I don’t really want to write about this, but it’s probably good for you to hear about it, and probably good for me to write about it. It’s the kind of case that we all have nightmares about, wonder if we’ll know what to do when the time comes, wonder if we’ll forget everything that we’ve learned. It was the kind of case that makes me feel like all those years of school and training were worth something, even though we couldn’t save his life. At least we knew how to try.

Yesterday, around noon, we were dispatched to the site of a construction accident. Actually, the landing site was at a prison because it was the closest safe place to land the helicopter. In the back of the ambulance, lying on the stretcher, was a young man with obvious difficulty breathing. He was taking huge gasps of air, but his chest wasn’t moving. Instead, his belly was going up and down, up and down. He had dried blood around his mouth and nose, and every exhalation was accompanied by little sputters of blood from his mouth. He had been crushed underneath a several ton slab of concrete while unloading it from a trailer bed…imagine getting one of those highway “jersey barriers” dropped on top of you from five feet in the air. Somehow, he managed to crawl free on his own.

He needed to be intubated and fast. My intern did an excellent job of getting the tube in the trachea, considering all the blood that was building up in his throat. Just as we had him packaged up to transport to the back of the helicopter, his heart rate started to drop. We verified tube placement again, and suctioned frank blood from the tube. There was so much blood that it was just pouring out of the tube and clogging up our bag mask filter. His neck turned purple, and subcutaneous air filled his neck and upper chest. I put a needle through his chest wall into his lung space and more blood poured out. We put a second needle in the lateral wall with even more frank blood. By this time, I tried to feel his trachea, and it was deviated…the first time I’ve ever felt trachea deviation. We popped his left chest as well and a huge rush of air came out. He continued his bradycardic demise despite atropine & epinephrine. We began CPR. He went into ventricular fibrillation. We shocked at 200 Joules. We shocked at 300 Joules. He finally had a heart rate, and we jumped on the opportunity to get him transported to teh helicopter. His distant, and only hope was to cut his chest open and start clamping major blood vessels, or even his entire left lung.

While en route to the hospital, he began to brady down again. Atropine. Epinephrine. FLuids. Heart rate of 30. I began CPR in the cramped quarters of the helicopter where I didnt even have enough room to get my elbow over my wrist for my one handed compressions. It was while I was doing CPR that my staff doc finally came over the radio for report. I conveyed his dire situation in rhythm with my compressions. My stomach started to hurt…partly from nausea, but also because of the awkward position of giving CPR. The medic took over for me. We paused to check his rhythm and he was back in VFib. Time to shock again. THankfully the ambulances defibrillation pads were compatible with our defibrillator. We charged right up to 360 joules and presed the button and … no shock. CRAP. Now he’s charged with enough energy to put any of us in vfib, and the machine won’t discharge. Again, in cramped quarters, the medic leans over and presses a few buttons. We see the patient’s body jerk and the paddles are finally discharged. Safe to touch him again.

He’s back in an ideoventricular rhythm and we continue CPR. All the while, the flight nurse has been suctioning his tube and has about another liter of blood. he’s gotten four liters of fluid by now. We finally land on the roof, transport to teh trauma team who’s awaiting with two chest tube kits and a thoracotomy tray.

By the time we arrive, however, he has no signs of life. Heart rate of 20 with no pulse. CPR initiated almost 45 minutes ago. Blunt cardiac arrest…nearly no chance of survival, even with immediated surgical intervention. He was pronounced dead.

Everyone was notably distraught. Mostly because he was so young, but partly because of the gore and the hopelessness of it all. I was crushed, so was my intern. We went over and over the case wondering what we could have done differently, or better. No one faulted us at all, everyone agreed that with such massive trauma, even with immediate surgical intervention, the chances would have been slim.

I spoke with his supervisors at the scene, they were clearly very upset. A burly, rugged man wearing Carhart overalls and a hardhat with tears in his eyes. I asked him for details about the accident, but no one saw it. i asked him to describe the concrete beam, he guessed it weighed 20,000 pounds. It was 4 feet wide, 8 inches thick and 20 feet long.

This morning, I saw my intern again. He had nightmares last night. So did I. AFter I got home, I noticed the spot of blood on my shoes. I’m surprised there wasn’t more on me considering how much blood poured from every hole we made in him. For some reason, the blood doesn’t bother me. It actually makes me feel good about myself. We did all the right things and it just wasn’t enough. Maybe the next time the medics we worked with have to pop a chest, they’ll make a difference. Maybe having seen it and done it this time will help the next guy they treat.