Dispatched: Injured From Assault - A Messy Scene

[WuLabsWuTecH]

A real call that I went on. Things happened so fast and we're still talking about it at my station as to whether the right calls were made and what-ifs. At the end of the day we've decided we did the best we could and the guys is alive so this was all purely theoretical conjecture at this point. I'm curious as to what you would do. Time IS a factor here, so before you write what you are going to do, note that it'll cost you time. You can start your own response or work off of someone else's I'll let you know how much time has passed (it'll be an important factor, just trust me).

T+0:00 Call Received by Dispatcher

T+1:00 Medic 19 (you) dispatched. "Injured from Assault"
No other units responding but they are working on finding you an ACLS engine.

T+1:30 Medic 19 Responding Engine 11 responding, ETE 20 minutes, EMS (Emergency Medical Supervisor) 2 unavaliable due to cardic arrest in the same district

T+5:00 Medic 19 Staging 1 and a half blocks from the incident.
BSI on, Ballistic vests on.

T+7:00 A police car wizzes past you followed closely by a K-9 Unit.

T+8:00 The first car that whizzed by you radios that another police officer is already on scene and that the scene is secure. He requests one additional unit for scene control and for a detective to be started that way.

T+8:30 Dispatch Verifies Scene is secure and Medic 19 is cleared to go in. Also, Engine 4 just cleared from a DOA and will replace Engine 11 4's ETE is about 8-9 minutes.

T+9:30 Medic 19 turns the corner and sees:

Male, unknown age, lying on the pavement in a parking lot. An officer is standing in a pool of blood, it looks to be about a Liter, maybe almost 2 of blood that has pooled around his neck. The officer is holding pressure on the neck with what looks like a small bandage from his first aid kit and a t-shirt that is bright red in color. The Man's T-shirt is Bright Red (we weren't sure of it at first, but I'll tell you now that his t-shirt was originally white in color. We were mistaken in thinking he was wearing a red t-shirt)

On your Crew: Medic 'A', Medic 'B', EMT-B and Medic Student 'C', EMT-B 'D'
Note: Medic A is the only one on the crew that has been trained to drive the rig.


Hospitals:

North Hospital: 7 minutes (hot) due north, Level III trauma Center
West Hospital: 20 Minutes (hot) southwest, Level II trauma Center
Central Hospital: 25 minutes (hot) almost due south, Level I trauma Center

Other agencies:
There are 3 other officers on scene, and remember the engine is responding which also has 4 paramedics on it. Their ETE is about 8-9 minutes.
You may also request - Engine 11 to keep coming ETE is 15 minutes at this point, they are the next closest engine b/c we have tied up 9 engines at a working fire.
Helicopter is available with a 20 minute ETE.
MICU is avaliable with a 20 minute ETE.

Other Considerations
Today is Sunday July 5th, the day after Independence Day.


Ready, Set, GO!

 

[boingo]

Cancel the fire, no need for 4 more paramedics unless you have more patients.

 

[paccookie]

Call the helicopter and get started on your rapid trauma survey. Sounds like this pt needs a level I trauma center and the helicopter might be your best option.

What does the rapid trauma reveal?
Life threats - pt is bleeding out in front of you.
C-spine
LOC?
ABCs?
Where is the wound exactly?
Anything revealed in the RT?
Baseline vitals?
Spinal immobilization

Pt needs to load and go, meaning it might be a good idea to meet the helicopter somewhere. Doesn't sound like this scene is a good LZ anyway. Get someone working on that and limit scene time to ten minutes.

 

[exodus]

Call the helicopter and get started on your rapid trauma survey. Sounds like this pt needs a level I trauma center and the helicopter might be your best option.

What does the rapid trauma reveal?
Life threats - pt is bleeding out in front of you.
C-spine
LOC?
ABCs?
Where is the wound exactly?
Anything revealed in the RT?
Baseline vitals?
Spinal immobilization

Pt needs to load and go, meaning it might be a good idea to meet the helicopter somewhere. Doesn't sound like this scene is a good LZ anyway. Get someone working on that and limit scene time to ten minutes.

Alright, we are 25 minutes away from an L1 Trauma. The helicopter is 20 minutes away. So we want to wait 20 minutes for the Helo to get there, land, spend probably 5 minutes or so getting the PT on the helicopter then spend im guessing 10-15 in flight time to the Trauma Center? In total delaying the Trauma care 10-15 minutes?

