Monday, 19 December 2016

Lessons learned

The conversation I was having with my patient's boyfriend and father was going quite well, I thought.  I was reassuring them that Annabel (not her real name™) would be just fine.  It might take some time, I explained, but I expected her to walk out of the hospital within a week or so.  As I am a realist rather than an optimist (though some would say I'm actually a pessimist), giving such reassurance is a rare occurrence for me.  Annabel's boyfriend was therefore understandably smiling when he said, "That's great news, Doc!  So the first lesson to be learned here is wear your seat belt.  And the second is not to crash!" he laughed.  I didn't.

His smile evaporated after the next thing I said.

But I'm getting ahead of myself.  Let's go back to a more appropriate portion of the story: the beginning.

Annabel (still not her real name™) was brought to me just before 1 AM on a Saturday morning, having been ejected from the car she had been driving.  The first lesson Annabel apparently never learned was to wear your damned seatbelt, because if she had been wearing it she would not have been ejected.  The second lesson she very clearly never learned (which both MomBastard and Mrs. Bastard drilled and continue to drill into my head) was to wear a coat in winter, because Annabel was not wearing one when she was found in a pile of ice and snow.

"Hey Doc, this here is Annabel.  She drove her car through a farm."

A farm?  Just when I'd thought I'd heard it all.  My look of utter bewilderment apparently prompted the medic to continue.

"Yeah, she crashed through a whole bunch of stuff including a fence.  We found her outside the car on the ground in the ice.  She's real cold and she's been unresponsive the whole time.  Blood pressure has been fine though."

On my initial evaluation she was ice cold and indeed unresponsive.  She was moving all of her extremities (good) in an uncontrolled fashion (bad), so while I considered the possibility of a brain injury, my concern for a serious neck injury was rather low.  But my concern for an Everything Else injury remained high.  Because she was both unresponsive and uncooperative (a rather difficult combination), we intubated and sedated her to protect her airway and allow us to complete our examination.  As the anaesthesiologist was inserting the breathing tube, I performed her abdominal ultrasound.

As Annabel was a rather, ah, big girl, the sonogram was technically difficult to perform.  However, when I put the probe over her spleen I saw what appeared to be fluid between it and her left kidney.

Oh shit.

I moved the probe over to her right side and placed it over her liver, and this time there was no doubt: fluid.  Blood.  A lot of blood.

Damn.

The next several minutes were spent drawing labs and getting X-rays.  Other than a fractured left humerus, nothing jumped off the screen at me.  Even her initial lab work was normal, except for one number: her blood alcohol level was over three times the legal limit.

Sigh.  God damn it, Annabel.

The questions in my mind immediately became 1) Where was that blood coming from, 2) Was it still bleeding, and 3) What do I have to do about it?  Based on the mechanism of injury, the most likely culprits were the liver and/or the spleen (obviously), but there are several other potential sources (mesentery, omentum, bowel, diaphragm, pelvis, major vessels, etc).

Once I was sure her blood pressure was stable, we brought her over to the CT scanner.  The pictures flashed through very quickly, but even a blind parking meter maid would have been able to see the large laceration on the right lobe of her liver.  Her brain was fine, and her other scans showed no other injuries.

Fortunately the vast majority of liver lacerations stop bleeding spontaneously and require no intervention whatsoever.  Over the next 36 hours, Annabel's bleeding stopped, and her boyfriend and father showed up to claim her.  And this is where we pick up our story.

"So the first lesson to be learned here," Annabel's boyfriend started as he tapped her foot with a relieved smile, "is wear your seat belt.  And the second is not to crash!", he laughed.  I didn't. 

"Actually," I began, "the first lesson is don't drink and drive."

His smile disappeared quicker than free bagels at a breakfast conference.  He looked at Annabel, then back at me, then back at her again.  "She was . . . Was anyone else . . .?"

No, I told him, she had been alone, and it was a single vehicle accident.  He looked partially relieved, but only for a moment.  "What about the police?  Are they . . .?"

I informed him that the police never came, so because she wasn't under arrest yet, she probably had gotten away with it.  Again there was a brief moment of relief before I launched back in to it.  Annabel was still intubated, but she was awake and could hear every word I said.  Though I was speaking to her boyfriend, I made sure she understood that my somewhat gentle tirade was directed firmly at her. 

