Checks and Balances
Chapter 6
When the in-house fire alarm went off, blaring its warning throughout the station, all five men jumped up from their seats. In the nearly fifteen years that Captain Stanley had been with the fire department he had never had anyone pull an internal fire alarm in one of his stations. They didn't even need to resort to that the time Chet set fire to his skis in the locker room.
Mike was closest to the door leading from the day room to the apparatus bay. He charged out through the door sniffing the air trying to detect the smell of smoke with Chet, Roy, and Marco right behind him. Chet headed toward the Captain's office and the front of the apparatus bay, Roy ran to the front bay doors to open them, and Marco followed behind Mike who headed for the back of the bay and the dorms.
Captain Stanley moved to the radio just as the tones went out for station 10 to respond to the in-house alarm at station 51. Cap was expecting the tones. It was procedure to automatically tone out the nearest available station to any in-house alarm.
"LA, station 51. Hold for status." Cap called, into the mike.
"LA 10-4, station 51."
As Mike rounded the corner behind the squad he saw Johnny lying on his left side on the floor, half in the dorm, half out in the apparatus bay. He wasn't moving.
"Roy, Cap!" Mike thundered, calling attention to the problem. Mike rushed over to Johnny while pointing back at the squad. "Marco! Get the gear!"
Roy ran between the trucks nearly knocking Marco over as he opened the compartment doors of the squad to get the paramedic equipment out. Roy felt his heart leap to his throat as he closed the distance between himself and Marco instinctively knowing that his partner was the problem. He grabbed the drug box and biophone while Marco reached for the oxygen and datascope.
Cap dropped the mike at Stoker's shout and headed toward the back of the bay behind the squad and stopped dead in his tracks at the sight of his youngest crew member lying lifeless on the floor. He turned and bolted back to the radio.
"LA, station 51. We have a code I. Dispatch an ambulance immediately."
"10-4, 51."
Cap didn't wait to hear the dispatcher cancel the call to station 10 as he raced back to the dorm and his downed man.
Roy and Marco were at Johnny's side with the equipment within moments and Roy and Mike gently turned Johnny over on his back and dragged him clear of the door.
"He's not breathing, Roy." Mike said, in his ever calm voice.
Roy was grateful for Mike's composure; it helped to ease the storm of fear that raced through him threatening to undo his own professional composure.
"Ambu bag!" Roy ordered. "Set up the O2 tank, and hook it in while I bag him. Marco, take over as soon as you can so I can check him out."
Marco pulled out the mask and hooked it up to the tank while Roy tipped back Johnny's head, noting that the trachea was diverted to the left. Marco placed the mask over Johnny's nose and mouth and depressed the release, forcing air into his lungs. Captain Stanley slid in beside Mike wanting to help, but seeking Roy for guidance.
"We need that shirt off of him." Roy said, as he pulled out his equipment. He handed a pair of scissors over as he continued speaking. "Cap, take the bandage scissors, and cut his shirt off. Make it quick."
Captain Stanley and Mike cut Johnny's t-shirt off while Roy pulled out the stethoscope and listened. Chet busied himself setting up the biophone. The station phone began ringing, but went ignored by everyone present.
Chet called into the biophone, "Rampart this is 51. How do you read?"
Johnny's face was slack, his lips were blue and he was only breathing as Marco forced air into his lungs with the oxygen mask.
"Johnny! Can you hear me?" Roy called to his partner, not expecting an answer. But it was standard protocol, and right now Roy needed to rely on protocols to get through this.
Cap grabbed the drug box from Marco and opened it.
"Rampart, this is 51, how do you read?" Chet called again.
"51, this is Rampart, we read you," came an unfamiliar voice.
Roy grabbed the phone from Chet. "Rampart we have a 26 year old male in respiratory arrest. There is left sided tracheal displacement. We have him on 15 liters of O2. He's cyanotic, diaphoretic, there are no breath sounds on the right, minimal breath sounds on the left. Hold for vital signs."
As he worked Roy couldn't stop the thoughts from assaulting him along with a healthy measure of guilt. All of the symptoms that Johnny had been exhibiting throughout the last few hours suddenly made perfect sense if he had a collapsed lung. Lack of energy, confusion, minimal vocal responses to conversation, and the coughing. Johnny had been slowly suffocating all evening and he didn't see it. "Oh, God."
