Thirty-five seconds
In the ambulance, Hesam heard the gunshots, slammed the stretcher into place and wheeled around as he heard the sound of the pickup racing on around the next corner. He took less than a second ascertaining it was safe, then jumped out of the rig and ran over to Four Charlie.
His mind tried to assess everything at once, but the sight of his partner doubled over on the ground, the hole of an entrance wound visible on the small of his back, momentarily overrode paramedic training.
"Peter!" he yelled as he crouched next to him, just as he heard Anne's shout, "He's hit!" from the inside. It took Hesam a second to realise that she was talking about their patient, not Peter.
The gunman in the car had certainly been trying to hit the Chinese man on the stretcher; two bullets had slammed into the back doors of the ambulance, another had grazed the man on the leg. Peter had been in the way of the remaining two. Hesam pulled off his gloves, which were still covered in their first patient's vomit, and carefully turned Peter on his back. He gave a curse when he saw the blood seeping through Peter's fingers, which were pressed against the large exit wound in his stomach. Peter gasped in pain as Hesam gently prised his hand away, careful to only touch his wrist, and saw a second gunshot wound in his right shoulder, though this one seemed to have grazed him rather than going through. With the dark rainwater pooling on the ground, it was hard to tell how much of it was actually blood. Judging by the size of stomach wound, it was probably a lot.
Like Hesam, Peter had still been wearing gloves, and Hesam now peeled them off, to minimise the risk for infection, knowing it was high enough with this type of injury. He tried for a blood pressure, yanking open his bag to get out several 8x10" abdominal pads.
"This is bad, right?" Peter ground out through clenched teeth. "Christ!" He laid his forearm across his face, gasping.
Hesam mentally went through several possible replies, but they all rang hollow. "Hang on, OK?" he told Peter. "Try to lie still. We're getting you outta here." He gave up the blood pressure as a bad job and pressed the pads on the stomach wound. Peter groaned with pain.
Anne appeared in the back door, staring at the scene, her face white. Simon had jumped out from the driver's seat as well.
"I'll call for backup," he said, but Hesam was already reaching for the portable radio at his belt, while still keeping pressure on Peter's wound.
"This is Two Victor. We got a ten-thirteen. Send a second ALS car here ASAP. Drug-related shooting. Peter's down. Multiple ballistic trauma, abdominal injuries, severe bleeding, no palpable pulse, but responsive. Still on Eldridge. Repeat, ten-thirteen." Later, Anne would tell others admiringly how calm he'd been in that situation. Only funny that, later, Hesam would hardly recall the patch at all.
"Two Victor, please confirm. One shooting victim?"
"Yeah, one. Peter." Hesam couldn't believe how they didn't understand the first time.
What he would recall long afterwards was his relief at the voice that came in over the radio. "Two Queen here. We're five minutes out. Hesam, hang in there." If Hesam had been allowed to pick someone as backup, it would have been Karen O'Neill.
Anne had vanished again, to resume CPR on their first patient. Dispatch confirmed the assignment as Hesam fumbled for a fresh pair of gloves in the pocket of his uniform jacket, and struggled to pull them over his wet hands. In his mind, he raced through the options. He was a single paramedic, assisted by two willing, but basic-level EMTs, with a cardiac arrest and severe trauma to take care of. Two patients, both of whom needed to be taken to the hospital immediately, two rigs, two possible drivers, one medic. Of the three of them, Hesam was the only one who was allowed to administer cardiac drugs, or do IVs. Not nearly enough. All he could do was wait for Two Queen to arrive. And maybe grow one or two extra pairs of hands.
He grabbed Simon's arm. "Get Peter into our rig, hook him up to the monitor, and put him on oxygen. I need him out of this rain in case I have to shock him. If you have time, get his clothes off. And whatever you do, keep pressure on that wound. I'll be with you in two minutes. Anne!" he shouted. "Help Simon get Peter bundled up. I'll take care of our other guy; we'll trade places in two minutes. Peter – stay with us, buddy, you hear me?"
Peter gave a tight nod, curled up on his side, as Simon knelt next to him to take over keeping pressure on the wound. Anne jumped out from Four Charlie to get the stretcher.
Hesam felt the minutes trickling away as he squeezed past her to assess their first patient's condition. The monitor still showed asystole, no change to him at all. Hesam did compressions, then bagged, then pushed a milligram of atropine through the patient's IV, trying not to remember that Peter had got that line less than ten minutes ago. He was on the second round of compressions when Anne arrived, and he told her to take over doing CPR.
He quickly slapped a 4x4 on the new wound on the man's leg, and then gave another round of epinephrine and atropine. The drugs didn't bring any change. By the time he was done, he felt it had been six or seven minutes at least.
