hurt?

In a conciliatory tone she answers, My head and my stomach hurt.

Does it make your stomach feel better to be curled up like that?

Yeah. How did you know?

Hiding the fact that I now suspect a major internal abdominal bleed, I answer, It’s my job to know those kinds of things.

The sounds of two sirens arriving followed by the sound of air brakes being set overrides the ambient noise. It’s Engine 6 and the first of the two ambulances Norm ordered. I get the same feeling I did when I was a kid in the theater and the cavalry reinforcements arrived to save the day.

It’s now time for my speech to victims trapped in an automobile. I want you all to pay careful attention and remember what I’m going to say. There’s going to be a lot of noise around the car before we get you out. I don’t want you to move because it could make your injuries worse. Don’t nod or move your head in any direction. Let us do all the work.

As I’m looking for signs of recognition of what I’ve said, I hear Norm’s voice coming from outside the front window. We’re ready. What you got in there?

I don’t want to say I have at least three criticals so I hold three fingers outside the window and then give a thumbs down.

I hear Norm’s voice, You got the works boss.

I trust that voice. It means the roof will be off this car in about three to four minutes.

Another fireman hands me four blankets. I tell the people in the car that the windows are going to be coming out of the car. I’m just going to put these blankets over you for about twenty seconds to protect you from flying glass.

The driver groans, My poor car.

I assure him, You ain’t seen nothin yet.

Two of the Engine 6 fireman who you wouldn’t want to meet in a dark alley approach the front side windows in full turnouts with their face shields down. They strike the windows almost simultaneously and the windows shatter along with my hearing. Gloved hands rip the windows out as another loud noise joins in - the sound of the Hurst Tool generator- the power system for the jaws.

I start cutting open the drivers shirt as the cutting attachment on the Hurst tool bites through the drivers side roof support. I shine my flashlight over the driver’s neck looking for a deviated trachea or distended neck veins. Neither is present yet; that’s good because those are signs of critically increased inter-thoracic pressure; that will kill him pretty fast. I lightly palpate the sternum and rib cage and shiver internally at the sickening sound and feel of bone ends rubbing against each other. Then I hear the center post snap as the jaws cut through it.

A fireman is standing on the trunk denting the rear of the roof with a pry bar along a line which he will then use to fold back the roof. The intense noise is too much for the girl in the back seat; she starts to cry. Grinding, ripping metal has a way of turning up perceptions of reality.

The driver is getting a detached look along with a more dusky appearance. I’m losing him. The roof is pried back and I breathe the night air for what seems like the first time in a long while although I know it has only been minutes. Norm has anticipated my first priority and puts an oxygen mask on the driver. Can’t use oxygen till the cutting is done in case of a spark.

Norm and I discuss the two patients in the rear. They have to be removed first so that we can get into the back seat to stabilize the front seat passengers. Norm relays to the firemen on the trunk with backboards that the male passenger has a suspected spinal injury. We haven’t ruled it out on the female either. We C-collar both rear passengers, taking great care to get the girl into the upright seated position. If anybody wants to know why so many fireman have back injuries, a film of the next minute will go a long way to answering that question. From every awkward position imaginable, five fireman struggle to get a firm grip under the arms, on the belt, on some part of the clothing of the guy in the rear seat. I estimate he weighs about 190 lbs. I yell out that I will guide his legs as I strain to reach in between the two front bucket seats. The backboard is pushed down between the patient and the rear seat making everyone’s angle of grip even more difficult.

Norm looks over the setup. I give Norm an ambivalent approval. He nods and tells the fireman stabilizing the head, You call it Ben. What transpires in the next few seconds is a mixture of prayer, belief in ourselves and a combined forty to sixty years of experience. The patient rises up along a nearly vertical board which is quickly tipped onto the trunk in a mystery that everyone has done more times than they can remember but no one completely understands. We take a few seconds to quietly celebrate climbing the mountain one more time, then the event slips out of our consciousness. There is a lot more work to do.

While the firemen on the trunk of the Firebird fasten the straps that immobilize the patient to the backboard, I climb into the now vacant rear seat to do a quick assessment on the girl. By quick, I mean about sixty seconds. We need to get her out for a more thorough assessment and, if my hunch is correct, two IV lines as large as I can get. As I’m checking her capillary refill- a test for severe internal bleeding, I hear one of the older fireman who was on the trunk say to the ambulance attendants, Come on in lads. Don’t be shy. This is no time for shyness. I savor his humor as I see that my female patient has delayed capillary refill- probable internal bleeding.