Captain Stanley looked sharply at his senior paramedic. "What is it, Roy?"
"We need to turn him over. I want to listen to the back of his right side."
Cap and Roy gently turned Johnny onto his left side. Roy placed the stethoscope on the right side of Johnny's back praying that he would hear some sign of breath sounds. Captain Stanley gasped as he saw the extensive bruising across Johnny's back for the first time.
"Nothing," Roy said, as he rolled Johnny back.
"Roy what's wrong with him?" Cap asked in a tone that said Roy had better spill the beans.
"I think his lung has collapsed."
Nurse Julie Rommel, who had taken the call, grabbed one of the nurses passing by. "We have a possible tension pneumo, find Dr. Brackett STAT."
Dr. Brackett slammed down the phone in his office looking very worried. "No answer. They must be out on a call."
Dr. Early frowned. "Maybe we should get the police involved? Find them, where ever they are?"
"We just may do that, Joe," Brackett agreed grimly. He headed for the door of his office with Dixie, Joe and Boot following behind. As Dr. Brackett stepped out into the hall, one of the ER nurses headed straight for him.
"Dr. Brackett, Miss Rommel is at the base station with a possible tension pneumo."
Dr. Brackett exchanged a glance with Joe. "Johnny!" and took off down the hall toward the base station.
"Rampart, vital signs are: BP 70 over 40, pulse 115 and thready, pupils are dilated and sluggish."
Dixie stepped over to Julie and took the pad of patient info handing it over to Dr. Brackett. "Julie, I want you to set up treatment 1 for a chest tube and endotrachiel tube."
"Right away Miss McCall." the nurse answered, and hurried out of the base station booth to ready the room.
Dr. Brackett heard Roy's voice as he quickly scanned the vitals pad then immediately pressed the transmit button.
"51, this is Dr. Brackett. Is the patient John Gage?"
Roy was relieved to hear Dr. Brackett's voice. "That's affirmative, Rampart."
"How do his lungs sound?"
"I am hearing no breath sounds on the right, minimal breath sounds on the left. The trachea is deviated to the left and the neck veins are prominent."
"Patch him in for a strip, insert an esophageal airway, and continue ventilations at 15 liters."
While Roy inserted the airway, Chet handed the leads to Cap who placed them along Johnny's chest. Once the airway was in place, Mike began with forced ventilations while Roy listened with the stethoscope. He shook his head then grabbed the biophone.
"Rampart, the strip is coming on lead 2. I've inserted the airway but he still isn't moving any air on the right." There was a strained edge to Roy's voice that no one missed.
Brackett looked at the strip coming from the remote EKG and his face grew grim. "Is there an ambulance at your location, 51?"
Roy looked up at Cap knowing that he had called for one. "It will probably be another five minutes, Roy."
Roy closed his eyes as he depressed the transmit button on the phone. "That's negative, Rampart. Ambulance ETA is 5 minutes."
"Five minutes is too long. He isn't going to make it in here. You are going to have to perform a Needle Thoracostomy."
Roy paled and his voice shook. "Rampart, say again."
Dr. Brackett abandoned transmission protocol at this point. "Roy, listen to me. Johnny has a tension pneumothorax. His entire right lung is completely collapsed and from what you've described, his left lung is now being affected because of the pressure. Even if an ambulance was standing by right now it wont matter unless you can relieve the pressure and get air back into his lungs. Johnny doesn't have any more time. He needs you right now, Roy. You can do this, you have to! Set the channel open on the biophone because you are going to need both hands."
Roy looked very unsure of himself, but determined at the same time. He nodded to himself slightly and depressed the open mike button on the biophone. "Okay. What do I need to do?"
"You should have sterile gloves in the trauma box. You'll need those, betadine swabs, sterile gauze, an 18 gauge needle with a 50 cc syringe."
As Roy grabbed and set out all supplies he was going to need he continued to listen to Dr. Brackett's instructions.
"Can you get Johnny elevated? He needs to be upright for this to work properly."
Cap took hold of Johnny's shoulders and raised him up sliding in behind him so the young man was supported in a sitting position leaning against Cap's body. He then placed his hand on John's forehead to hold it up and out of Roy's way.
"Okay, Rampart. I think we're ready." Roy said, as his stomach churned.
"Good, now you need to swab the upper right side of his chest really well with the betadine. You'll be inserting the needle in the second intercostal space between ribs two and three along the mid clavicular line."
