Tuesday, November 1, 2011

An Unexpected Test--Part II

I'd get to the girl, first I wanted to make sure Maggie was stable.

Maggie was well bundled up which made a quick primary survey almost impossible. I put my hands under her jacket and tried to feel along the bony aspect of the back of her neck. I pressed down on each vertebrae while asking if she was having any pain, numbness, or tingling. She said no.

I tried to move my fingers systematically around her skull feeling for any ridges, deformities, warm tangles of blood, boggy swelling. Nothing.

I quickly checked the pulse in her wrist—strong. That was a good sign, she had a decent blood pressure and wasn’t tachycardic, which meant she wasn’t going into shock (yet) from some hidden injury that was causing blood loss.

Maggie was alert and talking to me the whole time, she said one of the girls on the hike had lost control coming down too fast from the top. Maggie lunged after her, also losing her footing and going head first down the steep and rocky terrain. Now I was getting worried about this unknown girl and felt fairly certain that Maggie had no immediate threats to life or limb (despite my woefully brief and incomplete initial survey).  I asked the 3 young girls with her to try their best to keep each other warm, to continue talking to Maggie. I asked them to send someone over to me if she suddenly became confused, nauseated, or started complaining of numbness or tingling. 

I scurried over the slippery rocks to the second cluster of people, perched on the lateral aspect of the slope. A young girl was buried under a similar assortment of raingear and jackets, crying out in pain. Two of her teenaged friends were huddled against her, shivering in their thin hoodies and track pants. Her legs were splayed awkwardly but with no visible deformity, blood spattered the rocks near her feet. Under the hood of a green raincoat I could see that her hair was thickly matted to one side of her face with blood that appeared to have come from her scalp. Her cheek was also cut, just under the eye. She opened her eyes when I asked her to and told me she’d started coming down the mountain and couldn’t slow down, she didn’t know how she’d fallen or if she’d been knocked out.  Her pupils were of equal size, they constricted when she focused on my face, she knew where she was, and who she was there with.

Again I wrestled with the tangle of clothing trying to feel her neck and scalp. She said she had no neck pain but yelped whenever I touched her head, especially near her forehead. It seemed impossible to locate the cut as all the blood had dried in the lumpy nest of hair.  I looked in her ears and under her nose for blood or clear fluid that might indicate she had fractured her skull. Dry. She didn’t have the characteristic pattern of bruising associated with basal skull fractures, the bluish tinge behind the ear or black circles referred to as ‘raccoon eyes’.

I felt her wrist, trying to locate her pulse. As I measured her heart rate, which was fast but not worrisome, she complained of pain. I was reassured though, by the lack of a sickening crunch or odd angle to the joint, something I’d come across many times in the Whistler emergency department. I put my hands under her jacket, asking her to take deep breaths while I felt her chest rise and fall. Her rib cage felt stable and she said she had no troubles breathing. Good. She had a blood pressure and no breathing issues.  I felt her belly, tested the bones of her pelvis for pain or instability. She cried out in pain when I brought my hands down her left thigh and leg. I couldn’t feel any swelling or grinding under my pressure, the leg didn’t seem shortened but it was hard to tell and I didn’t want to move her limbs unnecessarily.

Somewhere in all of this I found out that the man with them was Father Henry, the priest who had been escorting a church group up the mountain, which is a famous pilgrimage for Catholics.  Maggie was the other leader of the group, which left him running back and forth between the two huddles, with one cell phone (and sometimes two) pressed to his face. 

It was during my assessment of Tina that I too started to shiver. Suddenly the combination of wind, fog, sweaty T-shirt, and stillness left me very cold and wishing I’d brought more clothes. I pulled on my damp wool shirt and windbreaker. Once I was crouched behind Tina with my hands along side her jaw and neck to stabilize her cervical spine, I realised that if I was that cold, the girls lying on the ground were in even bigger trouble.

At this point an athletic Swiss couple, each dressed in layers of hi-tech looking gear, arrived and offered extra coats to pile on the injured hikers. The woman pressed up against Tina’s legs, the man against her right side. Tina’s two friends took up positions on the left. A tall middle aged Scotsman came up and suggested we use his large backpack as something to put underneath Tina

I cringed with the realization that I should have thought of that ages ago.

