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Bieber

Moped Accident

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This is one of those weird things that seems like a no brainer to me but seems like I'm the only one I know that does it, and that is that I want his clothes off before he's strapped to the board. It takes time and sometimes manipulation to get good visualization when trying to cut the clothes off after the straps are on.

So I have Fire Ccollar him and hold manual Cspine, his clothes are cut off down to his tighty whities, and I peek into those in front and back for missing or damaged or bleeding parts. I have FE09 supervise the Cspine taping and continue suctioning as I have little faith in my unknown help not to suffocate him with the suction or possibly increase bleeding by being too aggressive, or perhaps not aggressive enough.

Are we able to determine where the bleeding is coming from? Is there any way to pack it in the inside of the mouth? Does he respond to being disrobed, or manipulated with any type of pain/indignation response? I'm going with Warfarin as his med based on his statement and the difficulty with managing the bleeding. To me this means that we have to be very judicious with our fluids and do what we can to pack/bandage any wounds with significant bleeding as a 20 minute transport can make a significant difference to this guy. (Yeah, see, here we go again. Likely your protocols say that you can bandage his wounds, but not pack them, so what are you going to do with those that you can't bandage? Let them continue to bleed?)

After he is strapped to the board I'm going to load him on the cot with a couple of blankets stuffed behind the right underside of the board so that his airway will drain. (Right underside is only relevant so that he will be tilted facing me, instead of away, when I'm on the bench seat.)

Does he struggle on the board? If so trying to clean him up at this point enough to get a decent set of electrodes placed to see if a cardiac issue may be occurring is likely a waste of time. His resistance is going to queer any of my results as well as take up a lot of time for very little benefit at this time.

Two 14s preferable both on the right arm, one a blood Y, where they will hang out of my way as I'm confident that we have abd bleeding already as evidenced by the distention/guarding and possibly falling B/P. (Not sure as of yet, as two readings does not make a trend, but combined with his overall assessment it seems likely.) We may also be managing a pneumo/hemo before transfer of care and it leaves me less obstructed access. It also helps avoid any of our 'helpers' from pulling them accidentally.

I need to get really, really good vitals, and really, really good breath sounds at this point, monitor his mental status and I'll certainly intubate him if/when be becomes unresponsive. I know many might believe that I should be focused on his head injury, but as long as he can keep his airway clear, other than stopping the leaks, there is little that I can do for anything in his head that might be going to kill him, so I will prepare for the things that I believe are going to go wrong before transfer of care that I may be able to influence.

IVs TKO, constant monitoring of his airway, PMS x 4 regularly, lights and sirens and best safest speed (Which means we ask a fireman to follow in the police car and have cop drive us) while I call the hospital and tell them to wake up all of the expensive people.

Dwayne

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This is one of those weird things that seems like a no brainer to me but seems like I'm the only one I know that does it, and that is that I want his clothes off before he's strapped to the board. It takes time and sometimes manipulation to get good visualization when trying to cut the clothes off after the straps are on.

So I have Fire Ccollar him and hold manual Cspine, his clothes are cut off down to his tighty whities, and I peek into those in front and back for missing or damaged or bleeding parts. I have FE09 supervise the Cspine taping and continue suctioning as I have little faith in my unknown help not to suffocate him with the suction or possibly increase bleeding by being too aggressive, or perhaps not aggressive enough.

Are we able to determine where the bleeding is coming from? Is there any way to pack it in the inside of the mouth? Does he respond to being disrobed, or manipulated with any type of pain/indignation response? I'm going with Warfarin as his med based on his statement and the difficulty with managing the bleeding. To me this means that we have to be very judicious with our fluids and do what we can to pack/bandage any wounds with significant bleeding as a 20 minute transport can make a significant difference to this guy. (Yeah, see, here we go again. Likely your protocols say that you can bandage his wounds, but not pack them, so what are you going to do with those that you can't bandage? Let them continue to bleed?)

After he is strapped to the board I'm going to load him on the cot with a couple of blankets stuffed behind the right underside of the board so that his airway will drain. (Right underside is only relevant so that he will be tilted facing me, instead of away, when I'm on the bench seat.)

Does he struggle on the board? If so trying to clean him up at this point enough to get a decent set of electrodes placed to see if a cardiac issue may be occurring is likely a waste of time. His resistance is going to queer any of my results as well as take up a lot of time for very little benefit at this time.

Two 14s preferable both on the right arm, one a blood Y, where they will hang out of my way as I'm confident that we have abd bleeding already as evidenced by the distention/guarding and possibly falling B/P. (Not sure as of yet, as two readings does not make a trend, but combined with his overall assessment it seems likely.) We may also be managing a pneumo/hemo before transfer of care and it leaves me less obstructed access. It also helps avoid any of our 'helpers' from pulling them accidentally.

I need to get really, really good vitals, and really, really good breath sounds at this point, monitor his mental status and I'll certainly intubate him if/when be becomes unresponsive. I know many might believe that I should be focused on his head injury, but as long as he can keep his airway clear, other than stopping the leaks, there is little that I can do for anything in his head that might be going to kill him, so I will prepare for the things that I believe are going to go wrong before transfer of care that I may be able to influence.