He went out again to check on his partner, leaving Anne doing CPR on their first patient. The man was dead; Hesam knew it. If a second dose of combined atropine and epinephrine didn't work, nothing short of a miracle was going to bring him back. But they were required to continue resuscitation; he wasn't allowed to assume him dead even under these circumstances. At least, protocol allowed him to concentrate his best efforts on Peter, as the one who was still within his ability to save.
Once outside, he pulled off his gloves and fumbled in his pocket, but it was empty. He ripped open his bag and finally found another fresh pair. He briefly registered that the police were on scene by now, but his mind was back on business as soon as he entered the back of unit Two Victor.
Simon had Peter strapped to the stretcher, put him on the monitor, and had applied new dressings to the wound in his abdomen after cutting away the front of his shirt. Now, he was just placing a non-rebreather mask over Peter's mouth and nose, cranking up the oxygen flow to ten litres. All the while, he was working one-handed; the other keeping pressure on the wound in Peter's stomach. Hesam felt his spirits plummet when he saw that his partner's pressure was 62 to 41. Peter's face was ashen, and he was shaking all over, his breath coming in ragged gasps. There was blood everywhere.
"What the fuck have you been doing, man?" Hesam snapped at Simon. "Get his damn clothes off! Did you even see the wound in his shoulder? And how'm I supposed to get a line like this?"
Simon stared at Hesam, but made no reply, only got to work on Peter's sleeve with the trauma shears, while still trying to stem the flow of blood with his left hand. Hesam felt vaguely sorry, but there was no time for anything more than vaguely. He feared now that one of the major abdominal blood vessels had been ruptured, and with a blood pressure this low, and unable to reach a hospital within the next quarter hour, Peter needed fluids, immediately.
As soon as Simon had Peter's left arm free, Hesam tied a tourniquet around the bicep, found the antecubital vein, and decided it could take a fourteen gauge catheter.
He briefly squeezed his partner's uninjured shoulder. "Peter," he said. "You with me?"
A jerky nod.
"I need to get an IV. I'm gonna go in with a fourteen." He was already unwrapping a fourteen gauge catheter as he said it.
It was hard to tell whether Peter nodded, or was just shaking uncontrollably, until he opened his eyes a fraction. His breathing was fast and shallow. "Any… chance for … painkillers?" he got out.
"I'm gonna call Med Control for orders in a minute. First I need to get your pressure back up. Hang on, buddy. All right?"
This time, Hesam was fairly sure Peter had nodded, gave him a reassuring pat on the arm, and went in with the needle. He felt the vein give way, got the flashback of blood that told him he was in, and then advanced the plastic catheter over the needle. "Simon, spike a bag of Ringer's."
Simon didn't look at him, just finished dressing the shoulder wound, and opened the drawer with the crystalloids, wordlessly taking out an IV bag of Lactated Ringer's solution.
Hesam withdrew the needle, released the tourniquet, secured the lock and taped the IV into place. He didn't wait for Simon to get the bag of Ringer's solution running, immediately bending over Peter to go for a second line in his other arm. A quick look at the monitor told him that Peter's pressure was crashing even further.
"Wait," Hesam heard him murmur feebly under the mask.
"I can't. You're in shock, Peter, and you're losing way too much blood. I need to get this second line."
Peter nodded again, shuddered, and then turned his head weakly as he vomited.
Hesam cursed as he tore the mask off Peter's face, cast it over at the biohazard container at Simon's seat, missed, and shouted to Simon for the suction unit and another non-rebreather mask. He pulled off his gloves, not even bothering to try and hit the biohazard bag this time, and cleaned Peter's face with a towel as best he could. Apart from the fact that vomit never looked particularly charming, it was too red for Hesam's liking, meaning there was blood in the stomach.
At that instant, Karen O'Neill's face appeared in the back door. She took in the vital signs on the monitor, Peter trying to double over, coughing and gasping, while being gently held down by Hesam, who was yanking a fresh pair of gloves from the attachment with his free hand while Simon suctioned reddish puke from Peter's airway. She jumped on board and took the suction unit from Simon, so that the EMT could finally spike the bag of Ringer's solution.
"What do you need me to do?" Karen asked when the suction tube remained clear.
Hesam assessed his options. Suddenly, there were so many. "First, I need us to get the hell out of here," he said. "Simon—"
Simon just tersely nodded his acknowledgement, and jumped out from the back door, the paper wrapping of an abdominal pad stuck to the sole of his boot. The ambulance looked like a medical battlefield.
"Intubate?" Karen asked when the back door slammed shut, with a worried glance at the monitor.
"No," Hesam said, echoed more weakly by Peter.