 

[paccookie]

Alright, we are 25 minutes away from an L1 Trauma. The helicopter is 20 minutes away. So we want to wait 20 minutes for the Helo to get there, land, spend probably 5 minutes or so getting the PT on the helicopter then spend im guessing 10-15 in flight time to the Trauma Center? In total delaying the Trauma care 10-15 minutes?

I said go ahead and start the helicopter to towards the scene. Doesn't sound like the scene is a good LZ anyway, so meet the helicopter somewhere on the way. If the level I is 25 minutes drive time going code from the scene, flight time should be pretty quick. Much less than 10-15 minutes. I did not say wait on scene for the helicopter. Would you prefer to transport the pt to the closer hospital who may not be able to treat the pt? That hospital has to stabilize the pt and then get a physician at the receiving facility to accept the pt, assuming they have a bed available, before he can be transferred. This can take hours. And that's not considering transport time. How far is the "closer" level III from the level I? That's IF he survives the wait. Stabilize him as best you can in the truck and either haul butt to the level I or meet the helicopter on the way.

 

[WuLabsWuTecH]

What does the rapid trauma reveal?

Medic A does this and we find that he is bleeding from the neck, but no other major injuries of note.


Life threats - pt is bleeding out in front of you.

Yes, yes he is.

C-spine
Where is the wound exactly?
Spinal immobilization

The wound is on his neck. When EMT-B 'C' removes the dressing to get a quick glance at a the wound and to apply a sterile dressing (instead of the T-shirt we've been using), you note that there is both oozing and spurting from the neck. There are multiple wounds on the right side. There is a shallow wound on the left side of the neck that is not actively bleeding.

Since Mr. C is applying pressure, there's no way to get a C-collar on--want to try other options for c-spining, or just be careful?


LOC?
Pt says he's been down for about an hour, bystanders say he staggered in just about 10 minutes ago. LEO says he was talking when he got there about 10 min ago. Hard to communicate with the pt since he spaeks spanish only. EMT-B 'D' speaks some spanish but not enough to ask him specifically about "loss of consciousness"

ABCs?
Airway intact, no tracheal deviation
Breathing is slightly rapid, shallower than normal but not too far out of the ordinary.
Besides all the blood I've mentioned there's nothing further you notice about circulation.

Anything revealed in the RT?

D-none noted
C-some on arms noted, hard to tell on torso since it is soaked in blood
A - Yes, noted on arms
P - No penetrating injuries save the stab wounds on the neck as already mentioned
B - No burns
T - tenderness around the
L - Yes, the wounds mentioned and the shallow lacs on the left side of the neck. A few on the arms but superficial
S - Swelling - nothing that immediately jumps out at you

Baseline vitals?

We didn't take vitals until much later 3 minutes out form the hospital but they were:

BP 78/?
Pulse 115
Respirs 28

We never got him on a monitor or a glucose check. I believe that at the hospital he was Sinus Tach. I don't think they got a glucose either.

The assessment costs you 2 minutes no matter what.

If you decide to C-spine it's gonna cost you another 3 minutes. But you'll have to be inventive about the c-collar and head bed.

Vitals if you want to use them costs another 2 minutes.


That's why I included times and such for the hospitals, it was these (real life) facts that made the decision so complicated. The Level III is 7 minutes due north going code, the Level I is 25 minutes almost due south. I just plugged it into my GPS and it seems the two hospitals are going to be 31 minutes apart going hot.

We can put the helicopter enroute. Do you want to go to one of the other hospitals and meet them there after stabilization or do you want to meet on the side of the road somewhere?

You can go 15 minutes southwest and meet the bird at a High School, probably 5 minute flight to the trauma center after loading.

There is another high school 15 minutes south. But you are on the edge of downtown now, other than these two high schools that you can think of with large fields, there are no other good LZs unless you plan on stopping in the middle of the highway.

Pacookie: are you suggesting that going to the LIII could take hours before he can be transferred?

 

[paccookie]

What does the rapid trauma reveal?

Medic A does this and we find that he is bleeding from the neck, but no other major injuries of note.


Life threats - pt is bleeding out in front of you.

Yes, yes he is.

C-spine
Where is the wound exactly?
Spinal immobilization

The wound is on his neck. When EMT-B 'C' removes the dressing to get a quick glance at a the wound and to apply a sterile dressing (instead of the T-shirt we've been using), you note that there is both oozing and spurting from the neck. There are multiple wounds on the right side. There is a shallow wound on the left side of the neck that is not actively bleeding.

