Ambulance accident

[certguy]

It's a relatively slow summer weekend shift and you're on your way to your residence to pick up an extra uniform after a pretty knarly GI bleed call . You're two blocks from home , waiting to make a right on red , when your partner notices a couple friends who work for a competitor company approaching in thier POV's . ( they just got off work from thier station about a half mile away , they're also boyfriend - girlfriend ) The girl's in the lead , smiles , waves , and pulls directly in front of a station wagon going approx. 50 mph through the intersection . Her car is t - boned and does 3 rolls before impacting your modular rig just behind your door . You and your partner are both stunned and can't tell if you're hurt yet . Your friend is screaming in the upside down car . There's no noise initially from the other car but then you hear children screaming and you can see 2 adults in the front seats , not moving . The boyfriend is already running through traffic screaming his partner's name while running past the station wagon .

To quote a line from the movie Speed ; POP QUIZ HOTSHOT ! WHAT DO YOU DO ?

This scenerio is based on an actual incident .

[Sapphyre]

Hmmm,
Step 1, call it in.
Beyond that, not sure yet

[reaper]

Call it in and start triage! Starting with yourself.

[enjoynz]

Ditto, to the first two threads!
Plus Safety First! Once that is sorted, grap the Resus (Jump) Bag and head for the Patients (the parents of the car with the kids in it) that are not moving first!

Cheers Enjoynz

[Grady_emt]

7256 Radio, we have been involved in a 41 (MVC) at Maple and Elm, our crew is OK, three vehicles involved - one overturned, out checking:" This for us would automatically start Fire, PD, a supervisor as well as two additional GEMS units.

I suppose we are lucky to have many units inservice at all times:
1) If we witness an accident we call it in, and then start assessment so long as we are not transporting a critical pt.

2) If there are no injuries, we are to go back to our unit and "zip-it" until PD or a supervisor arrives to avoid conflits with bystanders/others involved.

[certguy]

HAPPY EASTER EVERYBODY , sorry I didn't update yesterday but there was a lot going on family wise . Here we go ;

You regain your composure enough to call it in , requesting a full rescue response and air in the process , then realise with a shock , that your partner and the boyfriend ( both excellent EMT's under normal circumstances ) are trying to right the car with her in it . You yell for them to knock it off and get thier heads in the game . Thier panic stops and the training kicks in . PD is arriving in force already and is setting up traffic control . You run to the station wagon and find both parents unconscious , driver is pinned in by the steering wheel , and 1 infant and 2 toddlers in car seats in the back , all conscious , crying , with apparent small lacs from flying debris , but no major bleeds . That's all for now , gotta get ready for church .

[certguy]

Also , the friend in the rollover vehicle is conscious , c/o neck , back , left shoulder , and left rib pain . She is hanging upside down from her seatbelt .

[Sapphyre]

Collar the friend. Allow either your partner, or the boyfriend to stay to keep her calm. The unconscious parents, ABCs ok? Is it possible to get the kids out, carseat and all? (hmmm, maybe I'm off base here)

[certguy]

Fire arrives on scene as well as two additional ALS and 2 bls units , 1 engine assists extricating your friend and the balance of the response is invloved with the remaining extrications and setting up an LZ for air . Your triage is ; 2 red tags , 1 still pinned in , 1 yellow tag , 3 green tags ( peds ) . This doesn't count you and your partner , still involved in pt. care .


Good thinking about the car seats . Add a little padding , and they're like an improvised kiddie KED .

Vitals on red tag passenger ;
pt. still unconscious/unresponsive
b/p 90/60
pulse 136
resp. 34 shallow
skins pale , cool , diaphoretic
pupils PEARL
lungs clear bilat.

on assessment , you find multiple lacs , none appear serious , seat belt bruising is evident across chest and abd. Abd is rigid to palpation . Priapism is present ( this is a male ) . Deformity noted in right tib/fib area and right humerous . 6 - 8 inch space intrusion from dash board noted .


All 3 green tags vitals wnl , only apparent injuries are the lacs mentioned earlier . Extrication still in progress on the other red and yellow tags . More to follow .

[Airway Junkie]

First make sure your not going to be a patient yourself!

