As in any trauma case, I constantly monitored the captain’s AVPU scale—another great lesson from goat lab. AVPU (which stands for alert, voice, pain, unresponsive) is a tool for assessing level of consciousness. If the person is awake, opens his eyes spontaneously, and responds to questions, he’s alert. In that case, I would make a mental note or ask someone to record Alert 1545.
The patient is one step lower on the scale if he doesn’t move or open his eyes spontaneously but does respond to a voice; in other words, if the patient makes any sort of groan or movement when I ask, “Are you okay?”
Below that is pain—that is, responds to painful stimuli only. For example, the patient moans as you apply a splint or IV. I might also tweak the person’s ear or rub the sternum with the knuckle of my middle finger to see if there’s any response.
The worst case, other than death, is when the victim is unresponsive to both voice and pain.
Initially, Captain O’Brien was totally unresponsive. I tweaked his ear and did a sternum rub, but no response.
I monitored his airway constantly, because an airway can become obstructed at any time by bleeding, vomit, mucus, broken bones, teeth, or swelling. Just because the patient has an airway during your initial assessment doesn’t mean that it won’t close during your treatment.
Captain O’Brien had an airway, and we had stopped most of the bleeding. Now I needed to get fluids in as quickly as possible. Since he’d lost so much blood, he needed a blood-volume expander—Ringer’s lactate. But I had a hard time finding a good vein because all of his limbs were injured. I finally managed to get two large-bore IVs in his good arm, then pumped in 4,000 ccs of Ringer’s lactate.
Within twenty minutes, I’d gone through everything in my SF medical kit.
The captain’s pulse was over 140 beats per minute. His heart was beating this fast because his brain was crying out for more oxygen.
If a patient’s pulse was 110 and his breathing rate was twenty, and then I checked three minutes later and his pulse was 130 and his breathing was thirty, and then two minutes after that, it was up to 160 and forty, that meant something was seriously wrong; I’d need to correct it quickly or the patient would die.
What had been killing Captain O’Brien was all the leaks. Now that we had stopped them, his heart rate and breathing started to stabilize. Then he moaned and began moving around a little bit. He’d gone from being unresponsive to responding to pain. A step in the right direction. His pulse was getting stronger and his breathing was becoming deeper too.
Suddenly, he asked in a whisper, “Hey, what happened?”
I said, “Sir, what’s your name?”
“Captain Mike O’Brien.”
“Do you know what just happened?”
“No, but I went to pick up a flashlight.”
That told me that he saw the live rocket round in the Dumpster and went to pick it up.
He asked, “How come I can’t see?”
As a medic, I couldn’t say, Because your eyes are hanging down your face.
It was my job to keep him as comfortable as I could.
I said, “You’re going to be fine, sir.”
He asked, “How come I can’t feel my hand?”
I said, “We’ll look at that. We just called medevac.”
Half an hour had passed since the explosion. It seemed that medevac was taking forever.
Captain O’Brien asked, “How come I can’t feel my leg?”
He got to the point where he was actually joking about his condition. He said, “At least if I still have my nuts, my wife will take me back.”
The man’s courage was amazing.
I’d moved to Captain O’Brien’s side and left a guy I didn’t know in charge of keeping the captain’s head and neck immobile, something you always have to do in the case of a traumatic injury because of the possibility of damage to the patient’s spinal cord.
When I saw him starting to move the captain’s head, I said emphatically, “Don’t move his head!”
“It’s okay,” the man responded. “I’m an Army doctor.”
“Well, if you’re a doctor, how come I’m doing all this?”
The Army doctor said, “His neck isn’t broken. I can tell.”
“You don’t have x-ray fingers,” I shot back. “So you can’t tell. Hold his head still.”
After forty-five minutes the medevac team arrived and flew Captain O’Brien away. He ended up being treated at the Army burn center in Texas.
Later he sent me a letter. He told me that he’d lost one eye but had partial vision in the other. He’d been fitted with a prosthetic leg. Surgeons removed a toe off his foot and attached it to his hand so he had opposing fingers on one hand, which meant he could grasp objects and lift them up.