CAcBCDE. Catastrophic bleed. Airway/c-spine. Breathing. Circulation. Disability. Environment. 

All of this had been drilled into me again only weeks ago at the Advanced Trauma in Community course I’d taken. Environment. As in, assess complications due to environment such as cold temperatures and adjust to protect against these dangers. 

And so there we were.  All of us freezing, worried, and wondering how long it would take for the mountain rescue crews to arrive, if they were sending a helicopter, and if the helicopter would even be able to land amidst the fog and wind.  I asked one of the girls to take over c-spine for me as I went back to check on Maggie. She was well bundled up and had a similar gathering surrounding her. The tall and quick thinking Scotsman and his wife were monitoring her. This gave me peace of mind over the nagging thought that I was ignoring one of the casualties. Maggie was still alert and oriented, nothing had changed since I had first assessed her. She said she was more worried about Tina than anything else. I tried to reassure her before running back to my post: holding on to Tina’s neck.

We heard ambulance sirens in the distance which gave us hope that help was soon to arrive, hopefully with blankets at least and and possibly stretchers.

“Wait!!!” I asked Matt, the teen to my left, to grab my nearby camelback.

“I had an emergency blanket in there this morning…did I leave it in or put it in my other pack?? Ohhh…” 

And then I remembered the brief conversation I had had with myself before heading off this morning. “I am only going on a road ride and a run, I am definitely not going to need my emergency blanket or my headlamp.”

Of course.  Dammit! We really could have used that emergency blanket now.  Tina was shivering uncontrollably to the point where her teeth chattered causing her to cry in frustration, “Get me OFF this mountain!!!! Where are they??”

We tried to calm her by talking about Justin Bieber, the hot blankets that awaited her, the exciting helicopter ride she was going to have…it distracted her for short periods of time. Father Henry would threaten to start singing if Tina went quiet for too long. This proved to be an effective technique for getting her to start talking again.

By now, over an hour had gone by since I arrived on the scene.  I thought about sending the teens down with one of the hikers who was offering to help. Were they going to get hypothermia while trying to keep their friend warm? Were we only creating more casualties by keeping them with us? What was the legality of sending minors down the mountain with strangers? What if we were up here until the middle of the night? I remembered only a couple of months ago a woman being stuck on Carrantuohill until 4am waiting to be stretchered off the mountain with a broken ankle.  At least now they could get down safely in the daylight. For the time being we decided to keep them with us. 

Surely mountain rescue was going to arrive any minute.


Christopher said...

Have you done any of the NOLS Wilderness Medicine classes? Great stuff! You'll remember silly things like, "bring a whistle." You can't yell for very long, but you can blow a whistle for quite a while.

Did mountain rescue bring brandy with their St Bernards?

Anonymous said...

The retrospetascope is a powerful tool, eh?

Excited to hear how it ends.

Anonymous said...

awesome story so far! Excited for part III.

Made me think though, I have/am building all these ER skills that are great for use in the ED, but in a situation such as this, I often wonder what good is it really to do ABCDE and the like? Out on the street, I can't intubate, I can't resuscitate, altermed mental status? Can't do much about that... D&E, yes, you can do a few things about that, but I don't think being an ER doc gives me much of a leg up on the lay public for those last two. Maybe just having the experience to rationally think about D&E, much like you did. Anyways, excited for the conclusion.

audare said...

Girl! You are good at keeping us in suspense I feel like I'm reading a chapter in a newspaper and am on tenterhooks waiting for next week's issue. I know you don't know me personally, but I love your blog.
a first year med student

Knot Telling said...

This reminded me of a multiple casualty situation I was in about 10 years ago. Although I had (long ago) been an ER RN, my subsequent years in psych pretty much ruined me for anything more than Red Cross first aider type help. I felt so frustrated and helpless.

How were you feeling during all this? Your functioning sounds amazing.

Anonymous said...

Such an epic afternoon on the mountain. Can't wait to read the conclusion.

@Christopher NOLS Wilderness First Responder classes are awesome. I took one a couple of years ago as part of my WEMT certification and loved every minute of it.