[certguy]

Reaper and Airway junkie have a good point . Start triage with yourself . This scenerio is based on an actual accident involving me and my partner . The pts. in the station wagon were changed to make it more challenging . The rest is the real deal . I think I probably did my best deer in the headlight imitation watching that car rolling at us . It happened too fast to get out of the way and your mind refuses to believe what you're seeing . 2 major points ;

1 . In a situation like this , it's easy to get caught up in the adrenaline rush and pt. care and forget that you're a pt. too .

2. Given the right circumstances , if the pt. is a family member or close friend , even the best of us can panic and vapor lock on our skills memory .

How do we combat this ? Mentally step back , take a deep breath , and think before you act . No action without a plan first . Though my partner and I both AMA'd , we were both sore for several days afterward and probably should've been evaluated in the ER . DON'T TRY TO JOHN WAYNE YOUR WAY THROUGH A SITUATION LIKE THIS , GET TREATED AS NEEDED .


Back to the scenerio , both trapped pts. have now been extricated . Here's the info ;

Red tag

22 y/o female , restrained driver pinned in by dashboard and steering wheel intrusion . Steering wheel was bent and had to be removed by fire to extricate . 8 - 10 inch dashboard space intrusion . Dashboard was resting on her knees .

pt. unconscious / unresponsive .
b/p 86/p
pulse 140
resp. 38 shallow , labored
skins pale , cool diaphoretic
pupils sluggish
diminished lung sounds right side , left clear

on trauma assessment , you find a large lac. on the right lower jaw , a symetrical chest movement on the right side . Tracheal deviation noted to the left , bilateral deformity midshaft femur , and open wounds on both knees .


Yellow tag

21 y/o female
conscious , a&o x 4 denies LOC
b/p 148/86
pulse 100
resp. 28 shallow , non labored
skins pink warm , moist
lung clear bilat.
eyes PEARL

On trauma assessment , pt. c/o neck and back pain , 10 on 1 - 10 scale , neuros intact but unable to grip with right hand . Deformity noted right shoulder . distal pulse present . hand is numb and cool to touch . pt. c/o pain to right rib area . apparent seat belt bruising noted . Pt . has multiple small lacerations on her upper torso . 1 1/2 foot space intrusion noted on right side of vehicle , which rolled 3 times per witnesses before striking an ambulance . Pt. was hanging upside down for several minutes by her seatbelt .

There's your info , you're good to go except for trying to get the 2 EMT's involved to stop long enough to get checked out . Aside from needing a uniform change ( code brown ) they appear okay at this time .

[wolfwyndd]

Wow. I'm three days late on this one so lemme back up a couple of steps. If this happened to ME in one of our rigs I'd have to treat this as a mass casualty incident considering we only have TWO ambulances. Which would, make me the incident commander until further notice.

Noting that I'd see if I can flip on my own rig lights to see if they work, if they do, great, it'll help mark the scene until PD / Fire / someone else takes traffic control. Step two, call it in to dispatch request Fire, PD, our other ambulance and it looks like we initially have 9 patients. That would require Pleasant Hill's ONE ambulance, Tipp City's THREE ambulances, and Union's THREE ambulances. Partner, you get to be EMS Scene Command until further notice.

[certguy]

Wolfwynd , good thinking about the lights . That's exactly what I did along with initial triage and scene safety .


The golden hour's ticking guys , isn't anyone going to treat these pts ?


What do you suspect the injuries are on the male red tag ?

On the female red tag , seeing bilateral femur fx. what else would you suspect related to these injuries ?

On the female yellow tag , what level of care would you want to send her to ?

Though the peds appear to only have minor lacs. , what would your other concerns with them ?

How does MOI figure into your care on all of these pts. ?

[wolfwyndd]

Well, the red tag guy you mentioned earlier said seat belt signs and priapism. So I'm gonna guess possible internal bleeding into the abdomen, right leg tig / fib fractures AND spinal cord injury. I wouldn't place any bets on this guy surviving for very long. If I remember from my classes / refresher courses, priapism is a very serious indication that this guys pretty toasted.

[certguy]

Wolfwyndd ,

Priapism's an indicator of a possible pelvic fx . Given what you see on assessment and the v/s , how would you treat this guy ?

What about the others ?

[Jon]

Wolfwyndd ,

Priapism's an indicator of a possible pelvic fx . Given what you see on assessment and the v/s , how would you treat this guy ?