IVs TKO, constant monitoring of his airway, PMS x 4 regularly, lights and sirens and best safest speed (Which means we ask a fireman to follow in the police car and have cop drive us) while I call the hospital and tell them to wake up all of the expensive people.

Dwayne

Dwayne,

If you go intubation route you might want to try and premedicate the patient with lidocaine first. It is thought to help decrease ICP. which could be a major issue with him.

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Dwayne,

If you go intubation route you might want to try and premedicate the patient with lidocaine first. It is thought to help decrease ICP. which could be a major issue with him.

That's a good point. I don't see anything so far that would lead me to believe that I'm going to have to intubate. We do need to reassess and clearly define the need for pain management, as it may already exist but has not been the priority, but so far I think we're on a decent path.

Dwayne

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That's a good point. I don't see anything so far that would lead me to believe that I'm going to have to intubate. We do need to reassess and clearly define the need for pain management, as it may already exist but has not been the priority, but so far I think we're on a decent path.

Dwayne

That is what I was thinking. We have the IVs in already, im saying be ready because his pressure could start to bottom any minute since be is bleeding like hell. The thing that I would say I dont agree with you on with your treatment plan is trying to pack the wound in his mouth. We need to try and stop the wound but being in the mouth it endangers the airway by trying to pack the wound. If I have misunderstood what you meant by packing it please correct me. Hopefully this patient doesn't crash till we can get to the hospital.

FireEMT2009

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Dwayne,

Visual inspection of the mouth reveals several large avulsions to the interior tissue, however you note that much of the blood is also coming from the lacerations surrounding the outside of the mouth. When you try to pack the inside of the mouth, you nearly get your finger bitten off by the patient! The patient doesn't struggle, but he continues to curse at you for being a "jackass". His vital signs remain unchanged throughout the remainder of the transport and you're somewhat able to staunch the flow of blood with bandaging. The patient was also able to maintain his own airway with frequent suctioning of his oropharynx and had clear lung sounds and good oxygen sats the whole way in.

When you arrive at the hospital, the trauma team is waiting for you where they immediately RSI the patient and ultrasound his belly before he is taken to have a CT of his head done. Your truck is then put unavailable while you and your partner go to get your blood drawn and fill out three hours of paperwork relating to the blood exposure. Now you always carry a mask with a face shield and an N-95 respirator in your pocket when you're working. Thankfully, you find out that the patient's fast HIV came back negative and don't have to suffer through a month of combivir. You later find out that the patient is discharged within two days with a diagnosis of a fractured right patella along with two small brain bleeds: a subdural and a subarachnoid. No internal abdominal bleeding was found on the ultrasound.

Thanks for playing, guys! This was the call that I got the blood exposure on. =) Hope you enjoyed it and learned something from it, I know I did!

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I will also get my partner to check on the other patient in the truck if he hasn't already.

I read from the original posting to the last response, times 2. So far, I see a single vehicle involvement, to specifics, one Moped, with one patient, and one bystander who is possibly related to our Evel Knievel.

Where and when was a second patient in a truck, to be sending my partner to check, mentioned, or what did I miss, here?

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Beiber made a reference to viewing the patient from the 'truck', meaning ambulance. I think that that was misconstrued as meaning a second vehicle.

FE09, I truly get what you're saying about not blocking the airway, and of course that is a valid point. Sometimes though what will pay large dividends comes along with at least a little risk. After having the injuries more clearly defined I can see that packing wasn't an option, but if backing would have been an option packing, while leaving the leading edge of the bandage tied to the C-collar to avoid losing it isn't a great option, but might be viable if the blood loss is of an unacceptable quantity.

I once had my partner hold two big wads of dressing, one on the inside and one on the outside with Magil forceps, of a ragged cheek wound. It wasn't pretty, but I had no other way to stay the bleeding on this unconscious patient, at least no other that I was smart enough to identify. This was a 90ish year old male who'd fallen in the shower. Was unresponsive after hitting his cheek on the metal towel holder while falling. He was breathing on his own, Coumadin confirmed by spouse, B/P around 70ish systolic, about 350 gallons of blood in the tub but only this one wound identified...I just simply wasn't willing to lose any more blood if I could help it.

So, though I'm not implying that wouldn't also do what you have to do to treat your patients, I meant that if packing was appropriate, as with the dressing and Magils, then I wanted it considered in a patient that was possibly heading south, hemodynamically speaking. But, as often happens...he only headed south west for a bit before leveling of to due west the rest of the way to the hospital. :-)

Good thread...thanks to all for participating!

Dwayne

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Agreed, I find it very insightful to read about the thought process you go through regarding patient treatment and everything else, only shows how much I have yet to learn. It's things like these I try to bring with me.

Marc

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Agreed, I find it very insightful to read about the thought process you go through regarding patient treatment and everything else, only shows how much I have yet to learn. It's things like these I try to bring with me.

Marc

Yeah, I agree completely. I've made many, many decisions on scene based on issues that I had previously thought through with my friends here. It's a great way to share information I think.

Dwayne

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Agreed, I find it very insightful to read about the thought process you go through regarding patient treatment and everything else, only shows how much I have yet to learn. It's things like these I try to bring with me.

Marc

Hey Hutsy, keep reading these scenarios. Very good scenario writers here.

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