Since Mr. C is applying pressure, there's no way to get a C-collar on--want to try other options for c-spining, or just be careful?

----------------
Bandage wound as best you can. Did pt have c-spine trauma? Perhaps a towel roll with one of your people holding c-spine would work.
----------------

LOC?
Pt says he's been down for about an hour, bystanders say he staggered in just about 10 minutes ago. LEO says he was talking when he got there about 10 min ago. Hard to communicate with the pt since he spaeks spanish only. EMT-B 'D' speaks some spanish but not enough to ask him specifically about "loss of consciousness"

ABCs?
Airway intact, no tracheal deviation
Breathing is slightly rapid, shallower than normal but not too far out of the ordinary.
Besides all the blood I've mentioned there's nothing further you notice about circulation.

------------------
15L O2 NRB
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Anything revealed in the RT?

D-none noted
C-some on arms noted, hard to tell on torso since it is soaked in blood
A - Yes, noted on arms
P - No penetrating injuries save the stab wounds on the neck as already mentioned
B - No burns
T - tenderness around the
L - Yes, the wounds mentioned and the shallow lacs on the left side of the neck. A few on the arms but superficial
S - Swelling - nothing that immediately jumps out at you

Baseline vitals?

We didn't take vitals until much later 3 minutes out form the hospital but they were:

BP 78/?
Pulse 115
Respirs 28

We never got him on a monitor or a glucose check. I believe that at the hospital he was Sinus Tach. I don't think they got a glucose either.

The assessment costs you 2 minutes no matter what.

--------------------
Pt needs to be on the monitor. Don't skip an assessment. Ever. You can't treat without a decent, basic assessment. Time is a factor, but seriously, how can you treat your pt properly without assessing them? Do your treatments en route if you need to (this time, you need to), but don't skip your assessment.

By the way, is the pt moving? PMS in all extremities? Any evidence of a spinal injury?
--------------------

If you decide to C-spine it's gonna cost you another 3 minutes. But you'll have to be inventive about the c-collar and head bed.

Vitals if you want to use them costs another 2 minutes.

-------------------
Yes, I do want to use them. I also want two large bore IVs with fluids hanging wide open. Yes, I know it's going to cost me more time. This guy's pressure is down and likely falling fast. Meaning his brain is not being perfused. That's BAD. He's already tachycardic and hypotensive. Very bad
-------------------

That's why I included times and such for the hospitals, it was these (real life) facts that made the decision so complicated. The Level III is 7 minutes due north going code, the Level I is 25 minutes almost due south. I just plugged it into my GPS and it seems the two hospitals are going to be 31 minutes apart going hot.

We can put the helicopter enroute. Do you want to go to one of the other hospitals and meet them there after stabilization or do you want to meet on the side of the road somewhere?

You can go 15 minutes southwest and meet the bird at a High School, probably 5 minute flight to the trauma center after loading.

-----------------------
That sounds best. Do that. Or haul butt to the level I. Whichever is fastest. If the helicopter's ETA is extended, just drive.
-----------------------


There is another high school 15 minutes south. But you are on the edge of downtown now, other than these two high schools that you can think of with large fields, there are no other good LZs unless you plan on stopping in the middle of the highway.

Pacookie: are you suggesting that going to the LIII could take hours before he can be transferred?

-----------------------
Yes, I am. I've seen it happen. Critical pts need labs, CT scans, whatever prior to transfer. Hospitals fill up. Doctors refuse to accept patients. People die waiting to be transferred. Level III trauma centers may not have be able to provide the needed services for this guy. From what you've described, he likely needs stat vascular surgery and some serious life support. He needs blood, like, yesterday. In short, his golden hour has already passed. He is circling the drain and needs to be transferred to DEFINITIVE care, which means surgery, now.

 

[AnthonyM83]

The picture you paint is of a patient with uncontrolled active hemorrhaging from a large artery. It gives me an impression of someone who would not survive 25 minutes to a Level I trauma center.

Yes, a Level 1 has a surgeon (which he needs), but the surgeon does no good if he has already exsanguinated upon arrival. Are you able to reduce the bleeding on-scene? Slow the rate? Then, he might have a chance. Otherwise, go to the closest ER. At least they may be able to clamp the artery until they transfer (or get on-call surgeon there).

