Smooth Cluster

The nature of this business is, essentially, bringing order to chaos. It doesn't always go smoothly, but I love it when everything falls into place, all the jobs get done, and the team works together.

We responded to a report of a 25 year old male unconscious. No other information. Well, this could be anything. It turned out to be a combination of things. When we arrived on scene, we found our patient passed out in the driveway just outside the front door of the house. There were a couple of steps up to the door and at the top of the steps sat an empty wheelchair. According to the other people on scene, they were bringing him into the house in the wheelchair and he fell out face first on to the cement. They had rolled him over to his back which is how we found him. He didn't have any obvious trauma or bleeding of any kind although he was incontinent to urine (maybe more). I don't know how hard he hit the ground but he was out, out, out. I directed the firefighter to take manual c-spine and asked about the patients medical history and if he was perhaps diabetic. He was. I checked his sugar and it came back at 57. Now, this is low and low enough to be treated with IV glucose, but not so low that he should be this unconscious. So what was the real cause here? Did he fall out because he was hypoglycemic or did the fall knock him out and he also happens to be a little low on blood sugar? Chicken/egg, egg/chicken.

Well, the low blood sugar I can fix so we started there. Unbeknownst to me, while I was getting the blood sugar, my captain (also a medic but usually working the clipboard and not the patient) had begun setting up for the IV. I gave the firefighter the IV bag to spike and flood. He had to hold c-spine with his knees while he flooded the bag but the patient was so deeply unconscious he wasn't moving anyway. I started looking for IV access on the other arm just in case the captain didn't get it but since he had a headstart he got the IV (his first in about a year I think) before me. I got the glucose ready while the captain secured the IV and, warning the firefighter to be ready on the c-spine for when this guy woke up, pushed the sugar in. The ambulance crew arrived at this time and began setting up for full spinal precautions (rigid neck collar, long backboard, pads and tape for his head, and straps to hold him to the board).

The patient started to come around with the sugar on board and could now talk to us. I'm still not convinced this was purely a sugar problem alone since 57 really isn't that low, but it got our patient back to alert and oriented before he went off to the hospital.

There wasn't really any major chaos or anxiety, but I appreciated how all the jobs got done, and done well, with a minimum of verbal communication. Everybody knew what needed to be done and did what the other person wasn't doing. We had a bit of a confusing mystery, more or less solved and a patient who was deeply unconscious in the driveway talking and answering questions by the time the ambulance arrived. The firefighter was multi-tasking, the captain was using his rusty medic skills, and all the right care was being given. When scenes run smooth and the outcome is good it just make you appreciate professionals.

Decompression

This is not an easy job, for all the reasons I'm sure you've heard or can imagine and then some. I can't imagine doing it without the support of my family. From the time and effort put into training and traveling to take every test I could afford to reach to the heartache of constant rejection and struggling to achieve something I knew I wanted so much. But, having achieved my goal of joining the fire service, now more than anything it is having a place to go when things go bad on the job that, I believe, can make or break a fireman.

I responded to a call for a female, I'll say girl because that's the way I remember it although I can't recall her age, experiencing a miscarriage. I was on a crew with another medic but I was the lead medic on this call so I was the patient person. When we arrived we were led to the bedroom where the girl sat on a mattress on the floor bleeding. It was dark in the room and as I moved to examine her I could already see the umbilical cord. Worse, I could see something at the other end of the cord. This girl was only 18 weeks pregnant and with a baby that young there is nothing at all we can do. There would not be any attempt made at resuscitation. It was too late for that anyway. I used my pen light to examine the baby and found it to be surprisingly well formed and more identifiable than I would've expected. It didn't seem like a fetus, though that's what it was. It seemed like a miniature baby. I remember not knowing what to say and that it was so quiet in the room. Everyone just knew and accepted it. Not accepted it in the sense that they were okay with it but in the sense that they knew it was a time to mourn and be respectful.

The girl still had to be transported to the hospital as the placenta had not delivered and she needed further care. I asked the firefighter to get me an emesis basin from the rig while I wrapped the baby in gauze. When he returned I placed the baby in the basin, a beige square bucket about 10" by 10". This seemed so wrong to me, but it was really the best and only way to do what needed to be done. i tried to pad the basin and make it more like a bed than a receptacle but it still didn't feel right. The girl's bleeding had stopped and it was really just a matter of getting them to the hospital and consoling her now, though there was really nothing to say. The ambulance arrived and they all left silently.

When we returned to the station the captain asked us if we were okay and if we needed anything, like a stress debriefing. We both declined and said we were alright. I thought I was alright at the time too, sad but okay. This certainly is a part of my job. But it was a call and an image I couldn't shake. I couldn't help but think about it over and over again for the rest of the shift.

By the time I left work, I was just down. It was a weekend day when I drove home so everyone was home when I got there, my wife and all the kids. I didn't say anything and went about my normal routine when I got home. I was definitely affected and although I didn't realize it, I was projecting. My wife didn't get exactly what was going on but she could sense it. In fact, she started to get upset with me, saying, "God, you just got home and you're just thoroughly depressing." This is where it was vitally important to be honest and communicate. I could've gotten upset right back or ignored it but I didn't want to. I told her I had a really bad call last night and I couldn't shake it. I told her what had happened and she asked me what I wanted to do. I told her I just wanted to go out and have a day with the kids. We all loaded up in the van and went out to a park near the lake, had a picnic, played on the swings, and walked around the lake.

It was perfect. It literally made all the difference. I relaxed, I let it go, I enjoyed my family and my life. I believe that kind of outlet is essential to anyone in this type of work. Any type of work really. I don't know where I would be without it.