After we get the girl in the rear seat out of the car, I leave Norm in charge of the extrication of the driver and front seat passenger. I tell Norm about the crepitis that I felt on the drivers’s chest wall. I need to do more assessment on the two rear seat patients and Norm needs to take a closer look at the driver and his companion before we decide what we are going to do next. We hope to be rolling before a distant second squad arrives; and as we expected, the hospital has ordered Ed Barnsdale to follow-up in the ambulance with the two minor injuries from the other car. It was not helpful to have lost Ed, but we understand the hospital was considering mechanism of injury and covering their ass.

In a well lit ambulance, I’m writing vitals on my hand - blood pressures, pulses and respiratory rates. The young girl has a tender abdomen, right upper quadrant especially- probably hemorrhaging from her liver, with no other serious injuries. Her blood pressure is OK but the 120 pulse tells the story of a young heart compensating valiantly for blood loss. The heart of a young person has the nasty habit of compensating for blood loss right up until the time they crash and become unsalvageable. My anxiety level rises as I look for good veins on the girl’s arms. Am I going to be alright? she asks. Her anger has turned to fear. I hope she is not reading the tension on my face.

I answer with some stock phrase as I run my fingers over the veins I can see on her left arm. The feel of the vein is as important as what I can see. I have a reputation for getting difficult IVs; but that’s all in the past. I wish just this IV was as easy to establish as they are in the movies or on TV. The ambulance attendant is fumbling trying to get the IV tubing into the IV bag. There are no firemen available so I just have to hope the attendant figures it out.

Finally I feel a marginal vein in her forearm. I tear short lengths of tape to secure the cannula and line once the IV is established. The ambulance attendant finally has the bag of Normal Saline ready to flow. Now hands that have been doing heavy work must thread a cannula into a vein. I slap the area over the vein to bring it up, then wipe it with an alcohol swab. You’re going to feel a little stick in your arm. It’s very important that you don’t move.

She’s looking at the inch and a quarter long needle with apprehension. Do you have to put a needle in me?

The needle is just to get into the vein. There’s a plastic catheter over it that I slide into the vein, then the needle comes out. This is to give you fluid in case you’re bleeding anywhere.

She relaxes a little bit. I know that I need to put in another, even larger diameter needle in her other arm; but that comes later. The outside world shrinks to the tip of the needle pointed towards the vein. I pierce the skin and keep pushing till I feel the resistance of the vein and then the release of resistance, a sensory pop. Blood appears in the flash chamber at the end of the needle I am holding. It’s the one time in a paramedic’s life when the sight of blood is always welcome. I thread the needle and cannula about half an inch, feeling for even the slightest impedance that might indicate the needle is against the wall of the vein. If I pierce the thin vein, other than at the entry, the IV is blown. The needle floats in to the halfway point, sufficient for me to slide the cannula over the needle into the vein to the hub of the cannula. I quickly insert the line from the IV bag, tape the cannula down and turn the little wheel that lets the IV fluid flow. The attendant and I watch the drip chamber on the tubing more intently than stock traders watch the display at the New York stock exchange. It’s a regular, steady drip. I don’t care how many IV’s I’ve started, that steady drip that indicates the IV is flowing is like lift off at Cape Kennedy.

Good stick, the ambulance attendant whispers. I know it and now I even have two seconds to think about how good I am. Start another bag for me after you get her changed over to 12 liters by mask. I want her oxygen increased.

Norm appears at the back of the ambulance looking worried. The driver is going downhill on me. Let’s just roll.

Have you contacted yet?

No. Give me what you got. I’ll contact en route. One of the fireman from 73's will drive he squad.

