Kevin

It’s wild what you do and do not remember after a trauma or resuscitation.  There are a few that I can’t recall whatsoever, which is a little strange in some respects.  For whatever reason they didn’t impress themselves upon my mind and make me feel as though they were a part of me.  They were “normal.”  The first time I ever did compressions on a real person was memorable for just that it was the first, and perhaps that the injuries we later found are explained with no real ease and left the impression that it was intentional.  He was 3 months old, and I remember how tired and painful my thumbs were.  On small children you do compressions by wrapping your hands around the child’s chest and compressing with your thumbs rather than your palm.

We worked him for nearly 40 minutes, with his little heart wanting to jump start several times after each dose of epi.  But each time it would wind down and we’d have to start again.  While intubating, our attending doc could feel crepitus at the base of the skull – the feeling of bone on bone, indicating a severe fracture.  Basilar skull fractures are rare (~4% of all skull fractures), and even more so in infants.  Strangely, he had no outward signs of significant internal injury.

CT revealed that he did indeed have multiple skull fractures – roughly 7-8 that I can recall.  Foul play?  Most likely.  At this point his heart rate (HR) was around 150-160, a little below what we’d expect and desire with the epi dosing he’d taken.  The attending’s order was to notify PICU that if he coded again on the way up – it’s a long walk from the ED to the PICU, and an elevator up 6 floors – we would call it and turn back to the ED.  Not 30 seconds later his pulse began to drop, toned dispassionately by the Zoll one beat at a time.

I don’t remember his name, though I do remember that mom and dad (who had been watching the kid before work while mom was gone) – when told they could come be with the body but couldn’t touch it, as it’s now a Medical Examiner case – walked by the room and went outside to smoke a cigarette.  Rumor was that mom was already suspecting dad as the abuser; imagine dealing with that one.  People handle trauma in very strange and unexpected ways, sometimes.

My next round of compressions was a trauma, and I remember nearly every detail of that one.  Four year old boy, struck by a pickup at roughly 40mph.  Frankly, he was likely dead before he ever hit the ground.  The truck then ran over him twice before it could stop.  This was witnessed by his entire immediate family, including several brothers and sisters and his parents.  Normally, if he were an adult, he would probably have been pronounced dead on scene.  The community, however, would probably (rightly) frown on its firefighters arriving in million dollar trucks and just throwing a sheet over a bloody kid.  So to us he came.

It was late January and a beautiful day, probably around 4-5pm.  I recall precisely the month because I had just gotten my glasses, which would play some part in this later.  We were waiting bedside when they arrived, and my first recollection is that the firefighter was doing terrible compressions.  For peds, the prescription is between 100-120 beats per minute (a good bit faster than the layperson may realize), and 1.5-2″ or 1/3AP (anterior-posterior depth).  He was getting maybe 70bpm at 1″ (if that), and with one hand.  Now, I understand what he was seeing on scene and on the ride to us, but the parents are with you and, though they will likely remember very little from that day, at least look like you give a shit.  Pretend, until you get to us.  Nothing will stoke my ire like EMS coming in half-ass – whatever chance a kid had is now likely gone if you’ve done improper compressions for the better part of half an hour.  Just do it right or don’t do it.

But like I said, I understand his thinking: he was gone the moment he stepped in the street.  Now I’m standing over the top of him, my face just a couple feet from his, my hands square over his sternum and my eyes locking on the Zoll to establish proper rate and depth.  The Zoll will show both, and even speak to you; very helpful in a room full of chaos.  Just lock on and keep up.  Once I found it, I began to look around to see what else could be done.  There is usually one Looky Lou tech standing near the door, and while it’s technically forbade, he or she can be helpful to grab if you need something done right then.  Maybe a cup of ice for the lactic blood labs.  Or point-of-care (POC) testing (HemoCue and glucose) that can be done in the room without going to lab.

