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It's 1am and you are called about 5 miles out of town for a single vehicle road traffic accident. A pick up truck has crashed into a fence. There are two occupants, Uncle Jake and his niece. The niece has self extricated and is not hurt. Uncle Jake is slightly more crook, he is heavily trapped by his right leg which is pinned in between a mess of dashboard, engine block, centre console and fence post. He has a large piece of another fence post impaled through his right anterior thorax at the level of his clavicle, it is stable.

The local volunteer firefighters have shown up and are working to free Uncle Jake but the OIC says it is going to take about an hour to free him, at the least. About 15 minutes away is the local small rural hospital with basic x ray but no surgical facility and 25 minutes away by air is the regional base hospital which has general and orthopaedic surgical, CT and ICU capability but no cardiothoracic surgeon. 45 minutes away by helicopter is the large level 1 trauma centre which has cardiothoracic surgical capability.

Uncle Jake is conscious and alert with intense pain particularly in his chest, legs and abdomen with the following obs: BP 100/70, RR 18, PR 140, SPO2 98% RA, BGL 7 (140mg/dl) ETCO2 30. His abdo is very painful and rigid

At your disposal you have two ambos, the firefighters and some lady from one of the houses down the road who is a nurse. Chop, chop, chop oh look here comes the helicopter, it is carrying another paramedic but no Doctor today ... but it does have the standard HEMS Doctor pack onboard, which such things like ketamine and a bone saw, should you consider them necessary.

So, what are you going to do about Uncle Jake?

Oh yes this is a composite of two separate actual cases

Edited by Kiwiology

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I'll take a stab at this with what I've gained from reading.

C-spine on as a precaution first. Partner gets a history. What led up to the crash? Drinking? How many drinks? (Multiply whatever he says by 3)

My biggest worry is that fence post. Did it go all the way through? If it hasn't already done so, his lung is probably going to collapse. His heart might have been nicked as well. What are his breath sounds like? Let's stabilize the post so it doesn't move. Depending on the length, it might need to be cut to move and board him. That worries me as any movement on the post will make things worse.

Next worry is internal bleeding. Unless anyone can set up a sterile tent and perform field surgery, the FFs need to work harder.

Airway seems intact with his good SP02 and RR. What's his skin like?

Is his right leg just pinned or is it fractured/broken? Is there a distal pulse in his trapped foot?

I'm not sure what the HEMS pack has. If it has pain meds, I want Jake to get them before he goes into shock or becomes unconscious.

As soon as this guy is out of the truck, he's going to the level I trauma center.

Edit: Assumed it was, but should've written it. Is the scene safe? Are we shielded from traffic? Anything leaking from the car? Battery disconnected?

Edited by cscboulder11

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This is compensated shock. At that HR and and BP he is going to decomp fast. 1 hour extrication does not bode well for this patient. C-Spine, etc needs to be in the hands of the EMTs.

Stop any obvious bleeding. Avoid positive pressure ventilations. Consider MAST trousers inflated in the lower extremities only.... Do NOTHING to delay transport. Forget the rural center. Nothing they can do that you can't (that matters). Get him to the 25 minute destination asap. As long as they have surgery, this patient's big issue is the abdominal bleed.

Edited by Kaisu

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This is compensated shock. At that HR and and BP he is going to decomp fast. 1 hour extrication does not bode well for this patient. C-Spine, etc needs to be in the hands of the EMTs.

Stop any obvious bleeding. Avoid positive pressure ventilations. Consider MAST trousers inflated in the lower extremities only.... Do NOTHING to delay transport. Forget the rural center. Nothing they can do that you can't (that matters). Get him to the 25 minute destination asap. As long as they have surgery, this patient's big issue is the abdominal bleed.

You are spot on in my book sister. Compensated shock it is. He is obviously bleeding out. He has a diminshed pulse pressure which means his time in compensated shock is short.

Increase volume and transport ASAP. What he really needs is to sacrifice his leg in exchange for his life, but we do not do that in the field.

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Thanks Dfib.

Keep an eye on the niece too. Just because she self extricated and feels "fine" doesn't mean she isn't seriously hurt. Her body was subjected to the same forces as her uncle and may start circling the drain in front of your eyes. She's younger and may be compensating well. That could change very quickly.

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BP 100/70 with a heart rate of 140? That means he has a MAP 10 points above critical with a heart rate 10 points below being in SVT. That's really bad. How long prior to our arrival did the crash happen? If it was 20 minutes ago he may have a chance, if it was 10 minutes ago, not quite as much. Tell the OIC that if his men can't get him out and loaded on a chopper in 20 minutes or so he is going to die. Hopefully they can cut their extrication time down. I assume the local hospital can't do any emergency fence-post-ectomies, so we need to get him to a surgical facility ASAP. In the mean time, check for tension pneumo, relieve if it is causing a rise in intrathoracic pressure and reducing venous return. As well, see if they're is anything leaking from the leg that we can work on, make sure the pelvis is stable, fix as necessary. Start two large bore IV's, but titrate it to maintain a permissively hypotensive level. I don't think there is anything on the doctor pack that will help our driving-ability-challenged friend here. The worse case scenario for him is that he managed to transect the subclavian artery. That's one of those injuries that even if you have a trauma surgeon and OR suite sitting next to you, they may not be able to do anything before you bleed out. Reference two cases that high light this. The first is the 1986 FBI shootout in Miami. Early in the battle, one of the perps was hit with I believe buckshot which destroyed his upper thoracic vessels, however, he was still able to return fire for several minutes, killing two agents. No surgeon in the world could have repaired the damage that he sustained, he was dead, but it took him a while to realize it. Second, more poignantly, was the case of John Lennon. He was only 20 blocks away from a hospital and probably about 40 blocks away from a trauma center when he was shot, but he was dead on arrival at the ER, the bullet had also taken out his subclavian. So on that note, on top of everything else, tell the fire guys to make sure not to touch the fence post, for all we know, it's actually tamponading and even looking at it could spell the end for Uncle Jake.

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The scene is safe, the fence post that has gone into his thorax has not gone all the way through. His right leg is trapped up to the level of about his mid thigh, it;s a mess of leg, dashboard, centre console, engine block and fence.

The Firefighters tell you it is going to take at least 45 minutes to free him, they are working as hard as volunteer small town firefighters can, which by anybodies estimate is 400% above normal.

You put in a big bore drip, start a little fluid and some pain relief.

He is pretty crook and needs to be freed rather fast, so, should we amputate his leg to free him before he dies?

Edited by Kiwiology

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He is pretty crook and needs to be freed rather fast, so, should we amputate his leg to free him before he dies?

Is that a serious question?

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Is that a serious question?

Yes. Never mind you might not be allowed to do it, the question is if you could, would you do it?

In the several cases that this scenario is written off of the patient was heavily trapped and had their trapped limb amputated to free them

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In an alternate not so parallel universe where licenses are not revoked, malpractice is unknown, jails are non existent, kids quit eating and bills pay themselves .... sure.

Edited by DFIB

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