On Being A First Responder

It was the most gruesome human disfigurement I had ever seen, and it defied all the rules I had been taught for responding to emergencies...

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*The following article details an experience my team and I shared the weekend of Hurricane Sandy.  It is, for me, a catharsis opportunity, a chance to process the incident.  I have included some very practical and important tips for responding to traumatic emergencies below under the heading "What you should know when you are a first responder".  Feel free to skip ahead to the practicals!

Sunday, October 28th

1:10 PM Washington DC

We had decided to go. With the now legendary super-storm known as Hurricane Sandy nearing landfall, and all flights out of Washington DC cancelled, it was either bug-out now, or hunker down for the foreseeable future.

With just one more day before the catastrophic landfall of what has been called the largest Atlantic storm system in recorded history, we were only a few miles from the Dulles airport for the Take Back Your Health Conference. This would be the first - and I hope only - time I would implement the foreboding “act of God" exemption found in my speakers contract, allowing me to leave the event before I was scheduled to speak.

With no hopes for flights home, we decided to rent a car to chance racing the leading edge of the storm, for a full 14 hours, as we made our way back to Maine.  In the eerie stillness that preceded the storm, with news of people scrambling to gather the last available supplies and tuck into their homes, we went in search of one of the last rental cars in town.

With a bit of smooth talking, we were given the only SUV on the lot, a white Tahoe that had been reserved for FEMA.  By 1:10 in the afternoon, after a ballet of last-minute-but-coordinated packing, shipping, and route planning, we set out on an unplanned adventure, racing the super-storm up the eastern seaboard.

4:08 PM, Virginia

The sky loomed ominous and the air was moist and electrified on the two lane highway as drivers made their way north, some commuting home, others - like us no doubt - attempting to get to higher ground.  I was driving, my thoughts on the evacuations in New Jersey, New York, and Connecticut that still lay ahead.  Could we beat the bridge closings in NYC or would our FEMA-commandeered SUV be swallowed up in the vehicular clot soon to be clogging the highway arteries to the North?

Something was wrong

My awareness was suddenly pulled back into what felt like a languid, half speed reality.  Before I could crystallize a thought, a feeling-tone emerged.  It was the recognition that “something was wrong, something was very much out of place”.  Just then I understood, in a moment slower than life, a motorcycle just 15 yards ahead in the right lane beside us suddenly lost traction, the tread pattern of its wheels kicking out to face us as the driver went down, sliding and bouncing, along the breakdown lane.

We pulled over immediately, now a hundred yards from the man who had, just moments ago, been cruising at full highway speed across through the pre-storm drizzle.  I grabbed my pack, shouldered it, and started to sprint towards what was now a crumpled body as one of my teammates called 911.

As I ran, unsure of what would lie ahead, crucial lessons from my emergency medical training began to flood my mind.  “Be sure he has a clear airway”..  “Is he breathing?”  “Does he have a heart beat?”  “Stabilize his spine until advanced life support arrives.”

Blood was pooling beneath his head faster than I could run, and by the time I arrived a bright crimson puddle had accumulated beneath a black helmet that was split - a crooked mohawk crack - from one end to the other.  He was face down, twitching, his right arm twisted, unnaturally bent behind him like a fallen marionette.  For a moment I believed these are the last nervous-system spasms of the dead.

Erratic twitches began to coalesce into coherent movements and I - and those who had also stopped - realized that he was alive.

Though he was face down, I could now hear and see him breathing, so it was clear that his airway was unobstructed.  This of course meant he had also had a pulse.  The most important thing now was to stabilize his spine until the ambulance arrived.  This is to ensure that if his head, neck, or spine was injured in the fall, highly likely in a scenario like this, that we wouldn’t risk further injury, such as paralyzation, by moving him.

It felt like chaos, as ten or more bystanders had now gathered around us.  I had a gentle hand on his helmet and back, attempting to keep him still, and keep the others from acting on the impulses they felt as they shouted things like “roll him over!” and “take his helmet off!”.  Both of these are absolute taboos of first response, as both pose too great a risk of further injury.  What if his helmet is all that is holding his brain in his skull?  What if rolling him over causes him to begin asphyxiating on his own blood?

The highway behind me was still alive with traffic as - almost unbelievably - he began to push himself up onto his knees.  I stepped back, not wanting to have hands on him as he began to move, concerned that if he injured himself that I might be sued in the aftermath.  This may sound insensitive, but the concerns about civil lawsuits are ever present in the world of emergency medicine. I was soon handed the phone to speak with the state police dispatch, describing the scene, the accident, and the mans injuries when I first saw his face, or what had been his face.