In such a dramatic case, I would forgo full spinal immobilization, especially if you can ascertain good neuros in extremities. Even an extra minute in this case may mean him reaching such a severe level of shock that his organs might not recover from.

I would also deem it inappropriate to spend time on-scene getting two large-bore IV's on such a critical patient. Poster specifically said he was going to cost him more time (meaning they aren't being done en-route).


Based on the picture painted for us, I would use all hands on loading him onto a backboard (without straps for now) and getting patient off-scene. A true load a go. With four people, that's enough to get backboard and gurney at patient side while two cut clothes and another assesses. Realistically, on-scene length - 3 minutes. Maybe an additional one for discussion, quick rundown from PD, etc.

 

[paccookie]

The picture you paint is of a patient with uncontrolled active hemorrhaging from a large artery. It gives me an impression of someone who would not survive 25 minutes to a Level I trauma center.

Yes, a Level 1 has a surgeon (which he needs), but the surgeon does no good if he has already exsanguinated upon arrival. Are you able to reduce the bleeding on-scene? Slow the rate? Then, he might have a chance. Otherwise, go to the closest ER. At least they may be able to clamp the artery until they transfer (or get on-call surgeon there).

---------------------
While I agree that this guy needs care fast, sometimes you do have to consider that the patient needs to go to the closest appropriate facility. Perhaps EMS can radio ahead to whichever hospital they decide to go to and ensure that the proper resources are available if they don't think the patient will make it to the level I?
---------------------

In such a dramatic case, I would forgo full spinal immobilization, especially if you can ascertain good neuros in extremities. Even an extra minute in this case may mean him reaching such a severe level of shock that his organs might not recover from.

I would also deem it inappropriate to spend time on-scene getting two large-bore IV's on such a critical patient. Poster specifically said he was going to cost him more time (meaning they aren't being done en-route).

---------------------
Ok, this I truly don't understand. The OP stated that he had four people on scene. One of the medics must drive, leaving one medic, one emt-b/medic student and one emt-b in the back. Two of those three people should be able to start an IV. What are they doing on the way in if they aren't treating the pt? Let the B control bleeding/hold C-spine. The medic can work on one IV while the student works on another or attends to other needs the pt may have.
---------------------

Based on the picture painted for us, I would use all hands on loading him onto a backboard (without straps for now) and getting patient off-scene. A true load a go. With four people, that's enough to get backboard and gurney at patient side while two cut clothes and another assesses. Realistically, on-scene length - 3 minutes. Maybe an additional one for discussion, quick rundown from PD, etc.

---------------------
Yes, he is truly a load and go, but you have to do a rapid trauma assessment to figure that out. How are you going to know if that bleeding neck wound is your only wound or if you have a gunshot wound to the chest, a knife in the back and a fractured pelvis? You don't. Assessment is probably the most important skill we have. The OP made it sound like they just snatched and ran and hauled butt to the hospital without doing anything for the pt. I realize that may be wrong, but that's the impression I got.

 

[WuLabsWuTecH]

@ pacookie

O2 15L/min NRB is good. That was the one thing we all agreed we should have done as soon as we got on scene. We got so caught up in controlling bleeding and the hypovolimia that we didn't think of it until we got into the back of the rig.

The bleeding is still not fully controlled so a bandage probably is not the best idea, we still need to keep direct pressure on it. It was a witnessed collapse, level ground, from standing.

This is my opinion now, but while we are taught everyone who falls needs c-spine in school, there are clearly some situations that do ont warrant it or that it is not that big of a risk. IN this case, I believe the benefits of protecting c-spine was outweighed by the risk of him bleeding out.

We did the assessment enroute, once again bleeding was not controlled and I think all of our adrenaline was up since at least the other EMT-B and I had never seen that much blood splattered everywhere before. That adrenaline might have contributed to our quick actions (maybe a good thing, maybe a bad thing) any why we went so quickly.

No evidence of a spinal or head injury, pupils were round and equal, slightly sluggish. had trouble getting pedal pulses, but he could move his feet. At first we thought he had his right and left mixed up but then we realized i had my spanish izqueirda and derecha mixed up! Complains of pain in the neck, no abdominal pain. No pain in the arms or legs. can also move hands and arms when instructed to do so.

We ended up going to the LIII trauma center and called the MICU and chopper to meet us there.

Yes hospitals fill up but the trauma rooms were not all taken up (at least you hope!) We got lucky and there was a trauma surgeon there that day. It was the day after the 4th and a sunday, so he was not scheduled to be there but was only on call, but had dropped in to get some paperwork. Had he not been there though, why would we have to wait around for them to do CT scans? And how would a Level I center refuse an upgrade?