So I’m on target and looking around.  Dad is with the social worker at the door, probably 20 feet away from the bed.  As a “rule,” we don’t allow parents in the room during workups.  The caveat is if they insist.  I cannot imagine what it must feel like to watch your lifeless child bleed out in a room full of strangers in what appears to be disorganized chaos.  But there dad is, his shirt covered in his son’s blood.  And I have a view, on my pedestal, of the entire room.  It’s hotter than Hell (nearly quite literally; the room is heated to mid-80s since bodies experiencing trauma are less able to maintain homeostasis), we’re all wearing lead gowns to protect from radiation exposure, beneath our PPE gowns and gloves.  Then my glasses begin to slide.  I’m covered in blood from my elbows down, since our kid, now intubated, is expelling blood as quick as we can transfuse it, from his nose and right ear with each squeeze of the ambu bag.  His left ear is nearly detached, and there is a 60cm x 30cm gash out of his right forearm, down to the muscle sheath.  We get a nasogastric tube in, and the return is feces.  At this point it’s nearing flat-out disgusting.  And my glasses are sliding down my nose.  All I can envision is them falling onto his blood-covered body, and likely onto the floor where they would be destroyed, never mind becoming an absolute bio-hazard.  I look around; who can help me?  Everyone bedside is covered is as much blood as I am, and I don’t want to make a scene about such a small thing.  But it’s getting critical.  Across the room is another attending doc, and we make eye contact.  Bingo.  She laughs to herself and obliges, saving a small tragedy from accompanying the major one before us.

And the show continues.  I see dad, near the door, crying and covering his eyes, but looking up every few seconds, hoping against hope that something can be done.  But I can tell by his tears and his expression that he knows what we all know, already.  His handsome little boy is gone.

The sight gets even worse, with blood now cascading off the bed and pooling on the floor.  He is bleeding so profusely and violently from his head that we cover his face with a blanket, just to protect us from the spatter.  I was ready to quit.  Enough is enough.  By now his testicles are blowing up, nearly the size of a softball which, in case you aren’t familiar with 4yo boys, isn’t normal.  It means the air we are putting into his lungs is making its way to his testicles and beyond – his thoracic cavity is trashed, his vital organs have no integrity.  The trauma doc immediately performs somewhat sloppy but clinically effective bilateral chest tube placements to evacuate the air and restore “normal” internal spacing.  But at this point it’s all gone, and I just want to stop compressions.  The trauma doc holds out, and it’s getting worse.  Thankfully, a distinguished-looking older physician whom I had never seen before was standing next to our trauma doc, and professionally and tactfully but assertively tells him he needs to call this and stop it.  Now.  Trauma doc thinks for a few moments, and is admonished again.  I’m watching, silently begging him to listen.  One more: “You need to stop.”  He’s the PICU doc, he’s salty and knows when to quit.  Trauma finally relents, and my hands are off the chest before he finishes his sentence.

“Time of death is….”

We clean up, both the room and the body as much as possible. The injunctions we put in the body – IVs, airway, NG tube, chest tubes – have to stay in for the ME, but we can make him a little more presentable for the family, and mayyybe skirt the rules a little.  For instance, the rules say that you can’t take a locket of hair from the deceased, for the family, but…what ME don’t know won’t hurt.  The families don’t remember a lot of what we do; they’ll never know about the technical aspects, never appreciate our sweat and the battle we fought.  But they’ll remember the small things forever, and those are worth it all.  His mother, I found out as I walked by, was just down the hall in the family room with her other kids during the whole ordeal.  She was covered with more blood than dad.

Her son’s name was Kevin.

C|P

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“I Would Cook Tomorrow’s Breakfast On Its Coals”

The question to which, was, “If your past were on fire, would you go back and save it?” I ran across it, posed generally, on a friend’s feed and instantly gave my honest answer.

