In the winter of 1991 I moved from a very progressive EMS system in a large city to a very small system that wasn’t quite up with the times, or so I thought. I’d been a Paramedic at my big city department for two years, and felt that I pretty much had things under control. A seasoned paramedic knows, or at least should know, that there is no such thing as control in emergency medicine. Assuming you are in control is an invitation to disaster. This is the story of one such disaster.

It was three in the morning. My partner and I were working a 24-hour shift, and things had been busy. We dragged our selves out of bed reluctantly and tried to shake the cobwebs out of our brains as we navigated to the call. I was working with Kevin. Partnerships are like marriages. Some are blissful, and some end in homicide. My relationship with Kevin wasn’t horrific, neither of us had tried to murder the other, but it was very strained with a possible future promise of homicide. I was the know-it-all big city medic and he was the old salt know-it-all little city EMT. This strain was manageable for the most part, but it meant our willingness to cooperate was limited. This proved to be something of a problem later.

My big city trauma experiences had been somewhat limited for a two reasons. First, in the city we responded with paid, advanced-life-support trained Firefighters, so around the time we arrived at the scene or shortly thereafter there were five or six paramedics and dozens of trained extrication experts available to treat the patients and free them from the wreckage. Second, in the big city good hospitals were scant minutes away. In rural America, sometimes help is a bit harder to come by.

The call was at a place called Gords Landing. Gords Landing is a small boat dock on a lake where locals put in for fishing or water-skiing. The dock lies at the end of a very long, very remote dirt road. As we bounced down the road I was, as always, going over in my head what I’d be doing when I arrived. I recalled simple pneumonics about assessment and treatment and worked through in my head what I was going to do and when. The problem was, as this was my first rural trauma call, I had several preconceived notions in my head based on lessons that no longer applied. I was Westmoreland about to step onto the beaches of Viet Nam.

The first thing that struck me when we pulled up was the damage the truck had suffered. It was an older pick-up. It sat half in the ditch, parallel to the road with radiator fluid and oil still dripping from what used to be the front end. It had hit an old oak tree nearly six feet off the ground, I saw, and it had come back to earth the loser of the confrontation. The right front of the truck had been smashed flush with the windshield. As I was absorbing all of this a man that looked like he was right out of Friday the 13^th came up and said he was concerned about his buddy. I was pretty concerned about him, mostly because he had a huge open wound on his forehead and he seemed to be covered with blood from head to toe, but he seemed to be breathing and conscious, so I decided I’d better go have a look at his buddy before I made my final decision as to who got treated when. His buddy, as it turned out was neither conscious nor breathing. A Fire-Rescue truck had arrived just before us, and an EMT was trying to attend to the patient through the shattered back window. The driver’s buddy had been sitting on the passenger side of the truck, where all the damage was. He was laying across the bench seat, still. "He just stopped breathing," said the EMT when he saw me. I yelled the news to Kevin, who indicated he was going to call a helicopter and set off toward the ambulance. I pushed my jump bag through the window and wriggled in after it. There was little room to work inside the truck, so I set my bag on my patient’s legs and got a good look at him. Sure enough he wasn’t breathing. I grabbed the Ambu-bag, quickly put the mask and the bag together and pressed it to his face. A careful squeeze of the bag pushed air into his lungs. Air was going in, but not terribly well. I had an airway problem, and problems don’t get much bigger than that. I needed to get a little plastic tube down this guy’s throat and into his trachea before what little air he was getting became inadequate.

When you learn how to put a tube in someone’s airway, or intubate them, in school, you’re in a nice air-conditioned room. The room has lots of light, an instructor stands over your shoulder, whispering encouragement and you have plenty of room to kneel above your patient’s head, lay out your tools and prepare yourself. I was in the cramped cab of a truck that had been crushed, it was dark, and I was essentially alone. My partner was nowhere to be seen and the firefighter who’d been there when I arrived had presumably gone off to figure out how to get us out of the truck. Just as I was trying to figure out how I was going to accomplish all of this by myself, a firefighter stuck his head in the back window. "Hey," he said "How do you want us to get him out of the truck?" I was dumbfounded. In my world he was supposed to have all that completely under control and two assistants were supposed to be handing me stuff I needed. "I don’t know" I said, "I don’t care how you do it, just do it….and quick." He nodded and went off. I looked for my partner; he was nowhere to be found. How the hell was I supposed to continue to breath for this guy, and set up all the things I needed to intubate this guy with just two hands? After a few minutes I managed to assemble the things I needed between breaths, and I tried to intubate him. It didn’t work. I began bagging him again.

