Red bagged pants

I was nervous. I actually felt nauseous driving to the call, dreading what I would see. I was headed to a self inflicted gun shot wound to the head. I knew I would be the only ALS provider on scene and the dispatcher reported that he could hear agonal respirations over the phone. It was raining hard and all I could think was to drive carefully and breathe.

When I arrived, the scene was crawling with people; cops, firefighters, neighbors investigating the commotion. I dropped my bags in the foyer and headed upstairs, deciding already to get the patient out as soon as possible. On the way in I passed whom I assumed was the patients mother. She was covered in his blood, and a police officer was with her. One more thing I could cross off my list of worries.

I was met with a rather horrific scene where the patient had sat in a chair and pulled the trigger with the gun to his temple. There was a large blood stain on the chair and a bullet hole was in the wall next to him. He had fallen on the gun, and a note simply addressed to a girls name was on the bed. Absentmindedly, I picked it up. It was strangely clean and white compared to the rest of the now red and disheveled room. It was folded over and neatly taped on the edge. I put it back on the bed. The first responders had already gotten him onto a backboard. “Does he have a pulse?” was my only question which was met with several mournful ‘yeses.’ “Okay, let’s just get him in the truck, there’s not much to be done in here.”

They began to carry him down the stairs as the mother shouted words of encouragement to her son. She reached out to him at a loss for what to do. It is with a heavy heart that I know I give hope where there should be none.

I went ahead and into the ambulance to set up. I pulled out my intubation kit, IV kit, turned on the suction and got my community hospital medical control doc on the phone. They were loading the patient in as he picked up. From here, I had probably the most useless conversation with a doctor ever.

Despite brain matter herniating out of the gun induced hole in the head, our patient was still breathing on his own and had a pulse. This alone was amazing, but more vexing was that he also had a gag reflex. This meant that I couldn’t secure his airway without some drugs to calm and hopefully suppress this reflex.
When I called the doc I had nothing but a compromised airway. I needed orders.
I quickly explained my situation and was interrupted a few times by the patient giving a rattling horrid sounding breath; the brains’ last efforts to keep the body alive. The doc was slow to answer me.
Firstly he asked me if I could fly this patient to the trauma center. “No. It's raining.” This was apparently not obvious from where he was.
Then he gave me orders for ativan, which would have been fine, except that we don’t carry it.
“I don't have ativan. I have versed or valium. Which can I use?”
He asked me the patients blood pressure. Basically I didn’t know and I didn’t care. His airway needed more attention. My exceptional adopted partners at the time were giving it their best efforts to get one. I reached for the patients wrist, “I have weak radials, so at least 80.” About here the patient took another long and conversation interrupting agonal breath that was gurgling and loud.
There was dead silence on the other end of the phone. “Are you still there?!” I asked desperately.
He asked me how far I was from the trauma center.
“An hour probably.” My frustration was mounting, because I was learning I can only do so much while balancing a phone between my ear and my shoulder. “Please. I need orders.”
“Well, you know we can't really handle that, he will need a trauma center. You’re sure you can’t fly him?”
“Yes, I am sure. Everyone is grounded. I know he needs a trauma center, but I don’t think he’s going to make it that long.” I wasn’t even asking where to take him, but somehow it came up.
“Okay, well do what you have to in that case.”
“If I lose pulses, I'll be transporting to you.”
There was another long pause causing me again to ask if anyone was still listening as my patient breathed more blood into his airway.
“Okay, I still need orders for something, this airway sucks.”
“Yeah, okay, well if his blood pressure is over 110 give him versed, if it's under give him valium.”
“Great, valium it is. I’ve really got to hang up now.”

I threw the phone on the counter. I was giving orders of my own to my extremely helpful crew and started an IV. “Guys, I don’t want to come off as a bitch, but I need to do a lot of things right now, so please don’t take my ordering you around personally.” They were all totally cool and understood my stress level.
I gave him the valium, but it didn’t do it, and now I was worried about his pressure, so I nasally tubed him. It worked great, lovely, perfect. Breath sounds, Co2 and all that. Happy paramedic. From there I popped in another line, filled him with fluids and did some deep suctioning. That was all we could do. I packed trauma dressings onto his head, but they were all eventually soaked through. Like water on the deck of a ship, the blood leaked onto the floor and flowed into streams formed by the motion of the ambulance.

Nearly an hour later we pulled into the trauma center. Our patients’ pressure was terrible, his heart was beating fast and I frankly couldn’t believe he was still alive at all. I handed over to the trauma team, where I hear they waited for the family to arrive before terminating efforts.

I went in search of scrubs to wear home as I was sure my pants had blood on them. I got some from the ER and put my pants in a red biohazard bag and tied the top. It then took the three of us almost an hour to clean up the ambulance.

Its calls like these where I try to disassociate myself from the reality of the situation. I tell the story freely as with each retelling it seems the actual events are slowly archived into the annals of my life. Becoming more legend than true happenings.
This call was still with me when I went to bed that night. It was still there when I woke up the next morning.
As I drove home in my borrowed scrub pants, I couldn’t help but relive the call. I was proud of handling it on my own. Glad to have gotten the skills in, but the whole thing was still truly sad. There are so many people who want to live and yet are sentenced to death from cancer, heart failure, stroke or a myriad of other ailments that this patient didn't have. And yet he chose death over life. I will try, but I will never understand.