On our first call of the morning we were diverted from a difficulty breathing to an unknown trauma at the rail yard. Bob pulled Medic 13 on to the overpass and parked behind the engine already on scene. We got out of the rig and peered over the side. It was difficult at first to process what it was we were seeing on the tracks below.

Several sets of railroad tracks passed under the bridge. Two people were by the set of tracks next to the embankment on the right side. One of them was lying outside the right-hand rail, and the other was kneeling next to him. The guy lying next to the rail kept trying to roll to his right, but every time he did so, his left arm and leg stayed where they were and he would roll back to his left again. It finally registered that his left arm and leg were no longer attached to his body. The guy kneeling next to him was trying to get his belt around the stump of the left leg. Turned out later the guy who was kneeling was the patient s uncle.

We grabbed our bags, headed around the right side of the overpass, and half slid down the steep, garbage strewn embankment. About half-way down we met a couple of firefighters on their way up. Their eyes were wide, their expressions stunned. It would take a lot to elicit such a response from a North Philly crew that saw the worst the city had to offer daily. That was when I really felt the lump in my throat. One was carrying an arm, the other, a leg. I was just supposed to be observing on this tour, but my observer status didn t survive this first call.

The worst part about the whole thing was that the guy was conscious. I’ve seen a lot of more horrible stuff, but the patients were either dead or unconscious. Lack of awareness of what is happening to a patient removes a major psychological burden in treating victims of severe trauma. But this guy was alert, and he kept trying to get up. We could see what was left of his humerus sticking out of his stump purposefully moving around, unaware that the rest of the arm was gone.

Trauma isn’t usually medically challenging. The assessment is straightforward, the diagnosis obvious, the treatment clear. Stop the bleeding, immobilize, rapid transport, further interventions en route time permitting, Golden Hour. Here, the challenge was figuring out what to say to the guy while trying to get all this stuff done. How do you answer incessant queries of, Am I gonna be OK? The easy route is to lie — You re gonna be all right, just hang in there. Or maybe not say anything. Or maybe say something neutral — We are doing everything we can for you. Or, maybe, you should be truthful, to allow your patient to make his peace, or say a prayer, or something.

The leg didn t bleed much, but the brachial artery was spurting. We finally got that stopped with an inflated BP cuff. Unfortunately, he maintained his LOC, airway and breathing throughout the transport. Would he be a candidate for RSI? Probably not per protocol, but what about mercy? Anyway, that wasn’t an option for us back then. So he got a non-rebreather. Nothing else to do on the short trip but try to start some lines. And, well, comfort him as best we could. But how do you comfort an 18-year-old who just killed himself in a most horrible way for no good reason, but who is still alive, at least for a little while? We found out later that the kid and his uncle were entertaining themselves by jumping on and off the trains — certainly a noble cause for which to give up one s life.

It didn t take long to get to Hahnemann Hospital, one of Philly s Level I trauma centers. They were ready for us when we came through the doors. Something I had never seen before was the on-duty reimplantation team. Their only job was to prepare severed body parts for possible reattachment. While the main group was working on the patient, the reimplantation team was examining the condition of the limbs. Where s the rest of this arm, one guy hollered. Probably wrapped around a train axel on the way to Trenton; either that or the dogs got it, Bob replied. I looked at the arm. If they ever did get that thing sewn back on, he would have an elbow about three inches south of his shoulder.

We found out the next day that he didn t last the night. But for us, the call had taken up most of the first hour of the shift. Only 11 more to go, and at least that many calls to go. If I remember right a decade and a half later, the next run was for a woman with a sore knee.