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Riding the rig to the wreck

Pages from a Rez journal

Rendering health care within the confines of a crowded clinic can be challenging enough. When a call from the ambulance service requests a doc to "ride along," the stakes are usually higher, decisions more urgent.

Though we had three or four docs on staff, I was usually the designated hitter for such excursions. We required all our new docs to take the American College of Surgeons' "Advanced Trauma Life Support" course. This intensive training has been developed for providers in remote areas where the only care available during the critical "golden hour" after trauma comes from small undersupplied facilities. I'd been around long enough to become a course instructor, one of a couple non-surgeons teaching in the Montana area.

Working on the Rez had provided me some practical experience with local systems' capabilities, and I'd rubbed elbows with many of the law enforcement people in the area; I was familiar with them and their protocols, and they knew my hairy face on sight.

A critical component of multiple-trauma intervention is "triage" -- rapidly assessing who is salvageable, and prioritizing interventions; and sometimes, accepting that some victims, though still clinging to life, are already doomed.

Our past collaboration allowed me to scramble into a chaotic scene, poke around, and start issuing "suggestions" that would be implemented rapidly by others. I had no real authority, beyond any credibility I'd earned in the trenches.

Possibly my own low-income upbringing helped at such times; innovation becomes a way of life when resources are limited. In the middle of a disaster, it's important to know how to improvise, to re-purpose various found objects and bits of equipment, even invent new approaches on the spot. As long as they respect the science, it doesn't matter that extraction and stabilization can't always follow the book.

You just never know what you'll find.

Highway 212 snaked up and over the Ashland Divide east of town, full of tight curves, steep hills, and non-existent shoulders. A trucker hauling a semi full of lumber failed to control his descent down a particularly long steep curve. When the truck slid off and rolled, long pine 2-by-4s scattered like toothpicks down the slope to the forest edge, and the driver was pinned in his cab.

Peering into the debris-filled cab, initial responders thought he was probably dead.

In such situations, to preserve a little of the decedent's dignity, and conserve precious supplies, a doc could "pronounce" a dead victim on the scene. This allowed extraction to proceed in a safer, more deliberate fashion, rather than frantic haste.

My med-student at the time hailed from Duke. Sitting in the rear compartment of the ambulance, we checked out our laryngoscope blades and batteries in case we needed an airway, and arranged IV equipment. But we had no idea what we were facing, and she had butterflies. "How do you stay so ... mellow?" she asked.

"Powerful mind-altering drugs!" I said. "Also, I think we can handle anything we see, likely as well as anyone else could under the circumstances. But we might see something nobody could fix. That's not our fault. Trust your training, trust your colleagues -- and don't forget to breathe."

I showed her a "rapid-induction" technique, basically controlled breathing, muscle isolation, and mental focusing. In a minute or less, one can melt from consternation into The Zone. "As the Fat Man says, when you arrive on the scene, the first pulse you should check is your own."

In about 15 minutes, we stopped in view of the wreck. The crew started unlimbering a backboard and supplies, just in case we did have a shot at resuscitation. The student and I climbed and slid down the long grassy slope to the upside-down cab. The air reeked of fuel fumes, which made me a little nervous myself.

After jamming some soft debris across the jagged glass protruding from the side window, I eased through on my back. Squirming through the tangle, I reached the driver, who hung from his seat inverted, still strapped in.

As the cab had collapsed, so had the space between floor and ceiling. The driver's head was pinned against what had been the roof, his neck severely flexed forward. He wasn't breathing or moving.

I poked my fingers under his shirt and into his armpit. Still warm. I wiggled farther until I could feel for his neck pulses. Absent. Finally, I maneuvered until I could separate his eyelids; his pupils were "fixed and dilated."

Though I never heard for sure -- the driver wasn't one of our IHS "beneficiaries" -- I suspect the poor guy either broke his neck, or simply forced his head so far forward that his windpipe was kinked shut.

I inched back out, feet first. State and county officers could proceed with a safe (for them) and deliberate extraction.

We repacked the rig and headed back to town, sober and silent, beset by thoughts of our own mortality, inevitable yet unpredictable.

Our "patient" was dead. And -- my last pair of white trousers from long-gone residency days was stained beyond salvage by oily red and black fluids.

Funny the things you remember.

They're not all success stories.

Jon Hauxwell, MD, is a retired family physician who grew up in Stockton and now lives outside Hays. hauxwell@ruraltel.net