"She is damned lucky that she (you) didn't kill herself (yourself), and even luckier that she (you) didn't kill anyone else.  My wife drives my children around on these same roads, and if she (you) had injured or killed any of them, we would have a Very Large Problem."

I'm not sure how much of that conversation Annabel heard that day, but it makes little difference because she heard the exact same conversation in progressively firmer tones every day until she went home a week or so later.  

If Annabel had been wearing her seat belt, she wouldn't have been ejected and probably would have walked away from the accident.  But if she hadn't been driving drunk, the first point would be moot. 

Did she learn her lesson?  I'd like to think so.  I made sure to drive the point home with her boyfriend and father several times, and I almost demanded that they both continue drilling it into her once they took her home.  

I will humbly request that anyone reading this do the same thing. 

21 comments:

  1. the first fatal I responded on was because of a drunk driver. and so you don't take this wrong I will say it clearly. my official opinion is that if a drunk driver wants to kill somebody, it should be himself.
    I would still prefer no drunk driver and no killing.

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    1. Some cops are lazy too. I followed a drunk driver one time, I called 911, and I told the dispatcher that there's this guy driving a car, on this location, and he's all over the road. Dispatcher then transfers me to the cops, I explained the situation and told them I was afraid that he may hurt or kill someone because I suspected that he was driving drunk. So what did this cop tell me? Cop told me to DO NOT FOLLOW. He said if he crashes then they'll respond. But for the time being, he wanted me to go home and forget about it. That's exactly what I did.

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    2. sometimes they just don't have anybody available to respond unless it becomes severe. I've been on a few minor calls (usually a person who had "a couple" drinks) where the Police Officer told me if we didn't need him (or her) he needed to go take care of a higher priority incident; if we felt our scene was safe.

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  2. I hate drunk drivers. I will not take a case involving a DUI. Walking under the influence, maybe, but I really hate most drunk cases and am now at the point in my career where I can cherry pick and not take them.''

    Why? Two reasons - my dad and my older brother. Dad was in an accident back in the early '80's that involved a fatality - his mother. He walked away, though it never left him. My older brother because he's now in yet another non compact state on his DUI 4. Yeah, 4th DUI in that state, a state that doesn't look to other states to see if he's ever done this sort of thing before. He got 70 days in jail for that DUI 4. This is a man now 50 who has a record of alcohol related offenses, mostly driving, going back to age 16. The guy obviously doesn't get it - we don't care if you're a drunk, just don't drive. 70 days - fathom that. He's in a state that not only doesn't check his record with compact states, but pretty much doesn't care enough about its citizenry to take a repeat DUI off the road for any length of time that might actually protect the citizenry.

    Don't drink and drive - you'd think some people would learn. Nope. I'm related to one of them. Dad quit drinking before the MADD stuff resulted in bigger penalties in most states. Guess having your mother's death on your conscience will do this for you and for the rest of the people out there. He died stone sober. My older brother? Nope. He'll be rolling through an ER near you sometime soon, number 5 in the bank. Then he'll move to another non compact state and hope that he can simply not report his past and get a driver's license. If he can't, then he'll just drive without a license, without insurance. Aren't we all lucky?

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    1. I saw one who literally got out of jail for DUII, stopped by a bar, and then hit a sheriff's deputy almost head-on on his way home.

      heard of another who had been arrested for DUII/DWS so many times he was on a first name basis with the judge, and recognizing him was considered probable cause to pull him over.

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    2. I read the paper online for the town in Central Wisconsin that I grew up in. Every couple of months there is an article about someone who was arrested for their 7th or 8th DUI. How in the name of God, does a person get away with that. They've got blow through ignition locks, fingerprint ids, but these yahoos seem to think they are invincible. They might be but the person in the other car they hit isn't.

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    3. put the most simply, they buy a used car, cheap, from a private party.

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    4. Yep, or they get someone to blow in the intoxilator (police officer made up that word) machine for them.
      I got so many damn calls this summer for "dead batteries" my driver gets on scene and sees they have one of the breathalyzer machines on the ignition and he knows what's next..
      He jumps the battery even though he can hear the car click and sees the radio and dome light work perfect.