Roy tore open the betadine swabs and wiped down Johnny's chest as instructed. Then he opened the sterile gloves and put them on. Chet slid into the space that Cap had occupied at Johnny's other side. He had seen enough MASH type units work out in the field when he was in the Vietnam, and knew that once Roy had those gloves on someone was going to need to hand him the rest of the equipment after opening it just enough for him to take without contaminating his sterile hands.
"Okay, now Roy you need to attach the needle to the syringe, keeping the plunger all the way down. You will want to insert the needle perpendicular to the chest wall at the level of the superior border of the third rib."
Roy looked up at his crew mates. Each man in turn looked back at him with confidence in his ability and nodded to him. Chet had taken the needle's package and opened it halfway allowing the sterile instrument to hang out for Roy to take. He did the same thing with the syringe and Roy screwed the end of the needle onto the syringe.
"Have you found the intercostal space yet, Roy?" Dr. Brackett's voice asked from the biophone.
"Hang on just a second, Doc." Roy used his fingers to palpate Johnny's chest feeling an almost spongy texture to the tissue of John's chest wall. "There is sub-Q air in the chest wall, but yeah I have the second intercostal space."
"Okay now place the needle at the top of the third rib perpendicular to the surface of it. Use the rib's edge as a guide and slowly walk the needle into the chest wall over the superior border of the rib while maintaining negative pressure on the syringe. Once you have entered the pleural space you will need to stop. You don't want to puncture the lung. You'll know you're there when you hear a slight popping sound and feel the needle give way slightly. At that point the syringe will begin to fill with air and maybe a small amount of blood."
Roy had to concentrate in order to keep his hands from shaking. He placed the needle and began to push it through the skin using Johnny's rib to steady the needle. He listened intently and was relieve when he heard the pop that Dr. Brackett had described. He had to hold his hand steady because the needle did 'give way' and he could have easily pushed the needle in too far.
A spurt of bright red blood speckled the inside of the syringe and the plunger began to push out as the syringe filled up with air.
"Got it. The syringe is filling up with air, and a small spatter of blood."
"Okay that's great, Roy. Now remove the syringe keeping the needle steady."
Roy did as instructed and as soon as the syringe was removed from the needle he could feel and hear a soft hissing as air began to evacuate the pleural space through the needle. Roy looked to Chet.
"Take the stethoscope from around my neck and listen to his right side. Tell me what you hear."
Chet did as instructed and a broad smile crept over his face. "I can hear breathing, Roy. It's working."
Roy was still holding the needle in place not quite sure what to do next. "Do I take this needle out now?" he asked.
Dr. Brackett's voice also held a distinct note of relief. "No, Roy, you need to wrap sterile gauze around the insertion point and tape it off. You will have to be very careful even after you secure the needle. As Johnny's lung begins to re-inflate we don't want to cause any injury to it. Once you have done that I need you to set up an IV with D5W and get me a new set of vitals and another EKG strip."
Roy looked once again at Chet and asked him for the gauze which he obediently tore partway open so Roy could grab it and begin to wrap it around the part of the needle entering John's chest. Chet tore off several strips of tape which Roy used to secure around the needle itself, as well as the gauze and taped it all firmly down against Johnny's chest.
Roy set up the IV and took the new set of vital signs and was greatly relieved to report that John's pulse had slowed and strengthened and his blood pressure was up. The blueish ting had left his lips and his color was much better. He was now breathing on his own, but remained unconscious. The ambulance had arrived and the attendants were standing back waiting to load up their patient.
"Make sure the head of that stretcher is up guys," Roy instructed.
With Roy holding the IV Mike grabbed Johnny's feet while Cap took his upper body and they lifted him up and onto the waiting stretcher. Chet closed up the drug box and Marco packed up the biophone. As the gurney was being loaded onto the waiting ambulance Roy turned troubled eyes to his team mates.
"I'll call with an update as soon as I know what's happening."
Cap handed him a handie talkie. "Take this. I'll see if Dywer can come in to take over for John."
All the guys patted Roy on the shoulder or back telling him they would wait for his call. Once the doors to the ambulance closed, Roy turned back to his patient and continued to monitor his vital signs. In the back of his mind Roy knew that eventually the tension, stress and guilt would bring him to his knees, but not right now, not while he had a job to do.
TBC