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miles_g

Don't play in trees.

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Hey guys, it seemed time for another scenario so I figured id give it a shot. This is my first post so cut me some slack on the mistakes please, enjoy!

You are dispatched as a part of a search and rescue team with 6 members including yourself. Within your team you have three first responders 2 emt's and 1 paramedic.   The call comes in as a missing group of 3 teenagers somewhere on a hill, The RP reported hearing the teens sounding somewhat distressed on a hill but did not see them. Your resources are limited to a standard trauma bag minus an intubation or IV kit (Out of the SAR scope of practice), a titanium litter, a GURMA bag (Body sized vaccum splint backboard thing), and a technical rescue team at the ready with ropes and what not, you also have HEMS available to you. When your team finally arrives on scene at a large oak tree you find 3 pt's, the first is still playing in a tree, the second is walking around, and the third is unconscious laying supine on a log maybe 10 yards away from the base of the tree. All 3 subjects are on top of a very steep hill and getting them all down will be very difficult.

(the scene is safe)

What resources will you utilize?

what resources do you need?

how will you split up your team?

any more info/ questions?

Go!

(Ran this call a few months ago and was just curious as to what you guys might have done differently)

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Welcome and a very interesting first time scenario.  Just a few quick comments.  We have people from all over the world here, so try not to use local abbreviations.  What does RP mean?  There is no such thing as a standard trauma bag, everyone's is going to be different.  Maybe just say you have a trauma bag with BLS supplies.

On to the scenario.  This scene is a little concerning.  You have an unconscious kid at the bottom of a tree and two others who don't seem to care.  I would have the medic and one EMT go to the unconscious kid.  The other EMT and a first responder should check on the kid in the tree and I'll take the other two first responders and check on the kid that is walking around.  Let's get the helicopter headed our way since there is the potential for a very serious trauma pt.  What information can we obtain from the two conscious kids?

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Apologies, in our system RP stands for reporting party/s, and yes we do have a trauma bag with bls supplies, thank you for the clarification for future scenarios. 

You and your group of first responders find that besides having a strong odor of ETOH the pt requires almost no medical assistance. After the group dealing with the kid in the tree finishes consulting her to come down they also smell a strong odor of ETOH coming from  the obnoxious teen who repetitively asks who you are and why you're there. You request a bird which according to dispatch will be on scene in 30 minutes. 

Cheers!

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And what does the team taking care of the unconscious kid have to say?  Will we be able to get the drunk kids down under their own power?  Do we see anything else at the scene such as drugs?  What do these two have to say about the unconscious kid?

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My thoughts exactly, what else did the two flighty non-caring kids take?

What are my vitals on the unconscious kid?  

Full trauma assessment - head to toe?  I'm suspecting that this kid is probably so shitfaced which is the reason why he's unconscious but he could have fallen from the tree and have any number of reasons for being unconscious but the most probable reason is that he is drunker than the other two.  But caution dictates that we treat as a trauma.  So full trauma assessment.

Let's do a glucose as well. 

Pupils

My big concern are his respirations and if he is really as drunk as I think he is, I'm concerned about aspiration if he hasn't already done so.  

More info please.  

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The team with the unconscious kid says that there is a lot of bleeding coming from around mid shaft of his right femur, a large hematoma on his left forehead. Battle sign and "coon" eyes are also noted. Breathing is present and pt is responsive to pain. They tell you they're about to get vitals and start cutting some clothing. As for the other two kids they can walk down the hill they just may need some assistance from a member or two. As for drugs or anything else of interest at the scene you don't note anything, the two kids say that they were all drinking and playing in the tree when "Bobby" (not pt's real name) fell out of the tree and tumbled down the hill a bit. They don't seem very concerned...

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all righty, well Bobby(not his real name) needs some new friends to begin with

He also needs to be evac'd out toot sweet.  

With a bls trauma bag, not much to do but to cover that femur wound and keep pressure on it,  

Did you say that there was oxygen available?

How long till the bird?

Not sure what's in the trauma bag but use whatever is in it to do whatever magic you can for the head injury

Ready the guy for evac and await the helicopter.  

I think that's about it.  You really don't have much else to do at this point right?  

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If you have time/equipment prior to evacuation stabilizing the femur fracture should be a priority (huge potential blood volume loss). The other two should still have a full trauma survey before going with the probable drunk/stoned theory.

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the two "friends" say that all they did was share a few bottles of svedka then decided to play tree tag.

And you're very right rock_shoes, after "bobbie's" clothes are cut off they reveal an open mid-shaft femur frac (and yes, our bls bags carry oxygen and traction splints) the trauma assessment/ head-to-toe also reveals large thoracic blunt trauma left side about midclavicular, however no evidence of flail chest and no trach deviation, no spinal step-off either. other than that the  trauma assessment reveals nothing more besides that our "unconscious" pt is responsive to pain as he screams like a banshee in the night when you go anywhere near his right leg. you struggle to bandage the wound and splint it but eventually medicine prevails! However one of the friends now seems concerned and yells at you whenever you try to touch him.

the bird is 30 minutes out.

vitals:

  • HR 121 weak and thready
  • RR 7 weak and shallow
  • BP 100/40
  • SPO2 93%
  • pupils are slow and unequal to react
  • and his BGL is around 135

You start to package the patient but he repetitively vomits/goes into seizure/ respiratory arrest you have an OPA in and are bagging the patient.

I know this is out of my scope of practice but what would you do from an als point of view? besides obvious sedation and intubation, what drugs would you push? I was thinking maybe dopamine and midazolam or lorazepam.

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the two "friends" say that all they did was share a few bottles of svedka then decided to play tree tag.

And you're very right rock_shoes, after "bobbie's" clothes are cut off they reveal an open mid-shaft femur frac (and yes, our bls bags carry oxygen and traction splints) the trauma assessment/ head-to-toe also reveals large thoracic blunt trauma left side about midclavicular, however no evidence of flail chest and no trach deviation, no spinal step-off either. other than that the  trauma assessment reveals nothing more besides that our "unconscious" pt is responsive to pain as he screams like a banshee in the night when you go anywhere near his right leg. you struggle to bandage the wound and splint it but eventually medicine prevails! However one of the friends now seems concerned and yells at you whenever you try to touch him.

the bird is 30 minutes out.

vitals:

  • HR 121 weak and thready
  • RR 7 weak and shallow
  • BP 100/40
  • SPO2 93%
  • pupils are slow and unequal to react
  • and his BGL is around 135

You start to package the patient but he repetitively vomits/goes into seizure/ respiratory arrest you have an OPA in and are bagging the patient.

I know this is out of my scope of practice but what would you do from an als point of view? besides obvious sedation and intubation, what drugs would you push? I was thinking maybe dopamine and midazolam or lorazepam.

Phenylephrine, ketamine, sux, consider fentanyl as an analgesic adjunct but the ketamine should do the trick. Plasmalyte would be preferred if any fluid resusc. ends up being required. TXA. Strictly talking the pharm not the technique at this point.

Edited by rock_shoes

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