      The next question is, "can you blow in to that, I used mouth wash"..

      Wtf ahole you ordered this jumpstart two hours ago, that's not how this works..
      My guys will be fired if they blow in the "blow and go" machine and help an intoxicated person get mobile..
      The guy called me pissed and screaming how we didn't finish the job after my guy left, he used that same stupid excuse with me it was mouthwash, after he verbally abused me and disparaged my driver I finally asked him, "was it vodka flavored mouthwash", and was it more than just one "mouth washing" and did he swallow and not spit.

      Maybe next time time he won't call me a C U Next Tuesday 15 times.

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  3. The bane of my tow dispatcher life..Did an almost fatality- she "died" in route to the hospital, trooper calls back to say they brought her back and he had just visited her at the hospital..
    I had an animal fatality that my tow truck driver had to clean the scene, he came back a wreck and a mess.. Had to winch a dead guy out from under a truck because he was wrapped around a driveline, his head was ripped off, ME couldn't get him..
    Here in the states tow truck drivers aren't treated as first responders.. But this why they should be..

    I get my first life or death call, those are the rarest of rare, my boss has gotten one in her 8 years..
    It means if we don't respond the person dies, but my ADHD has me getting ahead myself..
    My life and death was called in by life flight, a car went off road pinned between two trees on its top, the top was pushed far in to the motor. Motor was smoldering so there was a fear of a fire while the motorist was trapped..
    I didn't have someone close enough, but when I was done talking to them I beelined outside to sob and puke..
    Did a baby fatality a couple months ago, that one screwed me up..
    All of them DUIIs. My guys are impacted, medics, firefighters, police, and all the others trying to put that person back together.. And there is lil ole me in my dispatch chair surrounded by screens and displays getting told before family, having to deal with family that is coming for the car, and it hurts..
    Don't FN DUII for fs sake, it really does impact more people than just you who will go to jail or lose you license..

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    1. call your local fire department and ask for Critical Incident Stress Debriefing, when you've had to deal with something like that; or if they give you the "huh?" response, ask to talk to their chaplain. we will occasionally have the tow driver assist with a body recovery, which usually consists of moving the vehicle to a more convenient place. hadn't really thought of inviting them to the CISD. I'll keep it in mind for next time. last significant DUII crash I was on, the tow dispatcher was on scene talking to the spouse of the DUII driver. apparently the spouse got a little abusive and demanding. she said they could pick up the car at the yard when they paid the tow bill, and hung up.

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    2. Thank you Ken, I will do that most deff. Here we help with body recoveries and sometimes body parts become property of the vehicle and get stored that way in our lot.

      My husband is a tow truck driver, his first fatality was the one that made him realize he wasn't prepared to be an officer, this man is a Marine and seen war time and all the horrors of it..
      His first fatality, he was the greenie, his first three days in to training and they get that call.
      Young girl in her early 20s, med student working on her MA certifications, working full time, school full time, fell asleep behind the wheel while mom and dad were following in another vehicle after taking her out for supper.

      Her vehicle went under a box truck with out the T guard. It killed her instantly, it was on the middle of the biggest busiest Interstate we have that stretches from Canada to Mexico.
      The accident blocked two lanes, and the police ordered the tow at the same time they ordered medical/fire, fire here responds first to vehicle accidents. Husband and trainer were 5 minutes out, guess who they beat to the scene.. The officer asked the two men to keep the family back til medical could respond.
      My husband died a little inside seeing her and trying to hug the family to keep them back. Medical showed up, pronounced her and asked the ME to come and receive her body.
      The truck was still embedded in her chest/sternum, and car..
      The family tells my husband their babies life story and it destroys him..
      Our oldest is her age, going to school for the same profession,DLs at the same time, working the same job, and when he does see her face she looks like our daughter.

      The horrendous part comes next, the ME assistant can't access her body, my husband and trainer had to pry the vehicles apart, and when it did it ripped the poor girl damn near in half..He watched her organs and blood spray the inside of the car..

      My husband didn't talk for two weeks and got angry to damn near the point of violence..
      My husband was also a volunteer firefighter before a Marine, he had seen death.. He has a passive personality, if a mom or dad with a baby can't afford a tow he will do it for free, he rebuilt a 70 year olds grandma's car and we paid for it, so she could got to church and the store. While he rebuilt the car he took her every where she needed to go, if she got scared in the middle of the night he went straight to her house and checked her locks. Never spanked the kids, never raised a hand or voice to me.

