Proper treatment....read on.

[Asysin2leads]

I'm with Dwayne. If you let this guy lay in -35 degree weather for 50 minutes, you're going to have a lot of explaining to do. We are not going to sit in front of a doctor and say "Well, we thought maybe the cold would help." We don't go with our personal theories in the field. We have operating procedure. We have rules. We have rules that are not open to interpretation, personal intuition, gut feelings, hairs on the back of your neck, little devils or angels sitting on your shoulder. We're all very well aware of what our orders are and what those orders mean. They come down from our Commander in Chief. They contain no ambiguity. MR. HUNTER, I'VE MADE A DECISION, I AM CAPTAIN OF THIS BOAT, NOW SHUT F--- UP!

Ahem. Sorry. Get the guy out of the cold and snow, get some tourniquets on him, and get him out of there. End of story.

[AnthonyM83]

We don't. I've never seen a protocol/procedure in the manual on removing or not or making decision to remove or not or anything similar. You'll tell the doctor we thought there was risk of exsanguination , so didn't remove it until we were ready to leave.

I partially being swayed to removing him because of the cold factor if you can't keep him warm...but the above is what you would tell the doc (though I imagine even if object removed, circulation would not be regained...aka metabolic waste build up continues but at risk of further bleeding.

[Asysin2leads]

For traumatic arrests, ours is pretty clear. It says in big letters "RAPID TRANSPORT IS THE HIGHEST PRIORITY" What I was getting at is personal theories about what the cold is going to do as part of our decision whether to remove or not is a good way to get your card ripped up. Stick with what you know, not with what you think.

The doctor is going to not like your answer about exsanguination. He'll have read the headline in the local paper which says "MAN DIES AS EMTS STAND AROUND" and respond appropriately. He'll remind you that you BELIEVED that he might be tamponaded(?) by the truck, but you had to have KNOWN that anyone with this type of injury needed to be transported to appropriate facilities as quickly as possible, and in any event, ALS was not going to be able to help.

Look, ALS is not going to be able to do anything about compartment syndrome of any consequence. Like I said before, normal saline, high flow oxygen, even high dose steroids, these are spraying down a house fire with a garden hose. He doesn't need ALS, he needs surgery. Put him on a snowmobile and haul ass if you have too.

[DwayneEMTP]

Uh, give up on what, man? Sorry if I've made anything confusing. Guess what I'm trying to say is that if you can examine the extent of the injuries the best you can by not lifting the object is half the battle. It can determine what the best course of action can be.

What I'm getting at is this.

If you can't assess without lifting the object, you must lift the object.

If you can assess the feet without lifting the object then one of two things is extremely likely;

One: You find you don't have pulses in the feet, so you have to lift the object to see if you can restore them, right?

Two: You have pulses in the feet, meaning that more than likely the legs aren't completely crushed, so you must lift the object to assess for further, possibly life threatening, injuries as well as high tail it to the hospital, right?

I'm just having a hard time understanding what you're going to find in your assessment that is going to convince you that leaving the weight in place is a sound medical decision in this case...

We don't. I've never seen a protocol/procedure in the manual on removing or not or making decision to remove or not or anything similar.

Surely somewhere in your protocols it suggests that you assess your patients before making life or death decisions concerning their care? How can you possibly defend leaving this man to freeze based on your GUESS that he might bleed if you free him?

You'll tell the doctor we thought there was risk of exsanguination , so didn't remove it until we were ready to leave.

Then you certainly shouldn't give the next seizure diazapam, as there is a risk of anaphylaxis and/or cardiopulmonary arrest.

I'll tell you this...I'd rather castrate myself with a dull spoon than go to this man's family, or med control and say, "You know, I thought about moving the weight, but was afraid he might bleed and I wouldn't know what to do!!"

Controlling hemorrhage is week one of basic class....you guys are breaking my heart by deciding to leave him on the ground because you feel the weight is controlling his bleeding...That's crazy...

We're educated/trained to help people and deliver them to the care they need...not create pie in the sky diagnosis based on urban legends* instead of sound medical principles.

No offense intended to anyone. It’s just that the further I go in my studies, and the more people I put my hands on, the more I realize that we’ve been given this amazing ability to change the outcomes for a small percentage of them…to watch you allow a lesser, possibly fatal outcome, based on a GUESS of what might be going on, while you stand and watch this man die simply knocks my world out of balance….

