The Ice Pick Story

The lady in the gutter was in extremely critical condition.

More like a just-about-to-die, extremely critical condition.

She was “circling the drain,” as we say when a patient is about to die.

We were dispatched Lights and Sirens to another “domestic", and it just so happened that we were parked about two miles from the location of the call. Our patient survived only because of this. Our care at the scene and on the way to the hospital was vital, but our treatments would not have been needed if we had not arrived so quickly.

The heart hangs like a pendulum from the Aortic Artery in the void of the chest between the lungs. The spinal column is behind it, and the ribs curve out from its Vertebral Bodies. Then, as they come forward, they wrap around both sides of the chest and under the arms, toward the front of the chest. It is here that they attach to the Sternum or the breastbone.

As they do this, they form a cage to protect the organs in the chest, especially the heart. The top part of the Sternum, just below the neck, is called the Manubrium, and the lower part is the breastbone.

Holding, or rather wrapping around the heart, is something called the “Pericardial Sac,” - Peri = on or around. It is there to contain the heart as it beats. Another reason it is there is to reduce the friction that is produced when the heart beats and rubs against the surrounding tissues.

If it were not for this sac, the heart would flop around in this open space between the lungs, and we would feel it hitting the surrounding structures inside us. The “Sac” contains and softens the movement of the heart, so we feel nothing.

Beneath this sac and above the heart's surface is a “potential space.” That is because the sac rides upon the heart; it is not attached to it. If it were attached to the outside of the heart, it would constrict the heart’s expansion as it fills with blood for the next beat.

The heart can also be constricted if any fluid collects within that potential space. When this happens, whatever the fluid might be and from whatever cause, it is a true emergency, and death can follow within minutes. Literally, in minutes.

Think of the sheets on a bed. The top sheet lies directly on the bottom sheet. There is no space between the sheets when the bed is not in use. However, when someone climbs into the bed, a space is formed when the top sheet is lifted off the bottom sheet.

When fluid collects between the sac and the heart, or the “top sheet and the bottom sheet,” space is created. As the fluid collects and this space is filled, the process is called a “tamponade” event.

The patient for this call was collecting blood under the sac from a hole in her heart, and it was collecting fast.

This story is about how she came to have that hole in her heart and the resulting events.

When we arrived, the police were already there, and a large crowd was standing on the sidewalk and overflowing into the street. They were in front of a one-floor apartment building that extended the entire block length, from right to left, and which was not one of Reno’s finest.

The front doors of the individual apartments faced the sidewalk and curb, and there were short pathways about ten feet long from the front doors to the sidewalk and curb.

The tenants parked their cars along the curb as close to the front of their particular apartment as possible, as we all would do. At this time of the day, the parking spots along the curb were filled with parked cars, bumper to bumper. Not one space was left.

The crowd was standing around one car in particular. It was a VW “Bug” of an early vintage, which today would probably sell for thousands of dollars. We had to stop in the middle of the street as we pulled up because the crowd was so dense and deep.

I jumped from the ambulance before it stopped and hurried to the center of the crowd that had gathered on the side of the VW against the curb. Everyone was looking down at the curb or street, so that is where I went.

When I reached the group and looked down, I found a woman lying in the gutter, on her back, face up, with the top of her head toward me. She wasn’t moving and had only a shallow and weak breathing effort. Also, there was a tiny hole in the upper part of the chest bone, or the Manubrium, which I mentioned earlier.

It was the size of a pinhole, just below and to the left of the “V” in the neck under the “Adam’s Apple.” She and her partner had a heated argument, and her blouse was torn. People in the crowd were saying he was beating her. That’s why she had run out of the apartment and onto the sidewalk. In the meantime, her assailant followed, grabbing an ice pick from the kitchen as he did. Why they had an ice pick in Reno was never determined.

As they continued to argue on the sidewalk, the man again grabbed her blouse with his left hand. Then, with his right, he plunged the ice pick into her chest. By the time we arrived, the police had the man handcuffed and secured in the back seat of a cruiser.

The lady in the gutter was in extremely critical condition. More like a “just-about-to-die,” extremely critical condition. She was “circling the drain,” as we say when a patient is about to die.

This refers to the water draining from a tub or sink. We’ve all seen it. As it drains, it forms a vortex “circling the drain” just before it falls in, never to return. It’s part of the paramedics and EMTs sardonic humor to which I have already referred in the story about “The Razor Blade Lady.”

As soon as I looked at her, I knew she was in trouble. Big trouble.

As I bent over her, I touched her eyelash with just the tip of my index finger to see if she would respond. Nothing happened. She didn’t blink or move her eyelid at all. Not at all. She was deeply unconscious, and that was a bad thing.