      But he changed after that fatality.. He said it was the sound, smell, sight, and he couldn't make them go away when he sat idly.

      The counselor in me finally went off, 15 years in my profession and I knew something was wrong the first day, but, I was going to give him the chance to initiate the conversation, two weeks later my patience level biffed it and we were going to have a therapy session..

      My guys come to me when we have fatalities, my guys vent, scream, cry, rage, and they tell me every detail, we sit in silence and I have held one of my guys hands while he fell apart. I craddle my call receiver last night and rocked her and stroked her hair while she wailed and sobbed over the animal fatality.

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    3. My driver that did the baby fatality is a mom and grandma, she came in angry and crying yelling at me no counselor bullshit with me CALI.. I asked, you want to go home? She said, yes please. I said talk to me first, she cried, puked, raged, and I hugged her and said you can't go home.. (I'm a bitch, right).. I said you have to go pick up the horse helper grandbaby and go spend time at your horses til you have hugged your grandbaby and horse enough.. She came in the next day diffused, but a little angrier at DUII drivers..

      One month I did a fatality every weekend and some times twice in a day. My on-call for weekends and I earned the nicname the tow grim-reapers, no one wanted on-calls with me after that month..

      My worst experience, motorcyclist was hit by a box truck, the bike and body went under the truck, the drive line as it turned grabbed the guy and wrapped him around it, my driver couldn't access the drive line to drop it to set free the body, the ME asstant had him try to winch the driveline to pull it out of the truck. The winch line grabbed the guys leg and ripped it off. Once they did free the body everyone had to look for the head, can't leave the scene without all the large body parts. The found his head off in the bushes several hundred feet away where the truck driver hit the guy to begin with. It was in the helmet, eyes open, jaw was ajar.. My tow truck driver flipped out and kicked it away from him in a panic, because he was done after seeing that and ripping the guys leg off.. He had no one to turn to..

      At the company we have special little clubs, when our greenie get their first fatality they join the club, everyone hugs, everyone talks, everyone checks on that guy for days..
      I belong to the life or death club, two of us do.. The first fatality I took solo was a family friend and by law I can't discuss specifics with anyone.
      The next club is someone my kid knows club. My daughter calls me at work crying, her friends were killed in a car accident (16 & 17) just a few minutes before and she wanted to know if I took the call and she fell apart.. That morning I had to go home and hold my messed up baby for hours while she mourned.. I was angry at the world that night and next day..

      When a DUII driver gets abusive with me, it doesn't end well for them. I had to release a car to one (I had to fill in at the lot for an hour), the bitch got lippy and accused me of stealing her car.
      We do NOT do private parking impounds. She tested my patience calling me incompetent for the fax machine not being cooperative. I finally turned and said, Look I'm helping you, I don't appreciate the attitude. She rolled her eyes and smacked her lips at me like a child mocking another child..
      I said, let's get this shit straight, I didn't go out drinking and driving last night like a fucking moron, however, you keep up the attitude and I'm one of those bitches that will grab an activator bar and send your ass out this gate on your back and bleeding, your locked in here with me, how the fuck do you think you're gonna get out twat..
      And the next 20 minutes went smooth, I was smiling and she was sour faced..
      People love me when I get them saved from danger and mentally and verbally hug them on the phone. One of my tow truck drivers got a gratuity tip, but, it was for me..

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    4. here, the tow does not get ordered until long after police are on scene - which can take several minutes after everybody else gets on scene. this can be an annoyance at some times, but it does prevent the tow company having to cover for the first responders. the wreck my dad will never forget was one in which they had to wait an hour for the tow to arrive; and then the tow driver dropped the car in the process of recovering it. after the car was hoked up to the truck, he asked the trooper to have "a chat" with the tow driver (he told the trooper to wait until after the car was secured because he didn't want to have to wait another hour) and yep, the tow driver went away in the trooper's car.

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    5. Oh that would be grounds for termination and there was an accident in front of my place between a tow truck and car, tow truck driver was wasted..
      Our process is a lot more complicated:
      We have to apply and get city numbers in each city we service, I have tow numbers for two cities, if I didn't have them I can't even talk to what is known as towdesk..

