He Blew Off the Top of His Head*
The phrase top of the head as in "He Blew Off the Top of His Head" isn’t used in the professional jargon of Emergency Medicine. It always conveys an incorrect image of what happened. It’s nothing more than the emotional, verbal reaction of an amazed and scared bystander when asked to describe what happened, as opposed to being an exact and correct medical diagnosis.
The phrase “He blew his head off” is the same. It doesn’t mean the entire head was separated from the body, although that also happens sometimes, just usually not with a gun.
What these phrases vainly attempt to describe incorrectly is quite different. Heads or tops of heads are not usually “blown off.” Sometimes bone is blown out from one side as a bullet passes completely through the brain and exits through the inside of the other side, taking bone with it, but that’s usually about it.
In truth, these phrases never portray a correct picture of what happened. However, “He Blew off the Top of His Head” was accurate for this particular emergency. Here is how it went.
We received the 9ll emergency dispatch a little after the high schools had let out. It came in as a “GSW” (gunshot wound) possible suicide in the Sun Valley area of the Truckee River Meadows area, approximately twenty to twenty-five minutes from Reno. Immediately we were concerned about the long response time.
People who otherwise would have had a chance to live go on to die because of long response times. When heavy bleeding is involved, long response times are killers, and this sixteen-year-old lad was doing just that. Bleeding heavily, that is.
In this case, however, our response time didn’t matter. He had done so much damage to himself, by himself, that he was brain-dead even before the family called 911.
The people living in this part of the Reno/Sparks area are challenged. Other Paramedics and EMTs refer to Sun Valley as “Slum Valley, the world’s biggest trailer park.” It was a rough life in Sun Valley in the Truckee River Meadows of Nevada, and on this day, it had proved fatal for one teenage boy.
He was tall. Long-legged and tall. He was also very thin, almost skinny. He looked as though he had never had enough to eat or what he had eaten didn’t have good nutrition.
He had told his family that his girlfriend had dumped him today. She had told him again he was too skinny, and she had done it publicly in front of the school. It was a big fight, and of course, everyone was there.
“I’ll show you. You’ll be sorry for this,” he yelled. “Just wait and see, I’m gonna kill myself, and it will be your fault.” He also said he knew where they kept the gun and was going home to get it. With that, he stormed away. Of course, this same fight had happened so many times before that no one believed him, again. However, for some reason, this time, he did it.
After completing a long, twenty-minute CODE THREE, lights and sirens emergency response, we found him lying on an old couch in the front room of his family’s trailer.
But, all of him wasn’t really on it. The lower half of his body was stretched straight out, and his legs were stiff as boards. Only his upper body was on the couch, leaning toward me, to his right. He was bent at the waist with his head and upper body still on the couch. Along with being as stiff as boards, his legs were shaking violently with convulsions.
He had held the handgun in his right hand and had placed the nozzle against his right temple area. I knew this because of his injury. I had seen it too many times before, just not this severe.
When a handgun discharges, there is a forceful kick, and the barrel jerks upward. As it jerks upward, it is no longer parallel to the ground, so the bullet does not go horizontally through the head. Instead, as it comes out of the gun's upward-slanting barrel, it goes upward at the rising angle of the barrel.
Also, when a person holds a handgun to the side of their head, they don’t usually hold it level in the first place. It’s a hard position to maintain even when a person isn’t under the stress of such a moment. I guess people don’t know these things because no one does a dress rehearsal for suicide by handgun. Everyone just keeps messing up this type of an attempt at suicide.
For this not to happen, the gun’s muzzle must be inserted into the opening of the ear canal and then pressed inward forcefully. By doing this, the gun barrel is trapped in the ear canal, preventing the upward jerk.
Anyway, this boy had made the same mistake. The bullet didn’t go right to left through his head for a quick death. It had entered his head high above the right temple area, and "He Blew Off the Top of His Head" along with all his hair, scalp, skull cap, and brain matter.
All these tissues had been blown onto the back of the couch to his left, where his head had bounced off after the blast. After bouncing off the back of the couch, it had rebounded to his right. That is why he was leaning at the waist to his right with his head on the couch.