What about the others ?
Pelvic fracture? I thought priapism was a sign of a head injury.

[certguy]

Hi Jon ,

I looked it up just to be sure , and by Emergency care of the sick and injured , nineth edition , they sure don't say much , just that " certain spinal injuries and some diseases can cause a painful erection called priapism . " I may be wrong , but I also remember it being taught as a possible indicator of pelvic fx. Can anyone shed some light on this ? Calling Rid !!!!

[certguy]

Okay Jon ,

I found it . I wanted to make sure I was putting out good info soooooo , According to www.emedicine.com , in an article last updated june 2006 , priapism can be caused by pelvic trauma , which is what I've been taught for years .

[Grady_emt]

How many Whirley-Birds are enroute??? What is the transport time to Highest Level trauma center available by ground? Combined to-scene, on-scene, transport times by bird? How long was the extrication?

If its gonna take the bird longer than ground, first due ALS unit will PUHA (Pick-Up-Haul-A$$) with the male critical as he has already been packaged.

Female critical is also low-sick, poss intubation while awaiting extrication as well as IV access. With the bilat femurs, she could be bleeding out (possible to loose over 1000cc blood each femur internally), and she probably has a hemo/pneumo developing that will require decompression. If a second bird is enroute it may be more practical to transport by air depending on ETA.

Female Yellow is still considered a critical pt due to the seatbelt bruising and possible intra-abdominal injuries. Also, the potential decreased perfusion to the hand (despite a pulse, there may be decreased but not absent perfusion), and the MOI. If the male left by ground and there is a bird available, she may go by air as well.

As for the Green folk, how bad is the bleeding to the facial lacs. Being as vascular as the face is, it may cause an airway issue in a pedi pt that young who may not be able to keep the blood clear from the face. Also, padding the voids of the carseat will work fine so long as the carseat is still intact (no damage). Both PHTLS and EPC are currently advocating this over a LBB when age/size appropriate.

[certguy]

Good job Grady ,

Level 1 trauma center 30 min. out by ground , 10 by air . 1st copter now 2 out . 2nd just ordered , eta 15 .

Extrication times ;

Red tag female ; 20 min.

Yellow tag female ; 10 min.


Good call on the yellow tag . Though vitals are stable , with circulatory comprimise in the arm , possible internal trauma from the seat belt that she could be compensating for , and MOI ( multiple rolls , 1 1/2 feet of space intrusion ) she should definitely go to the trauma center as a precaution .


On the green tags , there is no airway comprimise from bleeding , blood loss would be a concern , but all v/s still good . Due to MOI , I would suspect possible neck trauma to the toddlers , the infant should've faired better , being seated backwrd in the car seat . All 3 should be padded into thier kiddie KED's ( car seats ) .

[Grady_emt]

Male gets flown out in the first bird.

Red female should be extricated just as the second bird arrives, so she's going air also.

Yellow female, ALS transport upon her extrication.

All peds transported to a pedi trauma center, each in their own unit so that the carseat can be properly restrained to the stretcher. (if the trauma center (adult) has no pedi coverage)

You and your partner (should:excl:) go get checked out, and for the mandatory drug testing since you were involved in a vehicle contact:rolleyes:

[wolfwyndd]

I found it . I wanted to make sure I was putting out good info soooooo , According to www.emedicine.com , in an article last updated june 2006 , priapism can be caused by pelvic trauma , which is what I've been taught for years .
Wow. That's interesting. I have actually never heard that before. I'd always been taught that priapism, while can be cause by medical illnesses, that's clearly not the case here, so we should suspect either spinal cord injury or head trauma. I've actually never heard pelvic injury as a cause for that, HOWEVER, given the MOI, I would not be surprised to see pelvic injuries.

At this point though it doesn't matter. He's flying first (if he's extricated first, I've lost track).
If we do have a second bird, the woman with the bilateral femur fractures would be next (note: In our area, getting two birds at the same time isn't always possible, getting THREE at the same time, forget it.), if not, send her by ground to Miami Valley Hospital (only level 1 trauma hospital in our area) by ground, L/S all the way.
The yellow tag female also needs to go to Miami Valley Hospital too. (Any idea what her GCS is?) She's borderline on physical findings, but the MOI buys her a ticket there for sure(IE, high speed over 40 MPH, rolled, greater then 20 inches of intrusion).
As for the green tagged pedi's, they go to Children's Hospital. TECHNICALLY, they are only a level 2, but Miami Valley HATES it when we bring in kids, Both they and Childrens have agreed that we should take them there.