I give Norm the chief complaint of each of my two patients along with their vital signs. Normally, each patient has an MICU form filled out at scene. In cases like this, Norm has just enough on one sheet to let the hospital know what they’re getting so they can have the equipment and specialists they will need. There is a lot of debate about how long you spend in the field and what you should do before beginning transport. The main extreme opinion comes from doctors who have never set foot out of a hospital. They are the scoop and run crowd and their opinion is based on the dogmatic belief that every scene is five minutes from the hospital. They are capable of completely ignoring the monkey fuck that occurs in an emergency room when poorly assessed patients arrive. They also don’t notice when a potentially salvageable patient arrives at their doors unsalvageable. One ER doc who really understood prehospital care summarized the situation by saying, Too many ER docs don’t understand that you can’t make chicken soup out of chicken shit.

Norm and I know there is a lot more we could do before we start toward the hospital; but we are on the same page on this decision- we know that without having to discuss it. You have to know when to let go. The second guessers will be there no matter what you decide so we’re always ready to defend our decisions.

A sheriff’s unit leads off, followed by Engine 73, then Norm and I in the two ambulances. Our squad will come later after the firemen from Engine 6 have put all the equipment back. I look out the rear window of the ambulance as we pull out: the mess is noticeable for the first time but the scene has an emotional hollowness to it now as it shrinks into the distance. On the street or in an emergency room, medicine is a messy business.

The noise of the deep grinding sirens and air horns is unsettling but impressive. Drivers who don’t pull over at the sight of the sheriff’s car will move over from the primal instincts to get out of the way of about twenty tons of fire engine rumbling along behind it.

So much for noticing human behavior. I’ve got to try to start another IV on my female patient. Starting an IV in a moving ambulance on a patient with poor veins is a mixture of belief in yourself and a gnawing fear which I don’t discuss with anyone. The fear comes from an unhealthy crossing the line in identifying with my patients. I’m not just worrying that the patient will die: I’m fighting for my own life in some strange way. It’s as if you got an unknown number of lives and different patients lay claim to a different amount of them. If they die, they take that many of your lives with them until you run out. It sounds too crazy to tell anyone about: I’m not even sure I understand it, but the feeling is unmistakable and it’s a real killer.

CHAPTER 2

EN ROUTE

Time to check the guy who can’t feel his legs. No change. Without much conviction he says he’s doin alright. His name is Burt. I have the attendant get a set of vitals on him. All my senses are telling me that the girl is losing blood into those vast spaces of the body where it cannot perfuse the vital organs or help maintain blood pressure. I need to put in a second larger IV but don’t want to use the big vein higher up in her left arm. Best to save that vein for the last of the ninth inning and I’m hoping we’re only in the bottom of the seventh.

I lean over her to look for a vein in her right arm which is on the other side of the gurney. Trying not to fall on her as the ambulance swerves through traffic, I put a tourniquet on her arm.

What about there? the ambulance attendant points to a vein.

I take a second look after slapping it to bring it up. I want a bigger IV, a 16 gauge. That vein may not take it. Seeing the dejected look on his face, I add I may come back to it if I can’t find anything better. That’s a pretty good one. His body language shifts from dejected to back-on-the-team. The ambulance attendants are trained at the same level as our non-paramedic fireman but usually don’t have the experience. They are young dedicated kids paid very little by the private companies that exploit them. They don’t need us rubbing in the insane pecking order.

With nothing showing on her arm, I risk having the attendant unhook the gurney from the side of the ambulance. We move it out from the wall enough for me to get between the patient and the wall with her arm now below her body. Hold on to the gurney, I implore as I start searching her arm again. The attendant, a fairly husky fellow, gets out of his seat, kneels on the floor and stabilizes the gurney with all his might. I’m glad he’s still on my team.

My focus must again shrink to a tiny section of my patient’s arm. In a weak protest, she asks, Do you have to stick me again? The feeble nature of her complaint could be the adrenalin wearing off or it could be from blood loss. I call her name this time. Ann. I’m afraid you may have internal injuries. We need to get as much fluid into you as we can.

My stomach and back really hurt. I want to curl back up?

We have to keep you in this position in case your spine is injured. I am willing to bet her pain is caused by blood and lots of it irritating the peritoneal area.

Then she asks the question that always causes me to lie in these cases- Am I going to be alright? I’ve tried to develop a standard answer but I can never remember it at these times. The answer I find myself saying is, You think I’d be working this hard if you weren’t going to be alright? I just want you to remember to tell everyone when you get home what a great paramedic you had.

I wish I was home now, she says in a way that lays claim to another one of my indeterminate number of lives.