Fun discussion. I truly would like to see someone support the idea that leaving this man crushed and freezing would be viewed favorably by the general medical community.

Have a great day all.

Dwayne

*The urban legend I’m speaking of is the man who got trapped by a truck/train/subway car/statue (depending on the version of the story) and the powers that be decided he was not salvageable, at which point they brought him food and drink, he talked to his loved ones on the phone…had a grand ol’ time for a few hours, until they released him, at which point he died instantly.

[JPINFV]

We have rules. We have rules that are not open to interpretation, personal intuition, gut feelings, hairs on the back of your neck, little devils or angels sitting on your shoulder. We're all very well aware of what our orders are and what those orders mean. They come down from our Commander in Chief. They contain no ambiguity. MR. HUNTER, I'VE MADE A DECISION, I AM CAPTAIN OF THIS BOAT, NOW SHUT F--- UP!

Too bad Captain Ramsey was completely out of line in the referenced situation.

[firedoc5]

What I'm getting at is this.

If you can't assess without lifting the object, you must lift the object.

_______________________________________________________________________

Now I get you. I was trying to say that it would be optimal to be able to examine the extremities without having to lift the object. But you may have to especially if the patient is crashing. Then you have no choice. You'll have to lift it.

If the patient was left on the ground the family may ask about that. But on the other hand, if you lift the object and move him and he bleeds out and the family hears from some source that if they left him where he was he might have had a better chance, then they'll ask why he was moved in the first place. Just too many what if's and all.

[akroeze]

Again my question is what benefit is ALS? If you can get them to the hospital faster than ALS can then go.

[ccmedoc]

You guys are waiting for ALS to get there and do...... what?

Exactly...Move the machine, assess, pack wounds, tourniquet if necessary, stabilize, and transport to a better facility than you have...Life over limb folks!!!

If you wait, he will die from shock...whether hypovolemic or hypothermia, your choice. Inaction is as much negligence as acting inappropriatly...same thing. Unless the ALS carries blood products, it is a waste of time to wait for them.

Get your poop in a group and do something for your patient. don't be a :knob:

[rock_shoes]

If the patient was left on the ground the family may ask about that. But on the other hand, if you lift the object and move him and he bleeds out and the family hears from some source that if they left him where he was he might have had a better chance, then they'll ask why he was moved in the first place. Just too many what if's and all.

You can't base your treatment plan on what may be. You have to base it on what is. At those temperatures if you leave your patient pinned he will end up frostbitten and hypothermic in addition to his leg injuries. I would class that as making your patient worse. Yes assess as best you can first, but regardless the object atop the patient will have to be moved. This is not a patient with whom you should "stay and play". Again an EMR should be able to control major bleeding of the extremeties and should hand back their license if they can't. Would it be better to have ALS on scene? You bet. Can ALS get to the scene in a timely enough manner to be able to wait for them? Absolutely not. Those are just facts of life when your working in remote locations sometimes.

[Just Plain Ruff]

ok I've stayed out of this but I'm in it now.

How long can someone survive in -35 degree weather with a traumatic injury? Couple this with the fact that the ground is at least as cold as the weather. So how long will it take for this guy to freeze to death?

I think less than 50 minutes.

Why in the world are we waiting for ALS? Would this guy be better served and treated if you remove the item, assess the lower extrems and transport. You do have vans and suv's on site don't you? Clear off a place in the suv or van and get your butt in gear.

The helicopter has a 50 minute eta to you. It is75 minutes till nightfall and the helicopter cannot fly in the dark so there is no way that this is going to benefit the patient.

Just lift the freakin load off him, put him on a backboard, take some Oxygen tanks with you and get your butts to the small hospital. At least they will have a 50 minute or so head start to call in a surgeon or doctor who can hopefully do this guy some good. You have nothing, they have more than you. I think we know what wins in this situation - the local hospital wins hands down over you with oxygen and not much more.

You were dealt a crappy hand and you have to use it to your advantage and deal with the situation.

The obvious choices are

1. dead from hypothermia

2. Dead from compartment syndrome and hypothermia

3. dead either way

4. some possiblity that he survives if you transport to at least some sort of definitive care.

the least you can offer this guy is a chance of survival by getting him to the closest facility and let them work on him. If you do less then you have done him no good.