There was no time to waste. I spun around and began to run back to the ambulance. As I did, I looked back at the crowd and yelled loudly, “Move that car!” Then I turned back and continued running.

I was running to the ambulance to get the ”Scoop Stretcher.” The firefighters had already brought the gurney to the patient, but we also needed this particular device. As I ran, I passed a police officer.

“Is she critical?” he asked as he joined me running.

“Worse. Much worse,” I answered without stopping.

The scoop stretcher is an aluminum device about six feet long that opens and separates lengthwise from top to bottom down the center into two separate long pieces. Once separated, one of the two pieces is placed along each side of the patient, slid under their body, and clicked back together. Then the patient is “scooped” up and placed on the gurney with the scoop still in place. It provides a rapid and efficient method to lift and move a patient.

When I returned to the patient with the scoop, the crowd had moved the VW. They had banded together, lifted it entirely off the ground, and moved it into the middle of the street. By organizing this action independently, they became a part of the chain of events that saved this lady’s life.

As we rolled her on the gurney to the ambulance, I turned back toward them and yelled, “You folks helped save the life of this lady. You are all heroes.”

We loaded the gurney into the ambulance with the lady still on the scoop stretcher. They would also need it at the ER to move her. As I jumped in, the same police officer who had asked about the patient's condition jumped in with me.

Whenever there is an impending death by a deadly weapon, police must ride with the patient in case they make a deathbed statement. I was glad he was there. To save time, I would do all her treatments in the ambulance on the way to the hospital rather than in the street, and I knew I would need a second pair of hands.

While we drove Lights and Sirens to the emergency room, I administered oxygen with a face mask over her nose and mouth. Then I inserted a needle into the large vein in her neck. I didn’t use an arm vein because using a tourniquet on the arm would take too long. Instead, inserting it into the Jugular vein on the left side of her neck took about two seconds. As I did, she let out a low moan because of the pain.

“That’s a good sign,” I said, looking up and over to the officer. “If she’s feeling pain and moaning, she’s still breathing.” Then I attached a clear plastic tube to the needle in her neck and a soft plastic bag of medical water to the other end of that tube and hung it on the IV holder.

This IV was not to give her fluids. She didn’t need them. What she needed was a way for me and the ER staff to administer medicines directly into her vein. That way, if she needed them, they would take effect immediately.

Now that the patient was receiving pure oxygen and there was a route for injecting emergency medicines, I had the time to radio the doctor and give a report. But, at the same time I was doing that, I could not take my eyes off my patient. She could stop breathing at any moment. During the report, I told the doctor about the patient's condition, the argument, the fighting, and the ice pick.

Then I added, “There is a small hole in the upper part of the manubrium at its left edge.” Because of the patient's status and the hole's location, the doctor knew this patient had a hole in the sac covering her heart.

He also knew she had another hole in the upper left chamber of her heart, and that she was ejecting blood from her heart, out through that hole, and that it was collecting within that potential space between the heart and the sac.

Again, this condition is called Cardiac Tamponade. It develops when blood escapes from the heart through a hole each time it beats. It begins to collect because the hole in the sac has closed.

This happens because the human body is a miraculous machine. The sac tissue has the ability to “pucker.” It is able to constrict the tissue around the hole almost immediately and draw itself closed, as long as there isn't a lot of pressure pushing against it.

The heart, on the other hand, is a high-pressure system. Each time it beats, the blood is forced out through that very small hole and begins to accumulate under the sac. Even if it is a small amount each time, it can accumulate very quickly because, during an emergency event, the heart is usually beating very quickly.

As the blood accumulates, it begins to press on the heart. When enough blood is under the Pericardial Sac, it can produce enough pressure to keep the heart from expanding normally to accept the blood returning to it from the body. This, in turn, reduces the amount of blood being pushed out. This, in turn, reduces the amount of oxygen getting to the tissues, including the brain and the heart. And, of course, this, in turn, can cause death very rapidly.

All these things were happening to this lady as she lay there in the street, and we had no time to spare.

When this happens in some remote location far from a hospital, we must deal with it immediately. To do that, we carry a 6” cardiac needle and a large capacity syringe. We use these to suck the blood from under the sac. I have only done this once during my time “on the road.” We were so close to the ER this time that the procedure was not indicated, but I had the needle and syringe ready.

The first thing they did for this patient upon her arrival at the ER was this procedure, pulling out about a cup of dark red blood. Immediately, the patient regained consciousness but was still very disoriented. Once they stabilized her, she was sent to the operating room for an appointment with the surgeon.

After a few weeks, our patient walked out of the hospital on her own. Her domestic partner was sent to the Nevada State Prison for thirty years.

This patient was a true “save,” as we say in our profession.

Too many others were not.