other people's emergencies: random thoughts of an urban paramedic

For more than twenty years I've worked as a paramedic for the city of Boston, Massachusetts. The opinions expressed in this diary are mine alone, and do not represent the views of Boston EMS. Names, dates, locations, and physical characteristics have been changed to ensure patient confidentiality.

Saturday, May 23, 2009

Haste Makes Waste

I returned to the classroom last night, for another evening of mandatory continuing education. First a pediatrician talked to us about childhood pulmonary diseases. Then we heard from a surgeon about chest trauma. Finally, at the end of the night, a trio of Boston Police detectives talked about the status of various street gangs.

I enjoyed the gang lecture the most, because the topic was so unusual. The information will probably come in handy at some point. If nothing else, it'll help us to avoid transporting rival gang members in the same ambulance.

Of all the speakers, the trauma surgeon appeared the most comfortable. For some reason, surgeons always make good lecturers. Naturally confident, they appear poised, no matter how large the audience.

The surgeon who spoke to us tonight kept us amused. He opened his talk with a series of videos that demonstrated all sorts of ridiculous injuries. Then he got down to business, describing the proper ways to diagnose chest injuries and perform tracheotomies.

During his talk, he told a story. "These days, we don't waste time opening chests in the emergency department," he said. "Thirty percent of all trauma patients have either HIV or hepatitis. It doesn't make sense to reach into a thoracic cavity and risk getting exposed, especially when hardly any of those patients will survive. If a patient arrives at our hospital within eight minutes of getting shot or stabbed, we'll open him up. Otherwise, we just pronounce them dead."

He paused for a moment to let this information sink in, then continued.

"It wasn't always that way, though. Doctor Hirsch, the great trauma surgeon, told me about an incident he witnessed back in the seventies, shortly after he became an attending physician. Back then, they opened the chest of every shooting and stabbing victim. Whenever a trauma victim arrived, the residents would run to the emergency department, because they all wanted to open the chest. Whoever got there first would have the opportunity to do it.

"One night he gets a call from the hospital operator, who says that a shooting victim has come in by ambulance. He runs to the emergency department, and there he finds a resident with the patient. The patient has been shot, but he doesn't seem to be bleeding. Yet for some reason, there's a giant puddle of blood on the floor. That's when Doctor Hirsch notices that the resident is holding a couple of fingers in his hand. The resident had been in such a hurry to open the chest that, well, you get the idea.

"Anyway, that's why we're not in such a hurry to open chests anymore."

12 Comments:

Blogger Donna said...

Yikes!

3:23 PM  
Blogger TS said...

Yeah. Kind of creepy, huh?

5:43 PM  
Anonymous scannerbuff1 said...

Great story, as always. Do you know if the resident was ever able to practice medicine again? Were his fingers able to be reattached?
I'm particularly interested in the transporting gang members part. Is there a procedure in place with different hospitals for different gangs (ie. all members of Gang A go to MGH, Gang B goes to BMC, etc), that way ensuring that members of rival gangs are not in the same ER? Or does the Youth Violance Strike Force respond to the ERs where gang members are being treated in case the rivalry spills over?
I've just always been fascinated by how public safety agencies manage and respond to gang-related problems. The fact that gangs from neighborhoods one block away can be at war with each other or shootings can occur over the most minor issues seems incredible. I guess the most amazing part is that gang violance heats up every summer. Gang members lived in the same community all winter, with many fewer violent incidents, then summer rolls around and it's a nightly battle zone.
I'm sorry to stray so far from your post, but your bringing up the gang violance just really got my attention.

9:15 PM  
Blogger me said...

The trauma surgeon's story reminded me of Arrested Development, the TV show, where they use the one-armed family friend, J Walter Weatherman, to teach elaborate, tragic lessons.

"And that's why you always leave a note..." etc.

Which is only funny if you've seen it.

9:50 PM  
Anonymous Anonymous said...

I'd presumed the fingers were the patient's - after all I'd be clutching my chest if I'd been shot. Just our of interest, are survival rates higher or lower with less opening up?
j

11:18 PM  
Blogger TS said...

Scannerbuff1:

No, sorry, but I have no idea what happened to the resident. This was a story passed down from one doctor to another, then related to me. I was just a kid when it happened.

There is no formal procedure for separating gang members. It therefore falls to us, the EMS personnel in the street, to exercise good sense. We do our best to determine which patient was on which side of the argument, and send them to different hospitals, in different ambulances.

3:27 AM  
Blogger TS said...

Me:

I wish I had seen it, because I've heard good things about that show. But I haven't. Sorry.

4:05 AM  
Blogger TS said...

Anonymous:

No, they were the doctor's fingers.

The surgeons wouldn't have been cutting open the patient's chest if he had been awake. They do that only as a last resort, after the heart stops. Since this patient was dead already, he wouldn't have been clutching at his chest.

The survival rates have remained pretty much the same. Remember, we're talking about a last-ditch
procedure here--something to be done only as a last resort, on patients whose hearts have already stopped, when there's nothing left to try. Those who don't have their hearts opened are going to die, of course, but since they were almost certain to die anyway, the decision to open fewer chests doesn't really change anything.

5:05 AM  
Blogger brendan said...

Lol, EPIC FAIL!

1:15 AM  
Blogger Meaghan said...

Dr. Hirsch was a LEGEND at BMC, and by all accounts of my mom a nice guy too. I worked there for a few years and was at his memorial service last summer. Since he founded medflight boston there was a helicopter flyover. It was pretty epic.

2:03 PM  
Blogger TS said...

Meaghan:

I agree. If you go back into the archives of this blog, you'll see that I said much the same thing in a post right after he passed away.

3:16 PM  
Blogger JRey@XYZmedia said...

Wow, I can't believe they pronounce patients dead before they actually are. Hospitals are really getting busy these days. They must have some pretty good preventative action against aids and HIV by now. I saw an interview at this site about Becoming a Paramedic How did you get started?

2:46 PM  

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