[certguy]

I'm really surprised that people aren't being taught about priapism and pelvic injuries nowadays . I was taught that way back when I was first certified . Thought I was getting early onset alzheimer's there for a minute .


Wofwyndd , how would you treat the female red tag ?

[Grady_emt]

But here is the million dollar question. Priapism in spinal injury occurs due to a neurological condition and bad/partial signals being sent from the brain to the...umm....male anatomy:unsure:

In the pelvic injury why does this occur. If an artery or vein is severed in the pelvic region, is it the now free-flowing blood just filling up the empty...male anatomy:unsure:... or is there another mechanism that causes priapism in the presence of a pelvic injury?

[certguy]

Hi Grady ,

I've never gotten into the physiology , but good question . I just checked on www.medscape.com . A lot of what I read was way over my head , but the jist of it , as I understand it , is that it's caused by cavernous nerve damage. It makes sense , damage the nerves , and things you don't want happening at that particular time happen , causing additional pain . Something else I didn't know is that pelvic fx. carries a 55% mortality rate , which is a lot higher than I ever thought .

[wolfwyndd]

Wofwyndd , how would you treat the female red tag ?
Well, since I'm only a basic, what I can do for her won't do a whole lot of good for very long. But there are a few things I can do. First, get an ALS provider over to help with the IV she's gonna need and the possible punctured lung / pnumothorax / hemo going on. Let's see. C-collar, backboard, bag her with O2, treat the open wounds on her knees as best we can, and I'm actually thinking that this might be a good time to break out the MAST pants that we carry and haven't used (other then training) in the 4 years I've been an EMT and either fly (IF a bird's available) or ALS her to Miami Valley, our level 1 trauma center L/S.

[wolfwyndd]

Something else I didn't know is that pelvic fx. carries a 55% mortality rate , which is a lot higher than I ever thought .
Yeah that percentage increases dramatically when you get over 65 too. Last time we did a geriatric training session I think they said pelvic fractures have about a 90 percent mortality rate and that's generally within the first year after the injury.

[certguy]

Wolfwynnd ,
Hi , not bad but there's a little more we can do as basics . We can stabilize the flail segment of the chest with a pillow or bulky dressing taped in place . In our area , we no longer use the MAST and barely cover it for NREMT testing purposes only . A Saeger splint may come in handy as it can be used bilaterally or double HARE traction splints . but keep in mind in this situation the MOI becomes very important . when the dash hits the knees , the force is transmitted from there up the legs into the hips , pelvis , and lower spine ( there's a name for this syndrome but I can't remember it right now ) , so you may have fx and/or dislocations along that whole area . If there are additional extremity or hip fx , you won't be able to use the traction splints . Plan B , rigid splints or anatomical .


Thanks for the info on geriatric pelvic fx.



Craig

[Ridryder911]

But here is the million dollar question. Priapism in spinal injury occurs due to a neurological condition and bad/partial signals being sent from the brain to the...umm....male anatomy:unsure:

In the pelvic injury why does this occur. If an artery or vein is severed in the pelvic region, is it the now free-flowing blood just filling up the empty...male anatomy:unsure:... or is there another mechanism that causes priapism in the presence of a pelvic injury?


Priaprism is caused by multiple things other than trauma. Black widow bites, sickle cell disease, leukemia, adverse effects of medications, tumors located in the spinal cord, strokes, and of course trauma.


Technically, priapism is an abnormal erection for > 4 hours (hence the a/e of Viagra, etc). It is usually categorized into two major types: low-flow priapism or ischemic, which means that little or no blood flow is getting to the penis and this lack can cause damage; or high-flow priapism, which is the result of trauma to the penis.

When discussing priapism in spinal cord trauma, this is usually seen in the acute phase and why we teach EMT's to assess for it. Since it is only a short duration of occurrence, per sympathetic response of the neural chain causes a perfusion of blood and thus causes erection (temporary). With this can be an ominous sign of potential cord or high cerebral injury to the stem/cord.