My vantage point, crouched low, and just in front of him, provided me with the first glance, before anyone else had seen the extent of his injuries.  I sturdied myself for the reaction that I knew those around me were about to have as I tried - though in vain - to suppress a shutter as it moved through my body.

From his eyes to his lower teeth was now a large, black, gaping opening.  It looked as if his whole lower face had been torn away to reveal a chasm ringed by torn and brightly bleeding flesh.  Each time he breathed blood gurgled and frothed into and out of his airway.  His eyes, all iris with all but non-existent pupils, more yellow than hazel, revealed the severity of the shock he was in.  He reached up with his left, gloved hand to touch his face, though in its absence his fingers plunged into the space where his nose had been.  A simultaneous wince rippled through us all as we witnessed his moment of realization. I remember feeling ashamed for watching and enjoying movie violence, for the way we - as a species - glorify human disfigurement in media.  I thought of the violent euphemism oft-shouted between monkey-dancing males, "I'll rip your face off", and feeling the graphic and grotesque reality of the statement.

He had chosen to set out that day with a helmet that covered his head only, and lacked a face protecting shield.  His bike had kicked out from under him towards his left side, his right shoulder making first contact with the ground.  This initial impact either broke or dislocated his arm, however the black, heavy nylon motorcycle suit he wore protected him from any serious “road rash”.  The next impact was his head, protectively cradled by his helmet, as it bounced along the pavement.  The force of this impact cracked his helmet, absorbing the shock -just as it was designed to do - that would have otherwise splintered his skull.  Though I didn’t witness this next phase of the fall, I assume that what followed was his body rolling over, face down to the pavement, as the last of his inertia was absorbed by the delicate structures of his face.

It was a full ten minutes before the first State Trooper was able to respond to the scene, and 20 minutes from his moment of impact before the first paramedic arrived.  It felt like too long, though I know the reality is that these responders arrived as quickly as they could.

Once he had been back-boarded, and was being loaded onto the ambulance, I stopped the State Trooper to let him know I had witnessed the accident as it happened, had spoken to dispatch on the phone, and was ready to get myself and crew back on the road.  I gave him my contact information, and the three of us began walking back to our rented SUV, past a shattered motorcycle mirror 20 yards from the scene, past his battered motorcycle, laid on its side 45 yards from the blood its rider had spilled.  About 10 yards from the Tahoe I began to cry.  We were all deeply shaken, but steeled ourselves, there were still 13 hours of highway, and the perfect storm ahead...

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After Action Report...

We made it home safe and grateful early on the morning of the 29th, having beat the bridge closings and traffic by several hours.  New York City looked like a ghost town as we drove swiftly to, across, and beyond the George Washington Bridge.  We spent much of the drive Debriefing.

There are many standardized methods for debriefing a “critical incident”, but here is the short of it.  It is important for the mental health of first responders to accidents like this to debrief, or talk about what they've experienced.  Our make-shift debrief looked like this:

What did each of us remember?We each went around recounting the entire event as we remembered it.  Each one of us shared what we saw (or thought we saw) happen, each with our  uniquely different versions of events and each with our corroboration's.  It was helpful to get clarity by pooling the data and getting a more accurate assemblage of the events.

What did each of us feel? Next we discussed the emotions that we felt as each part of the event unfolded.  Here it is crucial that each person hears and understands that their feelings are normal and appropriate. This might sound cliche' or even child-like, but in-the-moment feelings can range from apathy to terror, from shame to thrill.  Each of us copes with violence and trauma differently, and this part of the process helps us to bring out and clear these emotional responses from our nervous systems.  It helps us to connect and to reconnect to our humanity.

What did we do well?We follow with looking at what we did to contribute, its a chance to feel good about the part we played in helping someone in need.  It is an opportunity to reflect on what worked in our response to the situation.

What would we do differently if we could do it again?During a critical incident we enter an altered state of awareness.  Our sympathetic nervous system becomes active, time may seem to slow down, we may experience auditory exclusions (not hear things around us) or tunnel vision.  We may make choices - say or do things - that upon reflection don’t make sense to us.  If we were there again, with our full faculties intact, what would we do differently?

Observations. A few things stand out to me about this accident.

-Motorcycle riding is inherently risky, which I suspect is one reason it is so damn cool.Motorcycles stay upright because of their forward momentum and the balance of the rider.  In other words, their natural state is lying on their side.  Riders know this, and ride at their own risk.