      Our cities a broken up in to what's called districts, areas, and counties, we service the state troopers as well along with all DOTs, all city transit systems, life flight and sheriffs.. Wouldn't believe the amount of cars on railroad calls we get, immediate 911 call and get the hell away from the vehicle..
      You have to have a fully licensed, bonded, insured impound lot in any District (D) and there is 7 of them, Counties (C), and Areas (A).. State police has to be an impound lot central to the major Interstates and we have three of those covered. We have D5, D8, A4, C1.
      To hold contracts we can only have drivers with city numbers run them, trucks licensed in those areas I mentioned above, and we have 20 minute response times..
      We have to have 4 drivers on shift at all times to hold the contracts, our company has 20 drivers with my crew being the smallest on graveyard.

      So for a fatality blocking a major intersection that becomes a huge risk to everyone's safety including first responders when the police order services they order the tow at the same time through their dispatch who calls towdesk and sends over a message to them, so the police can continue to help without having to stop and call services later for a tow, most police will call them in as a (example) D5>ofc-789>PNP-MVA>1043 (and it changes up if the person dies because of a result of a drunk driver the call will change to something like- D5>ofc-789>TIU-Fatality>Seizure world>1043>EXPEDITE..
      Expedite means we get to follow protocol of an emergency vehicle getting to a scene..

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    6. Because we have drivers every where at any given time we can sometimes be a minute or two away.
      In our A4 they won't call a truck out til everyone has cleared the scene but police, however, that changes when we become an extraction team.
      If a dispatcher suspects a driver is under the influence of anything keys are taken, the driver is pissed in the office and on the spot and they have to piss in a cup Infront of a manager watching with doors open to stall or standing next to urinal.. It's not pleasant when your boss is watching your dick, or watching your hands for a girl.
      We all signed confidentiality agreements stating we won't share names, vehicle types, post pictures or give addresses.
      Our fleet has, auto grips, light-mediums, medium duties, flatbeds, medium duty flatbeds, and specialty equipment.
      D5/D8 have three rotations, light, fb, medium.. We carry the D5 medium contract alone so we get called out of district alot to help with D6 and D7 and D4 because they have no mediums..
      I went to a suicide via vehicle in water and the lone sheriff was in his scuba gear, I was trained that day why cars in water require mediums, and I was trained how to do a water recovery.
      On D5 there is three companies on the rotations except medium.
      On D8 there is four companies.
      A4 there is six.
      C1 there is 7
      LO there is too many to count
      State police there is a few many.

      I have had the FBI order a tow, now that shit was scary. The FBI stopped my driver at the gates, did a full background check, did a vehicle inspection on our truck, brought out the canines and mirrors, and called me to verify that he is who we say he is.
      The agent called while my driver was dropping the vehicle and asked if they could pull a prank on him as a long standing tradition of pranking first timers..
      You know me I'm all for laughs. Six agents that escorted him in, escorted him out but didn't open the last gate because, "they found something on his record", my driver calls over the radio-BASE I'm being arrested!!!! Omg they found something from a state I never went to, they want you to send someone to get the truck or they are going to "FBI hold" it, and the distress in his voice was palpable.. 10 minutes later (I was starting to wonder if they did find something) he yells at me, BASE you son of a bitch while he was in laughing hysterics, you knew!!!!!! He was so amped when he got to the office he was climbing the walls telling me what the whole process detailed and how they all hugged and shook hands after..
      We are the largest tow company in our state with the largest dispatch. I work Fri/sat/sun, 15 hour graves and typically have 1-2 call receivers to answer the phones. We don't dispatch at home, we sit at our main office that's an alley away from our major impound lot.

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    7. As you can see our police tows are micromanaged and we have tow reports we have to do daily, I'm solely in charge of C1 because no one knows the tow report system like I do.
      I do a towdesk report, I help do the drivers impound paperwork and then I do a computer call report, and when the vehicle is released or liened we do another tow report to towdesk through paperwork that we do another call for..
      If a company passes too many police calls, or is late too many times, or does their tow reports wrong we get fixed fined and suspended from the contracts..

