mobey Posted December 12, 2008 Share Posted December 12, 2008 RuffEMS...just wondering...do you actually know all that much about combines and how they are constructed? I don't ask to be facetious, I ask because it would be a relatively simple extrication that could be completed long before Fire arrives. I work in a rural agricultural setting, the scenario you describe is not all that dissimilar from my experiences. Is sounds as though you are describng him trapped under the header auger and pulled into the feeder belt, is this correct? If so, how far into the feeder has he gone? If this is the case we can grab the "big wrench" and turn the feeder backwards freeing him..... however do not forget the "Fingers" in the center of the auger that could be impaling him, I would consider spinal precautions at this time if he was in fact grabbed by the pickup drape flipped onto the table and sucked halfway up the feeder housing..... Link to comment Share on other sites More sharing options...
CBEMT Posted December 12, 2008 Share Posted December 12, 2008 It would be a good idea for tourniquets regardless of what condition the lower extremities are in- they are NOT written off just because a tourniquet is applied!. Bleeding that can't be controlled by direct pressure (like, say, if the bleeding site is trapped in a Farm Machine of Death) is good enough reason to go that route. Kill the power, apply tourniquets if bleeding is still active and heavy, oxygen, titrated fluids, pain relief, blankets, extrication by qualified personnel. Link to comment Share on other sites More sharing options...
okmedic Posted December 12, 2008 Share Posted December 12, 2008 A set of vital signs would be a good start, is he still bleeding or is the bleeding controlled at the moment by the entrapment? A medical history would still be valuable in this situation, as well as medications and allergies. Definantly 2 large bore iv's but I wouldn't want to start any bolus over 250cc's until I know what his blood pressure is. What is the temperature outside? High flow 02, c-collar. Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted December 12, 2008 Author Share Posted December 12, 2008 If this is the case we can grab the "big wrench" and turn the feeder backwards freeing him..... however do not forget the "Fingers" in the center of the auger that could be impaling him, I would consider spinal precautions at this time if he was in fact grabbed by the pickup drape flipped onto the table and sucked halfway up the feeder housing..... no I don't really know anything about combines, nor does my partner on this particular scenario. I'm goin somewhere with this ok. Fire arrives and they find that they do not have the tools to get him out. Their grant never came in for the tools to do the job. So just for shits and giggles they don't know much about nothing. They are a small rural fire department that sees maybe 10 rescues a year and 9.99999 out of 10 are car wrecks. They are also very territorial and will not allow any other department in for at least the next 45 minutes to an hour. His pressure is crappy - about 70systolic, pulse rate 135 and resp rate 36. He's pretty scared. What else do we want to know now? Oh two other things 1. the temperature is about 87 degrees in the shade 2. He's stuck about mid-thigh. You can see about 4 inches of his thigh and nothing lower. Link to comment Share on other sites More sharing options...
reaper Posted December 12, 2008 Share Posted December 12, 2008 First find family or neighbor that knows the equipment. They are the best ones to figure out how to free the pt. They will know how he is pinned and the best way to get him out. Keep pt perfusing, try to keep him awake and try to keep bleeding controlled. Be aware of compartment syndrome since he has been trapped for a prolonged amount of time. Keep MC updated on the situation. Think about pain management for the pt! Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted December 12, 2008 Author Share Posted December 12, 2008 ok, medical control gives you orders for pain meds but his pressure is only 70 systolic. Medical control asks you to call them on the phone. (yes your cell phone works out where you are at) You call them and the physician asks how long it's going to be before you get the guy free. You answer at least 30 minutes or so. The physician then asks how comfortable are you in considering field amputations? The guy is going to die if you don't do something the physician says. What is your response? (this is where I was going) I guess I could have just asked it but I wanted to preface this with a real life scenario that may happen to you in your lifetime career as a medic or may never happen. Link to comment Share on other sites More sharing options...