Questions:
Why would you do the assessment while on scene and not enroute?

We did the first IV on scene while the rapid trauma was going on and bleeding was trying to be controlled, but everything else we did in the truck including the assessment.


Anthony, our thoughts were along the lines of your thoughts.

The picture you paint is of a patient with uncontrolled active hemorrhaging from a large artery. It gives me an impression of someone who would not survive 25 minutes to a Level I trauma center.

Yes, a Level 1 has a surgeon (which he needs), but the surgeon does no good if he has already exsanguinated upon arrival. Are you able to reduce the bleeding on-scene? Slow the rate? Then, he might have a chance. Otherwise, go to the closest ER. At least they may be able to clamp the artery until they transfer (or get on-call surgeon there).

That's what we were thinking. When PD asked where were were taking him, our first reply was the Level I but that quickly changed when we realized how the bleeding could not be completely controlled. The other thing is that the LIII had whole blood which also helped save him. We got lucky and there was a trauma surgeon there and he went up to the OR after about 20-30 min in the trauma room.

In such a dramatic case, I would forgo full spinal immobilization, especially if you can ascertain good neuros in extremities. Even an extra minute in this case may mean him reaching such a severe level of shock that his organs might not recover from.

We probably should have at least mentioned it to discuss it, but the risks outweighed the benefits and it would have been hard to do with the location of the injury.

I would also deem it inappropriate to spend time on-scene getting two large-bore IV's on such a critical patient. Poster specifically said he was going to cost him more time (meaning they aren't being done en-route).


Based on the picture painted for us, I would use all hands on loading him onto a backboard (without straps for now) and getting patient off-scene. A true load a go. With four people, that's enough to get backboard and gurney at patient side while two cut clothes and another assesses. Realistically, on-scene length - 3 minutes. Maybe an additional one for discussion, quick rundown from PD, etc.

Our on scene time after staging was about 5-6 minutes. The In Charge said that was a true load and go if he'd ever seen one! We used about 3 minutes to assess and try to control bleeding (2 medics) while the medic student started an IV and I got the cot and more dressings. After another minute or so we decided that we couldn't get bleeding controlled very well and we had to go. another minute or so was spent loading him up and picking up our equipment.

We didn't talk to the PD very much at all. One of them decided it would be a good time to ask if his condition could be considered "critical" after seeing us running around and all the blood and I think the In Charge snapped back that he was very critical and we would chat at the hospital b/c we didn't have time to do so here.

Most everything was done in the truck. I took over bleeding control, the medic student started another IV in the other (pt accidentally pulled the first one out). Took vitals on the truck. Tried to Start O2 via NRB but had issues with being able to reach the O2 and NRB. By the time we got it we had just finished getting vitals, and we were 90 seconds from the hospital. The monitor was important only if he coded on us, so that was to be done after O2 but we never got that far. Transport time was about 6-7 minutes.

2-3 minutes on IV and more detailed assessment. 2 more minutes on vitals and trying to get O2 and radio report of us being inbound and needing a team. and that was all we had time for.

 

[AnthonyM83]

While I agree that this guy needs care fast, sometimes you do have to consider that the patient needs to go to the closest appropriate facility. Perhaps EMS can radio ahead to whichever hospital they decide to go to and ensure that the proper resources are available if they don't think the patient will make it to the level I?

Yes, you must always consider that.
But
Sometimes you say: This guy needs an ER.
Sometimes you say: This guy needs surgery now. He needs a trauma center!
Sometimes you say: This guy's so so bad, he needs a doctor right NOW. Local ER will have to do.

I would definitely call it in to prepare them. Couldn't fathom not doing so.

I understand what you're saying about appropriate facilities, but if he won't survive to best facility (Level I), the closer facility (Level III) becomes the most appropriate. It's still a level III and has some surgery ability, on-call surgeons, and pre-planned transfer protocols with higher level trauma centers for patients who need more care. At least they can do SOMETHING...versus 25 minutes in your ambulance doing nothing (other than IVs)

Yes, he is truly a load and go, but you have to do a rapid trauma assessment to figure that out. How are you going to know if that bleeding neck wound is your only wound or if you have a gunshot wound to the chest, a knife in the back and a fractured pelvis? You don't. Assessment is probably the most important skill we have. The OP made it sound like they just snatched and ran and hauled butt to the hospital without doing anything for the pt. I realize that may be wrong, but that's the impression I got.