      I'm sorry Ken I probably bored you to death..

      My tow truck drivers are just as protective of the emergency first responders as they are of their own.
      My guy was lighting a flare and watched a truck come barreling down on an officer, my guy grabbed the officer and threw him out of the way and chucked a lit flare in to the bed of the truck.. The officer took off and pulled over the guy, the guy became combative and was berating the officer, my tow truck driver had finished hooking and cruised by slowly to say something to the officer. The asshole in the pickup kept running his mouth and my tow truck driver went ballistic on the idiot and the pointed out if he wasn't the idiot that damn near hit that cop, how the shit did the flare land in the bed of the truck. The cop could smell booze, my driver waited on scene as backup to the officer so he could take DUII to jail for wreckless driving and DUII..
      Some police are really good to our guys, and call to update them if something major happened.. It's honestly sweet of them to me..


      Sorry Doc I'm probably killing you with words of my boring tow job.. But I feel kindred to Ken

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    8. it's interesting. I'm in a smaller town with a much more informal process. I believe the police have their own impound yard - the tow companies go on a list and when the officer calls for the tow, the police dispatcher just calls along the list until a company has a truck available. - and does that for each car in the incident. right now, we have two large companies in the market - I think all the small operators have retired or otherwise shut down.

      in minor accidents our DOT responders will sometimes move cars to open the road, but if it is a major accident, Law Enforcement owns the road until their investigation is done, and they don't usually call for a tow until they are ready for the cars to go away. - unless the car is needed for an ongoing investigation, it then becomes the tow company's car until the bill is paid.

      which didn't make one of our neighboring community's tow companies happy when all dispatch told them was the original call came in via OnStar, and they got there on a Sunday morning to find a totalled 70s pickup down a ravine.

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  4. I grew up with an alcoholic father. He never drank at home but at least once a month he wouldn't come home from work and we knew he'd be out getting drunk. He would drive home severely intoxicated,falling out of the van when he got out. He would a lot of times leave the van around the corner in the middle of the street. Neighbor would bring it home. When I got to be 17 he taught me to drive so I was the one to drive it home. My mom would take his keys away so he couldn't drive but he had spare keys hidden everywhere so he would drive off again. It was a miracle he never got into a car accident killing some innocent family. He finally quit drinking in 1980 when he died from COPD. Going through all that I never drank, never wanted for my kids to go through what I did.

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    1. My biological father was killed by a drunk driver 1/28.. I was born the next month. I don't drink and drive and thank you for not doing it either. I'm sorry your dad was that way, but you became a better person because of it..

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  5. Thank you Cali and your people for doing such an important job. People moan about tow truck drivers, they don't realize that said drivers see things they shouldn't have to see when cleaning up a crash scene.
    WE all know about the emergency services and their people, what they do and what they see, no one knows or talks about the forgotten emergency services.
    When the fire department cannot access a patient and need help to make access available to the patient, when vehicles have to be moved to one side with the deceased still in situ or moving vehicles which may have all sort of bodily fluids or even body parts.

    Thanks to Doc Bastard and his team for sorting out the results of peoples stupidity, anger and other causes.

    Thanks for sharing your stories, i love reading them.

    Happy New Year and may 2017 be a better one for everyone.

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  6. Thank you for taking the time to educate this person, her father and her boyfriend.

    When I was 15 years old, my mother organised a party at our home. She invited two of her friends. One of them lived 50 kilometres (30 miles) away and the other lived one block away.

    It was fun until her severely intoxicated friend wanted to drive home. "Are you really going to let him leave like that?", I asked. We could have let him sleep at our place for the night, we had a vacant guest room.
    The other friend said "When he's like this, there's no way to talk sense into him". My mother just laughed it off. They were both drunk, but certainly not as much as their friend.
    "I'm sure he'll be fine, no one drives on the highway at this hour", she said. So they let him leave, and we all watched as he almost fell out of his van while trying to climb in.
    Again, I told them it was a really bad idea to let him drive, but they ignored me.

    The next day my mother told me he'd made it back safely.

    "He didn't even get arrested or anything!"

    And she said that with such a smug expression too, like I was an idiot for showing concern. I was relieved and furious at the same time.

    I later heard he was so smashed he didn't even remember how he got home.

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