"He's still conscious," Hesam added while he reached for a new non-rebreather mask. "And he's breathing OK. Put another line in his right arm – I got a fourteen gauge in his left AC."
"'m sorry," Peter said with a feeble moan as Hesam fastened the fresh mask over his face.
"Dude," Hesam said, shaking his head in disbelief, "that ought to be pretty much your least concern right now."
The engine started up and began to move with a little lurch. Peter's left hand involuntarily jerked towards his stomach wound, but Hesam caught him before he could clutch at the dressings. Trembling, Peter gripped the side of the stretcher instead.
"God, it hurts," he whispered, barely audible over the sirens wailing overhead.
Hesam grimaced. "I know," he said. "But I can't do anything about that at the moment. You'd go out on me."
"There's… always… Narcan," Peter managed feebly.
Hesam gave an incredulous chuckle. "So you can puke all over me again? You'd think once was enough." Through the mask, he could see Peter giving a strained smile.
Karen was in the seat Simon had vacated. "This looks like a main blood vessel was hit," she said with a look at all the blood as she laid out her IV equipment.
"Yeah, I think so," Hesam said, glancing at the monitor. "Need to be careful with how much fluid we flush into him."
"Not another bolus of Ringer's, then," Karen said.
"No. Not yet, at least. Just put in a saline lock." He set to work with the trauma shears again, to get off Peter's soaking wet clothes and search for injuries they might have missed.
Karen applied a tourniquet as far below the shoulder wound as possible. "Peter," she said as she swabbed the crook of his arm with an alcohol prep. "It's Karen. I know it hurts. Hold your arm still; can you do that for me?"
Peter coughed and gave a nod, teeth clenched against the pain.
She prodded the site approvingly. "Hey. Anyone ever tell you you got very nice veins?"
Peter made a sound that was halfway between a laugh and a sob.
"Just watch that one," Hesam told him. "She compliments your veins today, she's gonna propose to you next." He reached up to his neck for his stethoscope to check Peter's lungs, but it wasn't there. Irritated, he looked around on the seat next to him, even on the ground, which was spattered with vomit, blood, and debris, but it was nowhere in sight.
Karen held out her stethoscope to Hesam, who took it with an acknowledging nod, and listened to Peter's lungs. There was some fluid in them, and Hesam looked for the oxygen levels on the monitor. They were at 95 percent, which he was fine with. He was glad that he wasn't forced to make an airway, much less on a conscious patient.
"Patch to the hospital," Hesam shouted to the front, over the wail of the sirens. "Tell them we've got a Room 1 trauma. I want a full trauma room staff."
"What d'you think I've been doing?" Simon's voice came back through the doghouse window between the driver compartment and the back, sounding rather testy.
"Get me Medical Control," Hesam went on without missing a beat. "Ask for orders for ten milligrams of morphine."
Hesam caught Karen's raised eyebrows, and remembered she belonged to a different generation of paramedics. Until a few years ago, morphine had been given very sparingly in emergency medicine, and even though the regulations on its use had changed, some of the older medics were still reluctant to use it, and if they did, kept it in very small doses.
"He's been gut-shot, Karen," he reminded her.
"I can see that. But his pressure is too low."
"I'll hold up until it's stable, obviously. It should soon be."
"I still wouldn't give that much," she said.
Hesam felt irritated. "I would."
"Would you give it to any odd MVA victim?" she asked.
"Yeah," he snapped. "Because I was precepted in 2001, not in 1980."
He snatched a towel to wipe some more vomit from his sleeve, got up, scooped up the debris on the floor to finally deposit it in the biohazard container, and pulled his fifth pair of gloves from the attachment.
Peter was still shaking, whether in shock or with cold, and Hesam pulled a blanket over his legs, as well as giving 4 mg of Zofran for the nausea. It wasn't much, but in the absence of morphine, it was all he could do to make Peter feel at least a little less miserable. His partner's eyes were half-closed, and it was plain he was on the verge of passing out. While Hesam could see how this would have to seem welcoming to Peter, he couldn't allow him to.
"Peter," he said, gently shaking him. "I need you to stay with me, OK? We're working on that blood pressure." The fluid was running fast; for the first time in ten minutes, the numbers on the monitor had climbed slightly. Hesam peeled off the blood-soaked abdominal pads and applied new ones; blood was still seeping from the wound, although considerably less than it had been. He was relieved to see that it was still red in colour, not the diluted, watery pink that would have meant that the Ringer's had gone straight through. He'd never had it happen to him, thankfully, but he'd heard horror stories of medics who had run too much fluid into trauma patients, effectively flushing any remaining blood out of their veins with too much saline.