I think he was trying not to say exactly what they did on-scene to wait for us.
He definitely needed a rapid trauma assessment, which can be done with a crew of 4, plus a cop. Two people cut clothes (which I think is the main thing that slows us down). One to get equipment ready.

As far as the IV stuff. Your very last post implied you'd get the IV enroute. The post before, though, implied you would get it on-scene. That's what I considered inappropriate. All hands should be used for immediate/basic stabilization and packaging of patient.

 

[WuLabsWuTecH]

---------------------
Yes, he is truly a load and go, but you have to do a rapid trauma assessment to figure that out. How are you going to know if that bleeding neck wound is your only wound or if you have a gunshot wound to the chest, a knife in the back and a fractured pelvis? You don't. Assessment is probably the most important skill we have. The OP made it sound like they just snatched and ran and hauled butt to the hospital without doing anything for the pt. I realize that may be wrong, but that's the impression I got.

Well, we more or less did. We did a rapid trauma assessment, but vitals and such were not of the essence. What could we do that we weren't already going to do? Yes, from vitals we could tell he was compensating, but from our assessment we already knew he was in bad shape.

Now I'm not saying that you are wrong either. Some of the guys on a different shift agree with you, but thye also have expressed that they don't think we were wrong either, just that we did things differently. There we so many factors that went into this "save" and there was no one right answer.

I do like your reasoning though on the patient care part of it. I'm still not understanding why a LI Center would refuse an upgrade from an LIII. Now maybe its different in different parts of the country, but I actually worked at the LI we were going to go to, and for OSH's to come to our facility, they did not need preclearance. They called the LI physician with the patient information, and then the flight team radioed in 15 minutes out. There was no "let me consider if I want this patient" on the part of the receiving hospital.

I guess what I've just said in a really complicated manner is, I like your reasoning on the patient care, but could you explain your transport decision a bit better?

 

[WuLabsWuTecH]

Yes, you must always consider that.
But
Sometimes you say: This guy needs an ER.
Sometimes you say: This guy needs surgery now. He needs a trauma center!
Sometimes you say: This guy's so so bad, he needs a doctor right NOW. Local ER will have to do.

I would definitely call it in to prepare them. Couldn't fathom not doing so.

I understand what you're saying about appropriate facilities, but if he won't survive to best facility (Level I), the closer facility (Level III) becomes the most appropriate. It's still a level III and has some surgery ability, on-call surgeons, and pre-planned transfer protocols with higher level trauma centers for patients who need more care. At least they can do SOMETHING...versus 25 minutes in your ambulance doing nothing (other than IVs)





I think he was trying not to say exactly what they did on-scene to wait for us.
He definitely needed a rapid trauma assessment, which can be done with a crew of 4, plus a cop. Two people cut clothes (which I think is the main thing that slows us down). One to get equipment ready.

As far as the IV stuff. Your very last post implied you'd get the IV enroute. The post before, though, implied you would get it on-scene. That's what I considered inappropriate. All hands should be used for immediate/basic stabilization and packaging of patient.

I think my computer's cache is doing something funky, there is always another reply after i hit the post reply button!

An yes, I did leave out some of the details initially to see what you guys would have done.

The only reason we got 1 IV in the field was because we had all the hands we needed and the extra guy might as well have been doing something. We did not cut all the clothes but exposed enough to see there wasn't anything more major than what was going on by his neck. Ideally we should have exposed completely, since we might have missed a stab somewhere but we were pretty sure there were no others since the clothes were intact other than the T-shirt which was ripped.

Also, someone mentioned earlier canceling the engine. We actually didn't cancel them, but it was a moot point since they showed up about 4 or 5 minutes after we left the scene. Had an engine been dispatched with us and we had 8 sets of hands (6 medics, 1 medic student/EMT-B, one EMT-B) plus the 3 LEOs would there have been any advantage? Scene was already well controled by the 3 LEOs so I can't really see what an extra medic could have done? Possbily start another line on the other arm while assessment was going on? Maybe the 5th one could be doing that while the 6th one starts to take vitals? The 7th and 8th guys will wipe the sweat from the first 6 guys' brows?

