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Memorable Moments

surprisingly. But as we warmed him up, all the severed blood vessels that had been clotted off began to bleed again.

For the first time, I looked closely at the wound. I could see that he had positioned the blade so it was too far up on his neck to sever his carotid arteries. In fact, the blade had passed so high that part of his mandible, or jawbone, had been shaved off on the right. Most of the bleeding was coming from the right submandibular salivary gland. I had to use more than a dozen small vascular clamps on the little vessels before the flow of blood was reasonably stanched.

On the left side of his neck, there was less bleeding. As I was using a gauze pad to soak up the pooled blood, I came across the entirely exposed carotid artery. It had been bluntly dissected from the surrounding tissue and was standing free like a large pipe. Reflexively, I yanked my hand away from it, not wishing to disturb any clots. Had the blade reached this vessel, the patient would have achieved his goal. As I was completing the task of clamping off the final bleeders, I noticed the general surgeon standing over my right shoulder. After a long silence he said, "This guy has to go to the OR." It wasn't a hugely helpful observation, but it was a whole sight better than "Holy s—." Soon we were done packaging the patient for transport, and he was on his way to the OR.

I could finally relax, although my adrenaline was still pumping. I joined the EMTs and the police, who gave me a more complete story. A cop had been making routine rounds in a remote parking lot when he came across a car that had crashed headfirst into a tree. Its windows were frosted over. As he approached the vehicle, he noticed several large areas of deeply blood-stained snow. He opened the driver's door and found this guy sitting there, covered with blood. "Are you okay?" the cop asked. The guy turned silently and looked right through him. Later the cop told his partner, "I'm sure that if he had come toward me, I would have shot him."

Further investigation revealed the following items on the floor of the car: a piece of two-by-four; the blade from a large butcher's cleaver; a ruler; and several C-clamps. After a disagreement with his girlfriend, the guy had clamped the blade to the two-by-four, which he placed across the steering wheel. Then he accelerated into the tree, apparently in an effort to cut off his head. He nearly succeeded. I shudder to imagine his

We found the six-month-old girl lying on a stretcher; her eyes were open but she was barely responsive.

shock when he found himself still alive. The blood in the snow and the backseat of the car made it clear he'd moved around quite a bit, no doubt trying to find a comfortable way to breathe while awaiting death. But the cold weather, which slowed his bleeding, and his unacknowledged will to live conspired against him.

The next day I went to the ICU to look in on the guy. I felt more than a little trepidation about seeing him again because, frankly, he scared me. He was obviously a person who was capable of carrying out a plan, and I wasn't sure I wanted him knowing who I was in case he decided he was dissatisfied with his care.

Over the years, I have successfully erected a self-preserving wall between my patients and me. My emotions and I are

on one side, and patients and their problems stay on the other side. But the night before, this guy had come barreling through the wall, and before I knew it he was right there next to me.

I found him in the ICU with his neck wound nicely sewn together. He was medically stable and sleeping, thank goodness. I learned that the ICU staff had nicknamed him Mr. Pezhead. Although outrageously insensitive, such black humor is another defense mechanism—like my wall—that medical personnel use to cope with the sometimes grim nature of our work.

When I got back to the ED, the security guard asked me, "Were Ward and Wally there visiting?" The comment clearly sailed over my head, so he explained: "You know, the Cleaver family." I have to admit that I laughed. Maybe it wasn't the right thing to do, but it's what helps us get ready to face the next patient who rolls through the doors.

Timothy Bray, B.S.N.
At age 17, Bray was one of the first hospital-based EMTs in Massachusetts—in the ED of Framingham Union Hospital. That was 1972. He earned a bachelor's degree in nursing in 1985, then worked in emergency departments and intensive care units in Boston and in New London, N.H. He has also served on many volunteer rescue squads. In 2000, he joined DHART's then-new Mobile Intensive Care Unit, and in 2006, he became the service's first chief flight nurse. There have been many memorable moments during his career, but one transport stands out in his mind.

At 2:30 a.m., my paramedic partner, Tony, and I received a page to respond to a small community hospital for a child with sepsis—a massive infection—who needed helicopter transport to the pediatric ICU at the Children's Hospital at Dartmouth. The pilot characterized the weather as marginal, but within the acceptable minimums. During the flight to the community hospital, the pilot said we would need to be as quick as possible in the emergency department as the weather was expected to worsen.

Upon our arrival in the ED, we found a six-month-old girl lying on a stretcher; her eyes were open but she was barely responsive. She was clearly in septic shock. The diffuse rash on her trunk and the history of her illness suggested meningitis. Her mother and four-year-old brother were standing at her bedside. The

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