JakeEMTP Posted December 12, 2008 Share Posted December 12, 2008 Interestingly, at the C.A.P. lab we attended we were shown and actually participated in a field amputation. I'm not absolutely sure how comfortable I would be doing one in the real world, but if that is what is required well........... Eye protection at minimum, a tourniquet, scalpel and a saw of some sort and it could be pulled off. If we don't do something soon, the entrapped individual is going to die. He might very well anyway, but at least we gave him a chance. Link to comment Share on other sites More sharing options...
DwayneEMTP Posted December 12, 2008 Share Posted December 12, 2008 Bilat T's to give me time to get my assessment, vitals and start some fluids. Life before limb, and I can't pack wounds and look for the less sexy life threats at the same time, right? Manage the airway, possible nasal intubation? Adjust fluid volume to around 80-90 systolic as mentioned before, get appropriate pain control on board, then deal with the legs when I'm comfortable with everything else. Med control advises bilat amputation and my feeling is that I can't keep him from crumping without it? No, I have no issue with it. The legs have been described as hamburger, and this may be accurate, and it sounds like cutting them the rest of the way off will be no huge trick. The trick here, if we run with these assumptions; that he must get moved or die (say from an internal bleed as well as the obvious. Abd pain with distension becoming remarkable), that the legs below mid thigh do not appear salvageable in the time available, and that med control has decided from your serial reports that the patient is deteriorating, then attention should be directed to caring for and maintaining perfusion in the stumps. Amputate to the distal extremes possible, move T's distal if possible, get on the road, monitor vitals, monitor stump perfusion, get to the hospital. It seems as though when I was watching a documentary about baby Jessica (in the well, right?) that they showed a medic going down in the hole and the voiceover from the medic was something like, “I had been given instructions to simply pull her leg free (It was pinned up against her between her chest and the tubing wall if I remember), breaking it if necessary, and if that was unsuccessful I was instructed to amputate it, but to get the girl out by whatever means were necessary.” And then went on to describe the horror of thinking of removing a child’s leg, etc. Not sure why, after this long entrapment that that job fell to a medic, and my memory is a hinky thing, so perhaps I’m remembering incorrectly. Field amputations are not unheard of. The anatomy here is pretty straight forward, even though more complex than the baby scenario perhaps, but still, not rocket science. Dwayne Link to comment Share on other sites More sharing options...
p3medic Posted December 12, 2008 Share Posted December 12, 2008 How far is the hospital? Any chance to get a Doc and blood to the scene? I've done this in the past, once for an amputation that ended up not needing to happen as we were able to lift the train enough to free him. Link to comment Share on other sites More sharing options...
Arctickat Posted December 12, 2008 Share Posted December 12, 2008 The physician then asks how comfortable are you in considering field amputations? I figured you were going this way after that last one. No Need to amputate. At least if I am envisioning this in my head properly. Header Augers are surprisingly flimsy, with proper leverage it can be bent up with a pry bar releasing the individual from that area, then the feeder belt can be cut and the pulley turned in reverse to permit the legs to come back out. Now....if you were to change your scenario so that the farmer was unloading the combine and went into the tank to kick grain down into the auger and slipped...you might have a more difficult extrication, but by that time, it's no longer an amputation for EMS to do, the auger has already done it for you. Here's a good one. Farmer drives an old john Deere where the PTO shaft runs out of the engine and under a cover right beside the seat rather than out the back of the tractor. Mr. farmer removed the cover sometime long ago and knows that he can not step there. Mr. Farmer steps there and his leg wraps around the shaft up to his knee 3 or 4 times. All that is holding the lower leg on is flap of skin 3 - 4 inches across and some badly traumatised muscle tissue. The tractor is shut off and connected to a log splitter so you can not slide him from the shaft, nor can you unwrap his leg. The farmer is standing on the ground at the back of the tractor with his left leg entangled in the PTO shaft which is about waist height. It is mid winter in sub zero temps and he is heavily dressed, conscious, alert, very pale and feeling week. The leg does not appear to be actively bleeding aside from some occasional droplets. Whoops, sorry...one scenario at a time. Back to the combine Link to comment Share on other sites More sharing options...
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