I only ask this because our In Charge Medic was furious that they did not dispatch an engine immediately for a call of this magnitude and that they waited to see that 14 was still not clear before calling 11. He actually didn't even hear the dispatch for 11 since he was on the wrong radio channel while responding to the call (the rest of us heard it). To me, and to the rest of my crew, we didn't mind that there was no engine and most guys i've talked to on the other crews don't think it was that big of a deal. I think the In Charge's position was though that this was technically a Mutual Aid call, and for all dispatch knew, we were running a 2 man or a 3 man crew that day with no riders. If you're going to ask someone to help you in your district, at least be courteous enough to make sure you have one of your own going even if its from a farther distance than we are when you ask us for help.

 

[firemoose0827]

It all boils down to some very basic training...ABC's. I was trained in basic that if you encounter a problem in any of the ABC's than you are working on that until it is alleviated. You have bleeding from the neck, which in my opinion is all three. It is severe bleeding near the trachea which could also be compromised, which is Airway, Breathing, Circulation...work these the whole time. Try to control bleeding, monitor the airway and suction if need be, apply oxygen, start a line or 2 and go to the nearest appropriate facility, which for me is the level II trauma center. Half way point, better than the III yet closer than the I, so Im going there L&S while attempting to control bleeding and keep the airway open. Pressure infuse saline with a BP cuff or pressure infuser and go like hell. Advise the ED of your situation so they can make arrangements and get them to definitive care. Thats our job. Helicopter? Never. Too much time to waste. If this were an MVA with entrapment with extrication times in the ballpark of 10-20 minutes than yes, land the bird and they can take them to the Level I. But for this, ground pound them to the level II or III depending on patient condition. You made the right choice from what I am reading here.

 

[mycrofft]

Second Firemoose.

Only I'd boogie for the closest seeing as how your immediate stabliizing steps (whole blood, haemostasis and checking potential for pneumo or haemomediastinum or spinal damage) can be addressed at a basic ER in a hospital with a basic OR and imaging facilities, sort of like going to a MASH and not trying for the Mayo Clinic in one jump. Once stabilized that far, they can be sent on, or maybe even addressed defintively at that echelon of care.
Not to denigrate afteraction reports, but some people always get excited during the event and carry it over into writing new regs or ventilating on others. Watch out, they can be dangerous to your career.

 

[sp121988]

Scoop and Screw!

Like several others have said, I would do all i could to minimize on-scene time. I'd get him loaded asap, and meet the helicopter en route. As far as c-spine is concerned, as long as he has good peripheral CSMs, im gonna focus on the bleeding. I'd pop in 2 large-bore IVs en route, and start him on fluids. I would definitely take him straight to the level 1 trauma center b/c he needs an OR like last week! Obviously, I'd get him on O2 via NRB, and continue to apply pressure on the wound. I'd also call ahead to the recieving facility and brief them (and tell them he's gonna be coming in via helo, not by ground).

 

[AnthonyM83]

Like several others have said, I would do all i could to minimize on-scene time. I'd get him loaded asap, and meet the helicopter en route. As far as c-spine is concerned, as long as he has good peripheral CSMs, im gonna focus on the bleeding. I'd pop in 2 large-bore IVs en route, and start him on fluids. I would definitely take him straight to the level 1 trauma center b/c he needs an OR like last week! Obviously, I'd get him on O2 via NRB, and continue to apply pressure on the wound. I'd also call ahead to the recieving facility and brief them (and tell them he's gonna be coming in via helo, not by ground).

Wait, he's so bad you're going to forgo c-spine, yet you're still going to spend time waiting for the helicopter, waiting for landing, doing a hot load, letting it take off again, then flight time to the 'definitely' level 1?

Not that I mind if others disagree and present a good argument. I just want to make sure you're not doing it just because he looks bad, so definitely needs the chopper and level 1...

 

[Melclin]

Granted I don't quite get how your systems work over there, but calling a chopper to an urban area 25 mins out from a trauma centre seems ridiculous.

Only reason I think of to do that might be that the chopper carries blood, but then so does the nearest ED.

To me, it doesn't sound as though he was that bad off. He's conscious and the vitals you gave seemed like he was in the pretty early stages of shock (unless he was starting to brady down but he was still conscious so that seems unlikely) and that was later en route. 1L of blood is not really that much, I wouldn't wanna be him, but it's not immediately life threatening. Getting up towards 2L is getting to a bad place, but its not the kind of bad where he can't wait a few moments to let you assess the situation. I don't know why you would even get en route without at least a basic set of vitals to make some decisions. How do you know if you need to go to a trauma centre if you haven't got some vitals? I reckon it takes a little over a minute and a half for a single experienced person to take a pulse, ResRa, BP, GCS and to chuck a monitor on (less if you are using an auto BP on the monitor) and you had plenty of people. For the number of chaps you had, it'd take barely more than 20 seconds.

