Carol Cramer is a community and staff education nurse, education
department. Pioneer Valley I Hospital. West Valley City, UT.
In emergency nursing, a sense of accomplishment sometimes requires
looking beyond the stretcher in front of you.
The confusion at the crime scene was evident in the report received by
the emergency department. The paramedics initially called the patient critical,
then dead, then critical again. With two gunshot wounds to the face, she had an
agonal heartbeat, no pulse, and no respiration. When the ambulance arrived at
the ED, the paramedics were performing manual chest compressions and using a bag
and mask for ventilation. They were unable to intubate her.
"Load her up and bring her in," the ED physician directed. "We'll
decide what to do after we evaluate her."
The slender 33-year-old was carried in strapped to a backboard, her
dark hair matted with blood, her mauve crushed-velvet shirt torn to shreds. Gold
hoop earrings hung on either side of her blood-covered face. On her feet were a
pair of blue slippers.
We tried several times to intubate her, but the tube would only go in
about halfway. Between attempts, we ventilated her with the bag and mask while
continuing chest compressions. Intravenous epinephrine and atropine were
administered. Finally, her heart started beating again and her pulse
As I cut off the patient's clothes, a police officer took them and
hastily stuffed them in an evidence bag. He filled me in on what had taken
place. The woman's boyfriend had called the police and reported an "accidental
shooting." When the officers arrived, they heard shots. The boyfriend explained
that he was "unloading his gun into the carpet." Though the paramedics hadn't
been able to identify any exit wounds, the police believed two of the bullets
they found embedded in a wall had passed through the patient. (Figure 1)
No caption available... Image Tools
I pulled the cricothyroidotomy tray out of the cupboard and blew the
dust off the cover. After checking the expiration date, I set the tray on a
bedside stand. Turning to face the patient, I heard a strange flatulent noise
each time she was bagged. As I slipped my hand under her back, I felt crepitus.
The skin on her upper back and neck was filled with free air. I slid my hand
across her shoulders toward her neck and my fingers disappeared into a gaping
"I found an exit wound!" I said. My index finger rested on something
sharp, which turned out to be the remains of her fourth cervical vertebra.
X-rays later showed her entire third and fourth cervical vertebrae were blown
I removed her Saint Christopher's necklace and the physician made a
deep incision into her cricoid space. The yellow cartilage of her trachea lay
deep beneath the edematous tissue of her neck. We tried several different sizes
of tubing before we succeeded in inflating her lungs without losing oxygen
through the hole in the back of her neck.
With a secure airway in place and oxygen being administered, her pulse
became stronger and her blood pressure rebounded. But it was getting harder and
harder to compress the bag. A portable X-ray showed what looked like a
left-sided pneumothorax. We inserted a chest tube, but it didn't help. We placed
a second chest tube in the right lung. Still no improvement.
Finally, withdrawing the endotracheal tube half an inch eased the
resistance. I inserted a nasogastric tube with extreme caution-worrying that it
would thread into her brain-and then catheterized her bladder.
By now we were wading through paper, boxes, syringes, trach tubes,
linen, and blood. All the major trauma trays had been pulled out of the cabinet
and strewn on the floor in our haste to find the ones we needed. I was
scribbling notes on the backs of wrappers, to be transcribed into the chart
An hour after she arrived, the patient was stable. She was ordered
transferred to a nearby trauma center. As we put her in the helicopter, I handed
a police officer a plastic bag holding her blood-covered earrings and
"Was she pretty" he asked.
"I don't know," I answered. "I never looked."
The next day I called the trauma center and learned she'd been
pronounced brain dead. Her parents had agreed to organ donation, and her heart,
liver, lungs, and both kidneys were successfully harvested.
I never learned her name or anything about her. But I do know that our
work was a success, because our patient gave five other people the chance she
never had-the chance to live.