Not Your Emergency: Accepting Your Limitations

“EMS Reruns” is an advice column designed to address dilemmas you may have experienced in EMS that you did not know how to handle. But it offers you a luxury you don’t have on scene: plenty of time to think. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we’ll pay you $50. We don’t know everything, but we do know a lot of smart people. If we need to, we’ll contact just the right expert and share their advice with you. Send ideas c/o emseditor@aol.com.

Sometimes it seems as though no matter how hard you try to help, you’re just not good enough to get the job done.

You’re dispatched to a private address for a “man down.” When you arrive on scene, you see a tree-trimmer’s orange truck at the curb on the opposite side of the residential street. A fire engine is parked behind it, and the engine company is moving briskly toward a big pile of tree cuttings in the middle of the lawn. A bent yellow ladder leans against a 60-foot tree in the middle of the debris. The captain motions you toward that area as you pull up, but you don’t see a patient yet.

Once you get close, you see him: A guy in his 30s, unresponsive and trapped in a supine position under the cut end of a 15-foot branch. The part of the branch that’s on top of him is about eight inches in diameter, and it’s lying right across the man’s nipple line. His face is bloody, and you can’t tell right away if the bleeding is external or internal. There are loose branches everywhere, and the trailer-mounted chipping machine is making a lot of noise.

As the firefighters concentrate on disentanglement, you go for the airway. Sure enough, there’s a fluid level of blood in the retropharynx, and you move to suction it out before inserting an oral airway. The plan is for your partner to ventilate while you set up your tube. But this man’s face has been crushed, and the mask doesn’t do a lot of good. There’s no bony integrity at all in his face, and his pharynx fills with blood almost as fast as you can aspirate it. There are big, vertical linear abrasions in the midline of his anterior neck and upper chest. It’s 3 p.m., kids are out of school, a crowd of adults and children is gathering and it’s starting to rain.

Q. What are your priorities in this situation?

A. Number one is to shut that motor off to make it possible for you to communicate with people. Shouting, even when you’re not particularly excited, tends to get everybody else excited. Number two—only because you can relay it quickly—is to get PD on scene to set up a perimeter and control the crowd. Number three is to get the log off the patient’s chest. It may be accelerating his loss of blood, and if you can control that, it’ll simplify number four, which is to intubate his airway. Number five is to clear enough debris so you can protect the C-spine and have some space to work in. (Of course, every one of those things needs to be done first, right?)

Q. What do you think happened here?

A. Looks like this guy may have miscalculated the fall of that big limb and underestimated its weight. Living tree limbs can be really heavy, especially if they’re hardwoods like oak, maple, ash, birch or walnut. Usually, a tree cutter will try to remove a big limb by topping it first—cutting off its smaller branches. But you don’t need to guess. There should be a second worker with that truck. He may be able to tell you exactly what happened.

You really have to struggle to intubate this man, and you finally succeed on your third attempt. Despite that, he succumbs to a big flail segment and bilateral pneumohemothoraces, as well as a fractured larynx. It takes two hours to clean your uniform and your equipment.

Q. Wow, what did you do wrong?

A. Probably nothing. Just because you worked your butt off and the guy checked out anyway doesn’t mean it’s your fault.

Nobody gets out of here alive. We all take the Big Vacation someday, no matter how good our first responders, paramedics, ED friends or trauma teams are. Life is full of burning buildings, airplane crashes, homicides and broken-down hearts.

As terrible a call as this was for a young man and his family, it was not your emergency. Remind yourself of that when you arrive on a scene that looks real bad. It’s somebody else’s emergency, and what you can do to help may not be enough. As long as you keep yourself competent, it never has to be your fault.

The tree-trimmer died because a big tree limb crushed him, not because the folks who did their very best to help him were mere humans. Extraordinary ones, at that.