I feel a good vein. I can’t see it too well so I run my ring finger along it to try to determine its course. It seems firm and goes straight for about a half inch. That’s all I need. I unsheathe the 16 gauge IV needle but get tossed against the gurney by the ambulance’s slight swerve. Tell your partner to slow down for about ten seconds.

The kid nods in almost military fashion and yells up to the driver, Hey Ron, slow down for ten seconds. He’s gonna start another IV.

Damn straight, I say to myself. The ambulance slows and I make the thrust for the vein at a little less than a 45 degree angle. I feel the pop, see the flash of blood, level off and start to thread the IV into the vein when the ambulance hits a pot hole in the street and we bounce. My hand moves in unison with her arm using a trick Norm taught me so I don’t loose the IV. I thread the needle and cannula a little further then slide the cannula in. Once the line is plugged into the cannula and taped down, I notice I haven’t taken a breath in about thirty seconds. The ambulance picks up speed and I start breathing again. Another blood pressure reading shows her pressure has dropped 10 mm- time to run both IV’s wide open.

I’d like to rest for a minute but we attach the gurney back against the wall and go for a set of vitals on the other patient He is beginning to show signs of shock. I wonder if I’ve missed some other injury or if this is spinal shock taking place slowly. I can remember the course of high spinal shock but I can’t remember what I learned about lower spinal shock. I start assessing the guy again, angry at my brain fade. The victory with the IV in a moving ambulance is short lived.

My attention shifts to maintaining my balance through a series of sharp turns that signal we’re coming into the emergency room garage. I could never figure out whether the relief I feel is from arriving at the hospital or the cessation of the anxiety provoking sirens trying to hammer their way through traffic- Maybe both.

I feel more relief when I see Dr. Metzger waiting in the garage with two ER technicians and a gurney. He always represents calm wisdom in the storm. Between Norm’s radio report to the hospital and Ed Barnsdale’s warning that the four worst patients were still at scene being extricated, the ER is fully mobilized.

I hop out of the ambulance so I can brief Dr. Metzger without Ann’s hearing me. Solly baby, what have you brought us? I know Metzger’s humor is to disguise that he also crosses the line with his patients. It also hides a master at the chess game that is emergency medicine.

I think the girl has a hot abdomen, possibly lacerated liver. Her blood pressure is falling and she has a pulse of 120 with delayed capillary refill. The guy seems to be going into shock but more slowly. Maybe lower spinal shock; maybe I just missed something. He’s starting to look shocky

Lower spinal shock is a good guess. Where’d you pick up that diagnosis?

I was either a doctor or a spinal chord in a previous life.

Ann is out of the ambulance now and under the all seeing eye of Dr. Metzger as we roll swiftly into the ER. The team with the gurney is unloading Burt, my male patient. Another gurney team passes us at a dead run headed out for one of Norm’s patients. We pass by curtained cubicles of sick patients and into one of two major trauma rooms. Fully gloved and gowned doctors and nurses watch our arrival with the tension of cats waiting to pounce. The room is packed now but everyone knows to keep quiet as they prepare to move the patient onto the hospital gurney. Metzger will not put up with the bullshit you see on television- the noise of panic. The noises of an E.R. out of control- we call it a monkey fuck.

He goes up to Ann’s head and speaks to her while he checks her pupils and head. "I’m Dr. Metzger and your name is?

Ann. Ann Covello.

Do you know where you are?

In a hospital emergency room.

That’s great Ann. You know more than some of the people who work here. There is a muted laughter including mine. I feel myself relax a little- the Metzger magic.

We’re going to be doing a lot of things for you so we can find out where you are hurt. If you have any questions, just ask. We may even know the answer. Even Ann laughs this time.

Metzger’s kind but penetrating eyes examine her further, stopping at the abdomen to palpate with hands that are as sensitive as any high tech equipment. The trauma surgeon moves beside him and for thirty seconds they speak a language that I can barely understand. Metzger concludes, I don’t see any point in wasting time on an abdominal tap. The surgeon agrees.

The staff has cut and removed all of Ann’s clothing and stands poised as Metzger rattles off a series of orders and the entire staff reacts as if by reflex. Metzger looks at me and says, Well boychick, over thirty years of medical experience has come to the same conclusion as one paramedic.

Metzger just made this and a lot of the