I will still never forget that call or that image, but it has softened considerably. I struggled to remember the details of the call as I wrote this; did I cut the cord?, what did the girl look like?, did she say anything? I don't remember. Those moments are awful. Those moments are heartbreaking. But, I'm glad to be the one to help those going through it. And I'm thankful for those in my life who help me move past it, re-energize, and go back each day to face it again.

Hey, look! A train.

A friend and co-worker recently blogged about a fire he had near the railroad tracks which reminded me of a call I had early in my career which taught me a valuable lesson.

In the back of the district I was working in then there is a business park. Behind the business park is a small sound wall separating it from the railroad tracks. Behind the tracks is an empty field that runs right up to a freeway overpass. This field and the space under the overpass is routinely used as a homeless encampment and subsequently catches fire just about once a year.

We responded to a report of smoke in the area of the business park. We drove to the back of the buildings along the sound wall. This district and the overpass happen to border the city limits so we had an engine from the neighboring city responding as well. They were a few minutes behind us.

From over the sound wall we could see that there was a tree on fire across the tracks and that the field was starting to take off as well.

With our not so great position and lack of a convenient water supply and the real potential for the fire to spread quickly, my captain decided that we should use our deck gun and quickly knock down whatever we could hit. The deck gun is a large, turret mounted, fog nozzle up on the top of the rig. It is capable of putting out 1000-1200 gallons per minute. The water tank on the engine holds 500 gallons and without a water supply that meant we had less than 30 seconds to accomplish our goal before we had to shut down or risk cavitating the pump on the engine. We had a pretty good angle of attack over the sound wall and decided to douse the tree and whatever grass we could hit.

As we began to put water on the fire, the engine from the other city arrived. We knocked down a good chunk of the fire on the tree but not a lot of the spreading grass fire. Our water ran out and the field was still burning, so this other engine crew pulled a line off their rig, climbed over the sound wall, crossed the railroad tracks and began putting out the fire. In their minds, I'm sure it was a cool, cowboy move and they would be able to brag about how they put out our fire.
\We, on the other hand, were thinking like the one smart kid from Stand By Me who said, "Anybody know when the next train is due?"

As if on cue, we heard the horn in the distance.

"Trraaaaaaaainnnnnn!"

The other crew had about 100 feet of hose stretched across the tracks, fully charged. Which meant they couldn't just disconnect it because the pressure was too great. We shouted to the engineer to shut down and to the hose crew to 'bleed the line' (that is open the bale and let the water flow to help drain the hose) and, of course, to drop the hose immediately. We then joined the engineer in frantically pulling the line hand over hand back over the tracks and the sound wall. It was like a game of tug of war where the loser, instead of falling in the mud, gets hit by a train. In hindsight, it was quite comical. Even in the moment it was funny but we were a little too busy racing the train to laugh just yet.

We literally pulled the end of the line over the soundwall about 100 feet in front of the passing train. So, the valuable lessons learned were:

#1 - Don't ever stretch lines over train tracks.

#2 - Cowboys are stupid.

We work on the tracks plenty, but we never stretch lines across an active railroad track. If we are going to work on an active line, we radio whichever railroad runs on it and have them shut it down. We then confirm it is shut down before we go to work on it.

One of the things I did find funny about that incident was the fact that in most Fire Department Entry Level Physical Agility Tests there is an evolution in which you pull a hose 100 or so feet and then hand over hand pull all the hose over the finish line as fast as you can. I guess I now know why that's in the test.

Breaking and Entering

There are a lot of times and a lot of reasons why we in the fire service might have to force entry into a building, vehicle, or what-have-you. We have a variety of tools to accomplish this, from simply kicking down a door, to using the 'irons' or haligan/axe combo, taking a circular saw to a roll up door, or using specialized auto tools to get into a locked car without damaging it.

For the most part we try to do as little damage as possible unless it is an absolute emergency. My favorite trick for avoiding damage was one my captain pulled out of his mental toolbox a little while back.

We were called to a house where the resident had locked herself out with her child still inside. Normally, we try to get in through a window or other entry point before we start destroying things, but there was no way into this place. We knew we were going to have to force the front door. This of course is usually quite destructive and costly no matter how well you do it. However, my captain figured out a great way to get in with the most minimal amount of damage. We took our reciprocating saw with a metal cutting blade and simply cut off the doorknob. This way we only had to use pliers to turn the inner mechanism and open the door (house thieves, please disregard the preceeding instructions).

The homeowner now only had to replace and re-key her doorknob instead of replacing an entire front door. It worked great.


The golden rule in all forcible entry, though, is 'Try Before You Pry'. That is, always try to open a door or find another way in before you resort to forcing anything.

Sometimes you need to try twice.

For example, I worked with a different captain and we responded to a report of an unknown medical. When we arrived on scene the captain went to the front door and tried it, only to find that it was locked. He radioed dispatch to see if they could call back the RP (reporting party) to let them know we were there and to let us in. The ambulance pulled up and I went around to the back of the house to look for another way in. I found that the sliding glass door to the backyard was unlocked. I went and got my captain and he followed me around to the back and we entered in through the slider. We moved through the kitchen to the living room where we ran into our firefighter and the ambulance crew. My surprised captain asked how they got in, to which they responded, "The door was unlocked".
So, maybe we need to revise our rule to Try Before You Pry And Then Try Again. Or, to quote my abashed and colorful captain, "Open the door with your man-hand like the firefighter did and not with your pussy-hand like the captain."

Of course, it turns out that our potential patient had decided to just drive himself on to the hospital. I guess he didn't want to wait the full 3-4 minutes it took us to get there. He was very fortunate that the sliding door was unlocked or he would have come home to a lot of damage and no one to blame but himself. If you call 9-1-1 and then leave, do us all a favor and call back to inform the dispatchers. It could save us all a whole lot of trouble.