It demands reflection.  There are many parts of my past which I regret to some degree or another – I am, after all, in many ways human.  And as we’ve passed the midway point for 2017, I find my greatest individual regrets stacking up at the door, insisting each that I give to it thorough inspection and attention before moving on to its repair.  It can be at times overwhelming both physically and emotionally, and the toll is obvious as I sit here putting it all to paper, as it were.  As it is, I have several notebooks full of real ink and paper, all attesting to in some greater or lesser degree the experiences which have brought me here.

Naturally, my sentient readers will ask, “But, CP, what exactly has all happened, and how are you recovering?”  Which, it’s a long walk to a little house, friend, and we don’t have that kind of time right now.

Suffice it to say, I would cook tomorrow’s breakfast on its coals.

C|P

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That’s Just The Way It Goes: A Primer

I haven’t sprung fighter jets from nuclear-powered ships off Minorca, but over a couple of years working in clinical medicine I’ve collected stories and thoughts that have stuck with me, and I am reminded of them from time-to-time in different, often subtle ways.  Some stories, undoubtedly, should be left where they are, and shoved into my brain’s trashcan.  They are often graphic, often sad, sometimes funny.  But they are true.

It is normal in large hospitals (I cannot speak to small ones, I’ve never worked in one and try to avoid visiting any type when and where possible) to have ED Technicians. No, no…they aren’t there to cure the occasional case of erectile dysfunction, the emergency it is; they are Emergency Department Technicians, and in my hospital they were always an EMT or Paramedic who has chosen to work in a clinical setting rather than in the more traditional field role, on an ambulance.  On the inside, what the common public refers to as the ER, we call the ED where there are many rooms and if you showed up and said you’re looking for the emergency room, we’d ask which of our 70+ rooms you were needing, exactly.  Which we’re really busy, so speak up…

Still, that was me.  The ED Tech.  An ED Tech.  There were a bunch of us, and we were denoted by our royal blue scrubs.  Many of us were transitioning to higher roles in medicine: some to the fire service, some to med school, many to nursing.  I began as the former, though my path has changed and now finds me away from it completely.  Still, it’s nice to know your correspondent, izzinit?

Our job was to be the Jack of all trades: to provide ancillary critical care and all the rest, from holding down patients during procedures (children don’t generally take well to IV needles and sutures and wound debridement, etc., and we’re trained to hold them down without hurting them or exposing them to more harm from the very procedures intended to help them) to blood draws for labs, point-of-care tests (pregnancy hCG, rapid strep, hemoccult, etc.), orthopedics (mostly splints as casting in the ED shortly after an acute injury won’t properly allow for swelling and has a higher risk of compartment syndrome), and chest compressions and other support during traumas and resuscitations (what we would refer to as a Trauma or Code, respectively).  There’s a lot of other crap we do as well, but this is just a general overview.

Each Level 1 trauma center (Level 1 being the highest designation, meaning it is staffed at all times by a team capable of providing services to all traumatic injuries or life-threatening events) has a dedicated team for every shift.  The tech (in our department called the “D” tech, for his position during a trauma/code; “A” being the Trauma Nurse Lead, “B” the chart nurse, etc.) generally has one of two roles: to get the Zoll defibrillator pads onto the patient after he or she is moved from the gurney to the bed and then trade off providing chest compressions, or to help the TNL with IVs (“lines”) and labs.  From there a tech will be the one to push the bed to the next destination, often CT, and help with moving the patient.  Again, jack of all trades.  Do what is asked, and try to anticipate what your nurses and other staff will need.  If you don’t know what you’re being asked for, speak up and/or find someone who does.  Often, though, Techs are a go-to source for finding items.  Me?  I’m good at delegating, which in a pinch can make up for not being a subject-matter expert.  Don’t know?  Find someone who does.

Most of the day-to-day is mundane and largely thankless, and the 12 hours of a shift can swing from one end of the crazy-fun spectrum to the other in an instant, and then back again.  Each day is different, most days kinda suck, but they are littered with brief moments of sheer adrenaline and hope, often followed by a heartache that each person experiences differently.  I’ve seen nurses cry during events, or immediately after, and I’ve seen some get angry; I’ve felt absolutely sick by what we saw, and other times felt nothing at all.  Sometimes it takes hours, days, weeks, or even months to feel something about a particular case, and other times it never comes up again.

