Case: The Wrong Way to Rob a Jewelry Store

[Asysin2leads]

WARNING WARNING WARNING EXHAUSTIVELY LONG POST AHEAD. ABANDON ALL HOPE, YE WHO ENTER HERE.

Requested for BLS intercept on what was initially a "minor injury" call type. The first rule of EMS in my neck of the woods is that BLS does not call ALS for trauma for almost any reason. Given the fact that you are rarely more than 10 minutes away from a hospital, coupled with the fact our BLS defines themselves, their families, and certain parts of their religions on working trauma victims leads to this phenomenon. So, if a BLS is calling for ALS back up on a trauma, something very bad is going down.

Arrived to find 19 year old mail in large pool of blood laying on numerous large shards of glass. Patient apparently somehow went through a 1/2 inch thick, roughly 6ft x 6ft sheet of exterior pane glass. Patient is in underwear, fecal incontinence noted, seizure considered, as patient is AMS and extremely uncooperative and combative. After much work avoiding getting cut to ribbons on the glass, give up on the idea of attempting to secure him to backboard and remove patient to stretcher, left arm has major injury to it, EMT bandages before I can get a good look at it. No other major injuries found, partner gets 14 gauge IV access while waiting for elevator, patient promptly rips it out. Did I mention this call is a mess?

Initiate rapid transport, enroute, try again for an IV while EMT attempts pressure on arm. Again, get IV access, again, patient yanks arm suddenly and violently, and IV access is lost. Lungs clear bilaterally, confirmed no other major injuries, BP:100/P RR:22, HR:140,GCS:13 (patient using incomprehensible words). Now turn attention to the arm, which has completely soaked through the bandage. Upon removing dressing, left arm has found to have complete transection of all major structures of the arm except for the bone. I raise the arm up to attempt direct elevation (hope springs eternal), and also to get what is left of his biceps brachii to stop noodling out of his arm. I apply direct pressure to the arm, keep elevation, and then go for my approximation of the pressure point for the brachial artery. I then hand off this task to the EMT while I get the materials together for a splint, and I am starting to wonder if I will actually have to tie a tourniquet on this guy. Lucky for me, we arrive at the hospital before I can get to that point, and into the trauma bay he goes.

Patient now has a BP of 90/P and a HR of 150. ER doc orders O negative and calls in a patient in Stage III hemmorhagic shock. Patient is sedated, stabilized, and sent to the OR.

All right, so I'll admit it, this call caught me off guard. I've dealt with extremity injuries before. I've had old ladies deglove their hands and I've had overweight women with their leg fully amputated mid femur from a subway, and I've had patients on coumadin put holes in their legs, and up until this point in my career I've thought it was rather hard to exsanguinate from an extremity injury.

I was wrong of course. Its never a good feeling being wrong. But, when I'm wrong, I go back and I learn as much as I can so I'll be better prepared for the next time. I reviewed my A and P for the upper extremity. Given the location of the injury, it was safe to say there was damage to the brachial, deep brachial, ulnar recurrent and radial recurrent arteries, which ultimately lead back to the brachiocephalic trunk that comes directly off the aorta, they are of course major structures which carry a lot of blood. An older physician at Roosevelt Hospital told me about a patient who was brought in on December 8, 1980 who despite being only 13 blocks away from the hospital when he was shot four times in the back, severing his subclavian artery, suffered 80% blood loss and died. (Plus five points if you can name the patient.)

So, I'd like to weigh in with the EMS veterans here. If you wanted to sedate this guy, which drug would you prefer? Is there any anything else we can do for this guy short of tying a tourniquet? Is this type of blood loss excessive for this type of injury? If so, what kind of factors could lead to this? Actually, any input from anybody on this matter, I'm feeling much like someone who just got there basic patch in the mail about now . Dustdevil, my man, I'd love to hear your input on these types of injuries.

[Dustdevil]

An older physician at Roosevelt Hospital told me about a patient who was brought in on December 8, 1980 who despite being only 13 blocks away from the hospital when he was shot four times in the back, severing his subclavian artery, suffered 80% blood loss and died. (Plus five points if you can name the patient.).

John Lennon.

I would guess there to be two factors that contributed to his rapid exsanguination. First, the proximity of the arterial transection. Bigger hose = bigger leak. Second, the clean nature of the clean, incisional nature of the injury. Stands to reason that the reflexive contraction/retraction of the artery would be more typical for a more traumatic injury such as a tearing laceration like a gsw or shrapnel. The lesser trauma = a lesser protective reflex = greater haemorrhagic control.