After rebounding from the impact with the back of the couch, he slumped from sitting up to lying on his right side with his head on the seat cushion and his legs still off the couch, bent at a right angle to his upper body. When I approached him, he was unconscious and having that seizure activity, and amazingly, he was still breathing.
The protocol or treatment plan for head injuries where the individual is still alive but unconscious requires a cervical or neck medical collar. It is to be placed around the neck just under the chin. All unconscious patients get one because they are not awake to tell us their neck does not hurt, and this lad was definately unconscious.
A patient’s head must be held simultaneously with two hands to place the medical collar. One hand must be on each side of the head over each ear, with the fingers grasping the angles of the jaw bone. Once the hands are in place, a gentle backward and chin-tilting upward pull is applied. This action is required to slightly elevate the chin to create a space to place the collar under it.
In this case, truly, he had blown off the top of his head. Blood, cerebrospinal fluid, and other tissues were on the couch around his head. It had collected into a pool deep enough for his ears to be submerged, and we had to put on a collar.
To do this, I had to sink my ungloved hands (this was in the days of no gloves) into this still warm, thick, smooth, dark red, pudding-like mass pooled on each side of this lad’s head. As I tried to get past the dreadful sensation, I placed my hands over his ears and grasped the angles of the jaw on both sides.
Then, I gently pulled back and upward to elevate the chin so my partner could apply the collar. All these years later, I can still feel that warm, smooth, and pudding-like thickness sensation on my hands. It is still disturbing.
To do this procedure correctly, I needed to be exactly above the face and kneeling behind the top of the head. My partner applied the collar and fastened it in the back as I maintained this elevated chin position. He, therefore, also had to emerge his hands into the same pool of warm, pudding-like human tissue.
“Oh, my God, this is horrible,” he said, whispering so no one else could hear. I silently agreed. It was.
Because I was kneeling on the couch above his face and behind his head, and because, the top of the head was entirerly missing, I could see directly into this boy’s now wide-open brain cavity.
The two pink lobes of the brain were visible. Between them is a natural groove called the Sagittal Sinus. Here, arterial blood collects after coursing through the brain tissue, supplying nutrients. Via this groove, the now venous blood is sent to the lungs for re-oxygenation.
When this system is intact, the groove is filled with blood circulating through the brain tissue. As I looked down, there was no blood. Not a drop. Most was on the couch in that warm, dark-red, pudding-like pool surrounding his head and in which my hands and knees were now immersed. This teenage boy was dead, but we had to treat him because his chest was still rising and falling, and many people were watching. The problem was there was no blood left in his body to carry the Oxygen.
I authorized the air ambulance to be dispatched from Reno, inserted a tube into his air pipe, and flooded him with pure oxygen. At the same time, my partner was starting three high-flow IVs, one in each arm and one in his neck. We hoped the fluid would keep his veins full of fluids and maintain a high enough blood pressure to keep his heart beating. But, it was only medical water and could not carry Oxygen whether the heart beat or not.
With the help of some of the Firefighters on the scene, we also put on the MAST garment. This item resembles a fisherman’s wading overalls with a high waist and two leg areas. The high waist area and both legs have inflatable compartments.
We inflated both leg compartments for this lad to give him at least some kind of a blood pressure. We hoped this would squeeze any remaining blood in his legs into the upper part of his body. No blood was left in his legs or any other body part, but this was a mandatory treatment protocol in these scenarios.
With that, we had done all we could do for this boy. We did not carry on the ambulance what he needed, whole blood and a surgeon. They were doing CPR as the helicopter rose into the air.
During many shifts, I must deal with bodily substances getting on me, usually mostly by accident. There is blood, spit (usually not by accident), sweat, vomit, urine, feces, cerebrospinal fluid, puss, and embryonic fluids, but this time it was different. This time, I had to purposefully reach down into that boy’s pool of blood, cerebrospinal fluid, and other substances and try to bring him back. It was a macabe task.
With my hands still in that warm mass, I remained positioned above his face and kneeling on the couch behind his blown-wide-open head. Then, I leaned down to get as close as possible to his bloody right ear, which I still held in my hand. I was so close my lips touched it while whispering, just for him to hear, “Don’t go, don’t go.”
It didn’t work.
Henry Lansing Woodward
Paramedic
*Taken from, "Lights and Sirens, One Day in My Life as a Paramedic."