That’s just the way it goes.

C|P

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France: The Real Tragedy or, No Free Lunch

It’s been a long time coming now.  For more than a decade, France has pushed an immigration policy that left, first, massive rifts in its social structure, and now – with much of the Levant destabilized after another decade of war and another massive refugee push outward toward Europe – the largest of what may be a series of structured, targeted attacks across not only the nation, but the continent.

And so today, while I flip across Facebook and the wave of French flags “waving” in support of the people, I’m pressed – the optimist I am – to not be merely indifferent.  I’ve been forced to delineate between the nation that has allowed themselves this – indeed, invited it to the table – and not only the innocent people who lost their lives, but the families that lost theirs too.  Between a government and a culture at-large that has weakened their domestic policy to the point of being an open international policy.

Still, I choose hope and love, knowing all the while that it is no mask for poor strategy.

Que Dieu vous bénisse et vous garde.

C|P

Posted in 2nd Amendment, Diplomacy, Espionage & Intelligence, Foreign Policy, Gun Control, National Security, Public Policy, Sad, Things That Make Me Shake My Head | Leave a comment

Which Is To Be (Jobless) Master?

Good news this week from the U.S. Dept. of Labor: unemployment is down to 5.6%!

Good news, that is, unless you’re actually unemployed.

‘When I use a word,’ Humpty Dumpty said, in a rather scornful tone,’ it means just what I choose it to mean, neither more nor less.’

‘The question is,’ said Alice, ‘whether you can make words mean so many different things.’

‘The question is,’ said Humpty Dumpty, ‘which is to be master – that’s all.’

C|P

Posted in (Un)Employment, (Un)Facts, Domestic Policy, Public Policy, Things That Make Me Shake My Head | Leave a comment

Formula One Legends: Jim Clark

There were few things I craved more as a child than speed, competition, and a sense of ever-present danger.  Incidentally, none of those desires have devolved much in the time since, having found but different avenues of exploration.

Bike crashes were the norm growing up, as were visits to the ER; so frequent were the visits that at one point my parents were questioned by Child Services under suspicion of abuse.  I’ve had stitches (thrice – narrowly avoiding a fourth time by having my eyebrow pieced together with super glue), my jaw wired shut after being crushed by a tractor, my gums split open twice and teeth knocked loose once, and two titanium plates and twelve screws in my right forearm.  I’m also pretty sure I now have a tear in my left knee. C’est la vie.

Just the same – thanks in part to the aforementioned desires and largely to a favorite daily-reader, Silodrome – Formula One has recently captured my attention.  It is fraught with what I love – speed, cars, innovation, danger, great style and championship – and has a history that is purely fascinating.

One of the greatest F1 drivers of all time comes from an early period of the sport, beginning his career in the decade following the War.  Jim Clark was in many regards different than other drivers.  His path to the sport was unconventional, his spirit indomitable, and he was considered by friend and foe alike, while fierce, a gentleman racer.

His involvement in a deadly crash early in his career provided an experience and guilt that would stick with Clark for the rest of his life.  Eventually, he was, like many great drivers of the era, killed in his prime, leaving behind an astounding legacy with 25 wins on 33 pole positions and 72 Grand Prix starts.

Feel free to have a look for yourself at Jim Clark: The Quiet Champion

(Thanks to BBC and Silodrome)

Posted in Auto Racing, Formula One, Grand Prix, Jim Clark, Legends, Private Interests, Silodrome, Video | Tagged , , , , , , | Leave a comment

Supercharged: Grand Prix Cars 1924-1939

This is a short film (50 minutes) highlighting the technological development of Grand Prix cars from 1924 to the beginning of the Second World War.  Any interest in motor sports will be livened by this.

Heads up: some accidents shown are graphic in nature, including possible fatalities.

(Hat-tip to Silodrome)

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