He dared to hope that, if his pressure continued to climb, they'd be able to give Peter some pain medication soon. He knew they'd knock him out anyway once they reached the ED, but until then, he wasn't keen on Peter crashing on him.
Simon's voice came back through the hatch. "Medical Control needs his blood pressure."
Hesam gnawed his lower lip. Peter's face was white, and by now, he was sobbing in pain.
"62 over 39," Hesam said. "But tell them we've got a large-bore trauma line running wide on Ringer's."
"Two if needed," Karen amended, neatly depositing the needle in the sharps box.
"Order denied," Simon reported back a few seconds later. "His pressure is too low."
Karen's raised eyebrows nearly crept into her hairline, eloquently saying, I told you so.
"Let me talk to them," Hesam said, getting over to the doghouse window. They knew him; depending on who the doctor on the other end was, they'd probably allow him to use his own discretion on when to give the pain meds.
Karen had returned her attention to Peter, who had started shaking violently, his respiratory rate increasing as his blood oxygen dropped.
"Hesam." Karen's voice was quiet and urgent, calling him back in a tone that sent a shiver down his spine. Her eyes were fixed on the cardiac pattern on the monitor, which had turned into a feebly zig-zagging line as Peter's eyes rolled back and he went into v-fib, uncoordinated cardiac activity from which the heart couldn't break on its own.
Hesam had told Simon earlier that he might have to shock Peter, but he hadn't actually been able to imagine himself doing so.
He stared at Karen, then at the now-unconscious Peter, for what seemed like a minute although it couldn't have been more than three seconds, then he nodded at her to get to the biotech case, while he set the defibrillator paddles to Peter's chest, and set the charge to 200 joules.
"Slow it down for a sec," Karen shouted to Simon in front.
"Clear," Hesam told Karen.
Peter's body arched, and Hesam took some small comfort in the knowledge that, at least, he wasn't feeling any more pain.
The squiggly pattern on the monitor levelled into a flat line. "Asystole," Hesam said, in a clipped tone. "Epi."
Karen had already pulled up a milligram of epinephrine, and Hesam watched her pushing it through the IV line. He began to ventilate with the ambu-bag.
"Get him on a board," Karen said.
Hesam got the short board out from under the bench and slid it under Peter's upper body. All the while, he kept staring at the monitor for a rhythm to return, for the heart to reset itself, for anything. But aside from a weak twitching on the monitor as the epi hit him, Peter remained asystole.
Hesam started compressions. "Atropine," he said, in the same flat tone.
He heard the sirens howling, heard the sound of the monitor, the short, artificial blip whenever he pressed down on Peter's chest, heard Karen telling Simon to patch to the hospital that they were coming in with a full arrest, and felt as if he was sleepwalking.
Press. Blip.
Press. Blip.
Press. Blip.
"Come on," he heard Karen say as she pushed the atropine through. "Come on."
Hesam didn't say anything. He stopped compressions to stare at the flat line on the monitor.
Come on, he thought fiercely. Come on. We've got a large-bore line running full. That's gotta count for something. Come on. Don't you do this to me, you goddamn son of a bitch. Gimme a rhythm here. Please.
He took up compressions again.
Press. Blip.
Press. Blip.
Blip.
Press. Blip.
Blip.
Hesam jerked back to stare at the monitor, just as Karen shouted at him to stop compressions.
Blip. Blip. Blip.
It was slightly irregular, and too slow, but it was as close to a sinus rhythm as Hesam could have hoped for.
Hesam laid two fingers against Peter's throat to search for the carotid pulse. At first he feared he was imagining it, but then he was sure he felt one. He nodded at Karen.
"We got him back," Karen breathed.
Hesam still didn't say anything. Peter hadn't started breathing again, so Karen kept bagging, while he checked the oxygen levels, the IVs, the dressings, the stretcher sheets, just to rule out as many risk factors as he could, all the while staring at the pattern on the monitor, as if by staring hard enough he could will it into a sinus rhythm.
He briefly considered intubating, but since Peter's airway was still free, and oxygen saturation was near 100 percent, he decided against it. It was another risk factor he simply didn't want to chance right now. That his last intubated patient had gone asystole immediately after passing the tube didn't help, either.
The cardiac pattern finally evened out into a regular sinus rhythm, at a pressure of 60 over 40, slowly, slowly climbing.
"He's trying to breathe." Karen was timing the rate at which she squeezed the ambu-bag to coincide with Peter's weak attempts to draw breath.
"We got him back," Hesam repeated, as if the realisation was only just sinking in, and he didn't quite dare to believe it yet.
"How long's he been gone?" Karen asked with a look at the monitor.
Half an hour, Hesam thought as he glanced at the paper strip.
"Thirty-five seconds," he said.