To successfully intubate a person you pretty much have to be able to look down his or her throat, push the flap that keeps food from going down the wind pipe out of the way, and then guide the end of a foot long tube into a hole a third of an inch across. The tool you need to do this is called a laryngoscope. It’s basically a flashlight with a flat blade attached to the end to make an L-shape. The light bulb on this flashlight is at the end of the blade, so you can stick the bulb and the blade down someone’s throat, lift their tongue and epiglottis (the flap) out of the way, and see the vocal cords. Once you see them, the trick is to guide the end of your tube through the vocal cords and on to victory. When the tube is in place, you inflate a little balloon that surrounds the far end of the tube. This seals the airway so vomit or other things you don’t want floating around someone’s lungs stay out, and air moves in and out through the tube. The problem was that I couldn’t get where I could see down my young patient’s throat. After a half a dozen tries in as many positions I resolved my self to the fact that this just wasn’t going to happen. I placed a less sophisticated "oropharengeal airway", a short curved plastic tube designed to keep air moving past the tongue, into his mouth and continued breathing for him. His airway was adequate, and that would have to do for the time being. Thus resolved, I began assessing him further. Everywhere I looked or felt something was broken or bleeding. A gash on his head pored blood, an arm was broken, and both femurs or thigh bones were broken. This kid was in serious trouble. I looked out again to see what the firefighters were doing. What I saw was impressive. The truck was laying so that the driver’s side door rested on one side of the ditch. The passenger door was within easy reach, but has been hopelessly mangled in the accident. A professional extricator with a good set of hydraulic jaws could have opened it in a few minutes, but these guys didn’t have a $6000 set of jaws and they had to get what ever training they needed done around their paying jobs. They were volunteers and they had hand tools, and common sense. What they did was dig. The drivers side door was undamaged and aside from a few cubic yards of dirt, nothing stood in the way of its opening. A minute later they had it open. We immediately slipped our patient onto a waiting backboard, keeping his neck and back stable as we did, and moved him to the stretcher. I tried again to intubate him again, but had no luck. Things just were not going as planned and I was becoming a bit unraveled. It was at this point that I made a fairly serious error.

People who undergo forces that occur in a crash of this severity frequently break their necks. A spinal column is like a broom stick with an eight-pound bowling ball stuck on the end. If the bowling ball gets hit pretty hard or the whole assembly stops really quickly the broomstick will break. The spinal column is a set of very thick, tough bones through which a thin, fragile bundle of nerves travel. The impact of a quarter falling twelve inches onto an unprotected spinal cord will destroy it forever. The spinal column does a fantastic job of protecting the cord, but when one of the bones breaks all bets are off. The smallest shift can cause broken bones to slice into the cord, severing it. It is for this reason that car accident victims are routinely treated with special care. A collar is placed around their necks, we ease them on to long flat boards to keep them still and we hold their heads still at first by hand, and once they’re on the boards with a head immobilizer. In short, we try our best to keep their necks very still until we can confirm by x-ray that nothing is broken.

Having just finished my umpteenth failed attempt to intubate this poor soul I decided it was time to get him to the more controlled environs of the ambulance where we could continue caring for him, and get him moving toward the helicopter landing zone. I told the firefighters as much and we began moving to the ambulance. At that moment I realized I’d left my bag on the hood of the truck. I turned to grab it before I realized that I had released our patient’s head. I grabbed the bag, spilling a few things out in the process and tried to catch up with the patient and the firefighters who were speeding off. It was at this point that my supervisor stepped around the corner of the ambulance. He’d heard the call on the radio and come to help. There I stood, disheveled, my patient bouncing down the dirt road with his head unrestrained, no tube and no IV. It looked bad, and I instantly felt like a complete failure. John, the supervisor, was a seasoned medic. He secured our patient’s head, and had him intubated in a minute. I started an IV, checked vitals and called report to the incoming helicopter as he bagged our patient. The parient was in even worse shape than I’d surmised earlier. He barely had a blood pressure and what little life that remained in him was fading away. We met the helicopter and they flew him to a trauma center where he died some hours later.

Afterward I had a carefully worded discussion with Kevin about where he’d been during the call. He’d apparently been busy guiding the helicopter to us for the half hour I was alone. This was normally a service the firefighters provided, but it turns out we were working with an EMT who’d been volunteering for 3 months, and two other volunteers who’d never been on a trauma call before. Under the circumstances they performed brilliantly. Further discussions with Kevin were unproductive, and we parted company a few weeks later.

The driver, still walking around looking like a horror movie character after the helicopter left, had let us clean and bandage his forehead, but adamantly refused all other assistance. When we left he was trying to explain to the Sheriff’s Deputy how he’d managed to hit a tree six feet off the ground.

A few days later I got called into John’s office. His first words to me were "The good news is you’re not fired." I was mortified. I’d been an A+ student in paramedic school and a hotshot medic in the big city and here I sat, being scolded. Our patient’s neck had been broken, he told me, and though he’d died of internal injuries unrelated to his neck injury, I had screwed up. I sat quietly for a second, trying to think of things to say. I’d been overwhelmed. My partner had abandoned me. None of it made any difference. I was paid to handle the situation and I hadn’t. I agreed with his assessment and took my lumps.

What I learned that day is one of the most important lessons a paramedic can learn. I learned humility. When you are trained to bring the dead back to life, and know in your heart that you can do it, It is very easy to begin thinking that nothing is beyond you. It’s a great feeling, but it is a dangerous fiction.

Many years later I sat beside a fairly new paramedic who was openly admiring my cool demeanor after a bad call we’d just worked together as we ate lunch. I basked in the admiration for a brief moment and then sighed and told the truth.

"Actually," I said "I was scared out of my mind. You will never feel worse than on the day you find yourself sitting on the back bumper of your ambulance, wondering if you can ever forgive yourself for screwing up, and the fastest way to get there is to think you have it all under control. You don’t have it under control, ever, and thinking you do makes you complacent. Watching someone else who has some experience can make you think it’s easy. It never is. Us old farts just know how to make it look that way so we don’t scare the patients." I smiled. My partner thought for a second, shook his head in understanding and went back to his sandwich. I hope his day on the bumper didn’t go too badly, and I hope he passes the secret on someday. The guy he tells probably won’t understand any better than he did, or I did, but at least he’ll know he wasn’t the first, and maybe he can learn from his mistake and get on with his life a little sooner.