Last week, I responded as a paramedic intercept to a motorcycle versus car.  The rider skidded along the pavement a distance of 84 feet (so the investigators say) before coming to a sudden violent stop by t-boning the car that had pulled out in front of him.

I exited my intercept vehicle, grabbed my ALS bag, and walked toward the crumpled motorcycle next to a crumpled patient.  He was surrounded by firefighters and EMTs.  I looked at the rider's face and could see he was awake, breathing, in pain, and answering questions.  One of the EMTs was kneeling next to his leg, got my attention, and nodded toward her hands.  In them was his left foot which had been severed from his leg except for a small fleshy bridge.  His tibia/fibula were protruding from his pants, and showed signs of damage and debris from where he tried to stand and walk after the accident.

We did the usual things we do in this situation.  Stabilize the foot and control bleeding.  Large bore IVs, secure to the long board and immobilize, move to the ambulance, detailed trauma exam, vitals.  You know the drill.  I gave him 200mg of ketamine, ran fluids, and reviewed details while I waited for the helicopter.  When the crew arrived and I had given report, we watched his vitals drop steadily.  His lungs were wet, breathing rapid and shallow.  I reached into his cervical collar to feel for his trachea, checking for a tension pneumothorax.  We did needle decompressions on both sides of his chest, and continued to watch his vitals drop.  Blood oozed from the right side, so I noted a hemo-pneumo and started an IO in his uninjured leg for additional access.  I continued the process of turning him over to the helicopter crew and hoped they would get going soon.  They decided to intubate (I work in a single paramedic system and cannot RSI alone), which burned some more time.

Finally we slid the patient onto their cot and I watched them load him up.  We waited to watch the helicopter take off, something that never gets old for me.  We waited.  And waited.  Finally I decided we needed to get back in service, so we left.  I got a phone call an hour later telling me the helicopter was still on the ground.  This meant the patient didn't make it, and they were waiting for the coroner and crime scene investigators to arrive and do their thing.

This is just one of many, many patients I have watched circle the drain and eventually die, or declared them dead after finding them pulseless and non-breathing.  Few really have any effect on my mood or mental health.  I remember some because the details are interesting or informative--for example this last one is the first tension pneumo that I watch progress from a conscious, breathing, fully alert patient to a dead one.  But, for the most part, my armor has been thick and effective in keeping my paramedic life and personal life separate.

That armor had, I found out recently, a weak spot.  A month ago I was called to a garage where dispatch broadcast "a woman was found hanging."  As I walked in the side door, the police officer beckoned to me to make my way around the car.  As I rounded the corner I saw a nineteen year old female, hanging from a bicycle lock cable, so low to the floor that her feet were on the ground and she was practically in a seated position.  Her feet were on the floor, which meant she could have stood up if she wished and changed her mind.  But she didn't.  Which means she really, really wanted to die.  Her long hair was completely covering her face, but her neck was visible, pale, and stretched out in an unnatural way.  She was dressed as a quintessential teenager.  Jeans.  Ugg boots.  Pink jacket.  I asked the officer what he needed me to do.  He asked me to confirm she was dead, and he reached for her hand and lifted it a bit.  Rigor mortis was well advanced, and her entire body rocked from that slight movement.  So I nodded my head and confirmed the rigor.

A few days later this young woman's photo appeared in the paper under the death notices.  Her picture is burned in my memory, along with her final disposition.  I thought about what despair it would take for this girl, seemingly with all the advantages of youth and everything to look forward to, to generate the sadness and hopelessness to end it all.

I still think of her often.  I think about her life and death.  It's going to stick with me for a long time.  The motorcyclist will eventually be little more than a war story with some interesting medical details.  But this girl, she'll be something that haunts me much longer, and on a much deeper level.

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