I agree it is not taught well enough, as also very few if never assessed by majority of EMT's. When was the last time you seen someone assess for it?

The usual giggle response is obtained in class, only to know when in the field that this patient truly has a severe injury. A very high possibility that is the last erection ever to occur due to cord injury, as well potential other lethal injuries does take away the humorous side.

R/r 911

[certguy]

Hey Rid ,
2 questions ,
Why aren't they teaching assessing for priapism in pelvic fx. in class anymore ?

Do you know the name of the impact syndrome caused by pt's knees striking the dashboard and the force transmitting through the legs into the hips , pelvis , and lower spine ? I know there's a name for it , but for the life of me , I can't remember it .

[wolfwyndd]

We can stabilize the flail segment of the chest with a pillow or bulky dressing taped in place . In our area , we no longer use the MAST and barely cover it for NREMT testing purposes only . A Saeger splint may come in handy as it can be used bilaterally or double HARE traction splints .

You know, I did consider the pillow / bulky dressing for the flail segment but I figured in the time it would take a paramedic to start treatment it MIGHT be in the way. I also considered the hare traction splints too, but I figured it would take more time to get them in place then it would to get the MAST pants on and I was going down the road of 'load and go' and 'life over limb.' Also for us, Careflight (air medical transport) will not fly a victim with traction splints, their helicopter isn't big enough for them to fit. And if we've got a bird available for this patient I'd rather NOT have to put a couple of traction splints on and then HAVE to drive them because I can't take them off.

[certguy]

Always have a plan B in mind . Don't always expect the medics to be right there , because Murphy's an optimist with a sense of humor . Be prepared to go ahead and treat to your level of training till they get there , you meet them enroute , or you get to the facility you're transporting to . Anything can ( and does ) happen out there , high call volume , other large incidents going on at the same time , rig breakdowns , etc . can cost both you and your pt.

As for traction splints , another advantage of the Saeger over the Hare is that it doesn't take as much room as the Hare . I wish we would've carried them on our rigs . We always had Hares . I've trained with the Saeger and boy , do I like it better . 1 man application , can be used bilaterally , and less space taken are all plusses . Check with your copter service , they may be able to transport with Saeger's , and would help justify the cost of getting some . I hope this helps with helo transports .

[wolfwyndd]

You know, I actually have a 'ride along' scheduled with CareFlight this Saturday evening so I'll ask them.

I'm also going to have to check the ambulance next time I'm at the squadhouse. I'm not even sure if we have sager's onboard. I know we've got traction and I know we've got vacuum because I've used them both. I honestly don't know if we've got sagers or not.

[certguy]

Hey Wolfwyndd ,

I've heard about vaccum splints but I've never used them . How are they ?

[Jon]

I'm not Wolfwyndd... but I'll take a stab at the question. I tried explaining them in the bar last Friday night... but that didn't work too well :)

Vacuum splints are heavy-duty rubberized/nylon packs that are filled with foam/plastic pellets. When the air is removed, the pellets form up next to one another and become immobile, held in the thick outer casing. This forms a splint that adapts to ANY injury site or limb positioning, filling all voids, and holding the limb in a position of comfort.

They are VERY solid.

[certguy]

Sounds cool Jon , I'd like to play with them some day and try them out .


Craig

[BossyCow]

We use them regularly. When fully deflated, they are almost as solid as a cast. They are light and easy to use. The only trick is making sure the pellets are equally distributed in the cast before deflating it. Otherwise you can end up with a lump in the wrong place or an area without support.

[wolfwyndd]

Jon, I couldn't have put it better myself. I LLLLLOOOOOOOVVVVVEEE the vacuum splints.

They are kinda the opposite of what I originally thought they were. I figured it'd be kinda like a baloon that you blow up to keep pressure on the appendage in question, but it's the opposite. You suck air OUT of the 'balloon' with the tiny balls in and it compresses itself around the appendage. IMO, however came up with it is a genius.

My only (minor) complaint is that when we bring a patient into the hospital with one of these vacuum splints we have to hang around till the patient gets looked at because no one in the ER seems to know how to get the thing off.

[certguy]

I watched a show on tv that showed british medics using an air matress sized vacum splint in lieu of a backboard . Looked wierd to me , but I'm a traditionalist on some gear .