I see them out here. Especially the femoral, which is damn hard to reach or control. I am a little surprised the EMTs in your case didn't TK the injury right away. It does seem that schools tend to scare the hell out of people about tourniquets these days though.

[OzMedic]

I see them out here. Especially the femoral, which is damn hard to reach or control. I am a little surprised the EMTs in your case didn't TK the injury right away. It does seem that schools tend to scare the hell out of people about tourniquets these days though.

I don't get it either, whats wrong with a good old tourniquet? I thought we had worked out all that compartment syndrome stuff and how to treat it!! Thats even if it got to that point which it probably would not. Hey Dust.......I'll tell you a secret but don't tell anyone else because I don't want the surgeon to get in trouble ok? This one time in band....I mean Paramedic camp, I was in an operating theatre and the surgeon was trying to fix this guys leg...........and he put this pumpy uppy thing on his leg and................he even called it a tourniquet, aaaaand he like didn't even take it off for like an hour and a half.

You would be surprised at the amount of shark attack victims here that exsanguinate for the same reason. A decent tourniquet early on would have saved most of them!

Asysin, not talking about your case mate just the boogyman issue that EMS education seems to have with tourniquets.

[tniuqs]

Try it you might like it, agreed the "T' not being as a first choice but a last choice is a throw back to the 1960s.

http://i130.photobucket.com/albums/p245/sq...FTTFullView.jpg

cheers

[jwraider]

"It does seem that schools tend to scare the hell out of people about tourniquets these days though."

I'm trying to remember what the lesson was exactly but we either aren't allowed to use them now or aren't trained to use them on purpose. I let it go so I can't recall but I'm sure that's why you're experiencing this with EMTs.

For an extremity bleed we are taught to pile on the bandages (never removing them) raising the arm then applying pressure to the brachial. THis is where the skill stops.

[Dustdevil]

It seems pretty clear that a tourniquet was immediately indicated in this scenario, however it is certainly not a cut-and-dried situation. And, unfortunately, the limited training of EMTs doesn't provide enough time to really get into the educational foundation necessary to trust them with this decision. Think about all the things that poor providers do simply because "they can," or because "my protocols say...." without ever really doing any serious evaluation of this particular patient or his situation. Tourniquets would be another one of those over-utilised and mis-utilised "skills" if we were to open this can of worms in EMT school.

There are, of course, damn few cases of bleeding that cannot be controlled with direct pressure. Even this one. But several factors come into play to prevent optimal management:

• 1. The EMTs were inadequately trained regarding tourniquets, although, probably rightly so. Consequently, they probably had neither the skills nor the equipment to properly do the job, not to mention the education to properly assess the situation and make the appropriate decision.

2. The EMTs were OVERtrained on bandaging, therefore giving them a "skill" to focus upon in lieu of thinking the problem through thoroughly and solving it more appropriately. Direct pressure isn't as sexy as piling 4x4s a foot deep on the wound, never removing them, as the mantra directs. Consequently, you end up with NO pressure at all being applied to the wound. But hey, at least it is covered, right? Out of sight, out of mind.

3. While direct pressure would most likely have been adequate while on the floor at the scene, it becomes almost impossible while moving, loading, and transporting the patient. Consequently, even this best choice becomes situationally inadequate. This is exactly why the tourniquet was created, to do the job of the medic, freeing the medic to perform other duties, like shooting back or moving the patient out of the line of fire, or simply putting oxygen on him and loading him into the ambo.

• Of course, there exist a lot of problems with teaching proper tourniquet utilisation in EMT school. It is rightly assumed that ninety-nine percent of the time, direct pressure is more than adequate for your patient. EMT school is about teaching you to deal with that ninety-ninth percentile, not the one-percenters. That is what paramedic school is for. And it is also feared, again rightly so, that wankers with a month of night school will often lack the educational foundation and intellectual tools necessary to properly implement tourniquet use. As a result, you end up with more people harmed by misuse than you have saved by proper use.

As always, this is just another example of how and why every dilemma in EMS can and should be solved through education. I have solved at least one of the above problems through education. When I teach, I do not teach that nonsense about appying more dressings over the originial. I teach that if your first dressings soaked through, you need to fix the damn, problem, not just cover it up!