Medic A: "G'day, I'm melclin from the ambulance service, whats happened today? Ah I see... Medic B can you chuck the monitor/pulse ox on and get a line in for some fluids; Medic student BP, Pulse & and run the O2; EMT can you cut his top off, take a ResRa, then take over the wound pressure mate? LEO, I'm ganna get you to swap that shirt with my bandage, ya shirts got some blood on it (assess wound on swap). What's your name mate? Pt? Okay pt., can you tell me what day it is...mmm and who's the president.... yep and where are you...great and can you reach up and grab both of my fingers...terrific? Just ganna role you over to get you on the stretcher mate, try stay nice and still". A minute later we're on our way to the L1 TC, or local ED depending on vitals and interim assessment, taking a history and making further, more detailed assessments (Resp status assessment, perfusion status assessment, another more careful GCS, pupils, temp, maybe neuro/dermatomes if there was suspected spinal involvement), cutting all his clothes off down to his undies and keeping him warm.

Am I missing something? I only skimmed over all the responses.



I can't for the life of me understand why you put four medics on a fire truck, to back up another 4 guys + some coppers, for one pt. You yanks are crazy

 

[WuLabsWuTecH]

Granted I don't quite get how your systems work over there, but calling a chopper to an urban area 25 mins out from a trauma centre seems ridiculous.

Only reason I think of to do that might be that the chopper carries blood, but then so does the nearest ED.

To me, it doesn't sound as though he was that bad off. He's conscious and the vitals you gave seemed like he was in the pretty early stages of shock (unless he was starting to brady down but he was still conscious so that seems unlikely) and that was later en route. 1L of blood is not really that much, I wouldn't wanna be him, but it's not immediately life threatening. Getting up towards 2L is getting to a bad place, but its not the kind of bad where he can't wait a few moments to let you assess the situation. I don't know why you would even get en route without at least a basic set of vitals to make some decisions. How do you know if you need to go to a trauma centre if you haven't got some vitals? I reckon it takes a little over a minute and a half for a single experienced person to take a pulse, ResRa, BP, GCS and to chuck a monitor on (less if you are using an auto BP on the monitor) and you had plenty of people. For the number of chaps you had, it'd take barely more than 20 seconds.

Medic A: "G'day, I'm melclin from the ambulance service, whats happened today? Ah I see... Medic B can you chuck the monitor/pulse ox on and get a line in for some fluids; Medic student BP, Pulse & and run the O2; EMT can you cut his top off, take a ResRa, then take over the wound pressure mate? LEO, I'm ganna get you to swap that shirt with my bandage, ya shirts got some blood on it (assess wound on swap). What's your name mate? Pt? Okay pt., can you tell me what day it is...mmm and who's the president.... yep and where are you...great and can you reach up and grab both of my fingers...terrific? Just ganna role you over to get you on the stretcher mate, try stay nice and still". A minute later we're on our way to the L1 TC, or local ED depending on vitals and interim assessment, taking a history and making further, more detailed assessments (Resp status assessment, perfusion status assessment, another more careful GCS, pupils, temp, maybe neuro/dermatomes if there was suspected spinal involvement), cutting all his clothes off down to his undies and keeping him warm.

Am I missing something? I only skimmed over all the responses.



I can't for the life of me understand why you put four medics on a fire truck, to back up another 4 guys + some coppers, for one pt. You yanks are crazy

Language barrier so assessment took a long time with my broken spanish! But yeah, as assessment with vitals might have been nice. Then again, if it only takes 20 seconds, why not start getting out of the neighborhood and make the transport decision later?

Also, engine medics are per union rules. And most medics only have 2 paramedics on them. We run 3 man crews and we had a rider that day.

 

[HNcorpsman]

i would have gotten IV ACCESS, but NOT actually given fluids until i lost the PTs radial pulse... giving fluids either NS or LR will only raise the blood pressure causing more bleeding, and it will dilute the blood causing bleeding as well... when a PT looses their radial pulse, this is the point where they absolutely need the higher pressure, so i would give them fluid until i regained their radial pulse and then would have stopped the IV... and i also would not have done c-spine...