-A full, face-shielded helmet would have prevented the most horrifying part of this accident.His arm would still have been dislocated, but his face would have been protected.  This could have been a close call rather than a life-changing incident.

-It was clear his protective full-bodied riding suit protected him from many serious injuries.Here in New England I see many riders without helmets and wearing nothing more than shorts and a t-shirt.  I often see women on the back of motorcycles wearing daisy-dukes and a bikini top.  The possibility for graphic, life-altering injury here is obvious.

What you should know when you are a first responder:

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-Now is the time to get first aid or higher level emergency medical training.Basic first aid and CPR can be learned in a single, inexpensive, half-day class.  Your local American Red Cross is running these classes frequently, and you might even choose to pursue higher levels of training as well.

-When you are a lone first responder, call 911before getting involved with the victim.  Once you are involved you may not be able to break away to call.  This may decide whether the victim lives or dies.  If others are present, be sure someone else calls for help before you get involved.

-Think "Scene Safety". Before you rush over to the victim, make sure the scene is safe to approach.  Is there oncoming traffic?  Is there spilled fuel or other chemicals?  Is there a fire burning?  Never enter a situation that puts you at risk of becoming yet one more casualty at the scene.  A well meaning bystander can quickly become another accident victim, further encumbering the rescue effort.

-Remember your ABC’s.When you come upon an unconscious or unresponsive individual, think “ABC”.

A = Airway.Is the victims airway open?  Can they get breath?  If yes proceed to B, if not clearing their airway is crucial.  If they can't get breath they will die.

B = Breathing. Their airway is unobstructed, but are they breathing? If so, then they are alive and have a heart beat.  This is good.  If not, proceed to C.

C = Circulation.Is their circulatory system, in other words their heart, beating?  Is there a pulse?  If yes, but they are not breathing, Rescue Breathing is used.  If not, this person is dead, and CPR or defibrillation becomes critical to artificially pump the heart until more advanced help arrives.  Seek out good training now. Again, I recommend the American Red Cross.

-Never move the victim of a traumatic injuryunless you have proper training to do so. If you are going to get involved it is crucial that you stabilize the victim in the position you found them in until more advanced help arrives.  This is to ensure that you do not exacerbate injuries to the spine and nervous system. The exception to this would be if the victim is in greater danger staying where they are (fire, traffic, poisonous chemicals present, etc).

-You may, or may not be protected from civil lawsuits (brought by the victim or their representatives) by “Good Samaritan” laws.  Getting involved may put you at risk.  If you choose to help, be clear and decisive in  your actions, and be sure that you are not doing greater harm to the victim.  Here is a great website that detailing the Good Samaritan laws from state to state.

-When you see an accident on the side of the roadwhere responders are already present, continue on safely but without slowing traffic.  We all have the impulse to crane our necks to see what is happening when we see an incident unfolding on the side of the road.  Just remember that there may be police, an ambulance, or other responders trying to get to the scene, and the cumulative effect of all that traffic slowing down to get a look can result in slower response times.

Some incidents defy the well defined parameters we train for:

This incident challenged my preconceived notions and prior experience.  For instance..

-I knew not to move the victim, but what about the victim moving himself?  I knew not to take his helmet off, but what about when the victim is trying to take it off himself?

-I knew to guard his airway, but when he rolled over he started to choke on his own blood.  How do I handle this?

-I know to stop bleeding with pressure, but what about when the bleeding is coming from the airway itself?

What I wished I had done differently:

I would like to have done a better job of taking charge of the scene.  Looking back, I see that I was the most qualified responder to do so.  I could have done a better job reducing the panic and commotion by giving each person present a “job” to do.  For instance, some people could have been helping to move traffic along, others could have been looking out for the ambulance, etc.  Often people want to help but are looking for clear leadership.  I could have done a better job providing this.

-While I had non-latex examination gloves (an effective blood barrier) in my pack, they felt inaccessible to me at the time.  I was hesitant to get my bare hands in his blood, which limited my capacity to get hands on.  Had I had more immediate access to my gloves I could have been more hands on.  I have since put gloves in a pouch on the exterior of my pack.

Conclusions

Its not always a safe and padded world.  Things sometime just happen, that's why they are called accidents.  Sometimes disasters happen during other disasters, as was the case here.  While we are very privileged to have an emergency medical system in place for accidents like these, 20 minutes is a long time. Its long enough to bleed out, its long enough to die.  Each of us can take personal responsibility - a word that means "ability to respond" - for our own training.  You might save a life.  You might save your own.

~Daniel Vitalis