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ngdawg · 02-25-2007, 07:18 PM

I found this incredible story in another forum and felt it so compelling, I wanted to open it for discussion. It's a long read-I edited out the unimportant aspects but kept some details in to show the grave situation this woman faced.

Quote:

Its 5 pm and you are kicked out for a 37 y/o male who's vehicle was struck by a large transport truck head on while driving on a highway @ ROS = 75 mph. The pt was driving a ford ranger.

You are the first ALS to arrive and there is only highway patrol to help.

You find the patient trapped in the truck by the dash. The firewall and dash are against his chest and abdomen and you can see his left leg underneath the firewall at an odd angle. There is no backseat in this vehicle.

The patient is A&O X 4 and talking to you. He says he feels pain in his chest and front of head (where you see significant bleeding).

History
none

Meds
none

Obvious Pertinent Physcial findings

- Pt is A&O x 4 now
- Pt is trapped with a 15 min ETA for extrication equipment
- Pt has difficulty breathing and head pain.

Vitals On arrival:
BP – 101/60 HR – 127 SAT – 91% r/a

On extrication:. We all have a good idea of what is going to happen in the BEST case scenario when we try to unpeel him out of the car - he is gonna crash secondary to the crush injuries. However, based on my experience with patients in situations like this --- it is going to be FAR worse. Imagine the unimaginable amount of kinetic energy that was transferred here.

Second --- there are 6 people on scene. Me, my partner, my pilot, the state trooper, patient #1 out of the big truck and patient #2 stuck in the little truck.
snip

We don't know what kind of condition patient #1 is in - I guess it depends on the size of his truck. But, I'm thinking that he may be injured, even though he’s walking around and coherent, as well (thinking kinetic energy potential again). Granted, he is probably not as bad off as patient #2 but ... are we just going to completely ignore him too? Your partner may have his/her hands full managing a second critical patient. Who knows? And who's to say that patient #1 isn't "more critical" and not entrapped in a vehicle? If we assume that patient #1 is okay, we may have another set of hands to assist in the improvised extrication attempt --- but they will be untrained hands, at best.

So, we've got a trooper. That's a good thing. However, chances are also good that it will be another untrained set of hands.

Me and my partner. Can't speak for my partner ... maybe s/he knows extrication, maybe not. I can speak for me. A LONG time ago, I was a volunteer FF in rural AR. I doubt that I could do it now. But, let's say that I can. So, we have two people to do the improvised extrication.

snip
... we have to get a GOOD patient assessment done on patient #2 (and don't forget that one of us has to assess patient #1, as well) - no one else is there to do it, so it boils down to me or my partner. We've talked about multiple large-bore IV placement, potential RSI, needle decompression of the chest, etc., I'm thinking oxygen NRBM - he is still breathing on his own and if I really want to do an RSI because of deterioration, I'd rather have him do his own nitrogen washout.

Back to the extrication issue --- okay, so let's say that we are FLIGHT DEMI-GODS and get all the ABC hoohah that needs to be done done (minus RSI) in 5 minutes. We have 10 more minutes until extrication arrives. My experience with extrication is that you don't just start cutting and banging - you gotta look at the problem first ... we are EXTRICATION DEMI-GODS too so this step is done in 3 minutes. Now the extrication crew is going to be there in 7 minutes. One of us is going to have to stay with the patient --- that leaves only one of us (plus, maybe two to three sets of untrained hands - without adequate extrication PPE) to do this job - without the right equipment
Another thought - we are not going to magicly "spring" the dash/firewall off him enough to pop him out quickly and easily. It is going to come off slowly no matter how he is extricated (pro vs. improv). He is going to start to crash prior to being completely released. I would really like my partner helping me and the patient at that point.

So, there is my rationale for waiting for the extrication equipment and the extra trained hands.

Now - remember I am half of the FLIGHT DEMI-GOD team ... we have 10 minutes +/- to figure out something to do. The patient is still AAOX4 with marginal V/S - of course they are going to get worse (recall insane amt of kinetic energy and crushed). He doesn't need to be intubated quite yet - probably soon, but provided that the O2 brought his sats up and he doesn't have a tension pneumo, he can probably wait another couple of minutes.

Okay, this is what seems to be the problem - I would ask him if there was anyone that he would like to talk to via cell phone. Parents, wife, whoever.

Why in the heck would I do that???

Cause we all know that chances of this guy coming out of this situation alive are slim to none. I know that I am thinking somewhat on the extreme pessimistic side of things,I still think that he no longer has any legs - that is just my experience and opinion talking. But, let's look at all of the facts --- extrication arrives in 10 minutes, they get started in 5-10 minutes, they manage to get the patient out in 15 minutes (they're REALLY good). 35-40 minutes gone. 5 minutes to get the guy loaded into the A/C and take-off. And 47 minutes to get to the trauma center. Plus, 3 minutes to get him into the perfectly prepared ED. 55 more minutes gone for a grand total of 85-90 minutes since you arrived at his side

He has a chance of survival - provided he has a managable lower half - but the chance is really really REALLY not good.

I'd like to be given the opportunity to call my significant other to say "I love you" potentially for the last time if I were in this situation. If all that we are doing is waiting for the extrication team at this point, I don't see why I shouldn't provide that opportunity to this guy. I'm not going to mince words with either him or his wife (or significant other --- PC crap again). He is probably going to crash and die as soon as (or soon after) we start the extrication. If he doesn't --- well, shame on me. I'll gladly accept that complaint letter any day.

No extrication equipment on hand and 5 minutes ETA for arrival

Cardiac Monitor is normal sinus tach currently at rate of 125.

Scene is safe no fuel leakage to speak of

When you touch the left leg you do not find a pulse. On further assessment it is NOT attached. Complete amputation mid femur left leg for sure. Cannot see right leg.

no obvious Arrhythmias

No feeling below the upper torso. You cant see where he is trapped at exactly.

He gives you his personal info. He has a wife and 2 small children in the area.

Currently you cannot see any IV sites.
On the passenger side if the vehicle you see alot of blood but cannot discern any actual body parts. It is unclear what is going on over there....

the patient tells you he really doesn’t feel much pain. He asks you if he will survive. What do you tell him?
My response was "Sir, I have to be completely honest with you. From what I can see and assess on you, your injuries are extensive and your condition is very very critical. It is a reasonable possibility that you might not survive this. I promise you we are going to do everything possible in our power, all of us, to help you make it through this but you very well may not." Then, got a phone, got him on the phone with his wife and children, focused my care on helping his psyche. He was still in “fight mode”.

Lindsey sets BLS and monitors, Bobby has rotors turning, PT is alert and responsive, states he refuses treatment, wants to see wife.
Wife en route.

Will arrive in less than 15 minutes

Pt states he has 7/10 pain in his abdomen.

Pt BP is 80/60 HR 140 Sat 92 % NRM

He would like something for pain now.

Lindsey has an EZ IO in his left shoulder.

Bobby monitored the dropping BP

We discuss pain med, I had to really give this one some thought. fact is, you may end up "codng" him in front of his wife anyways. Rescue is ready to go, I have them set up and do any preliminary things that would not further jeopardize his cardiovascular status(eg: "A "posts cut,roll the roof, get rams in place, etc) I explain to him that giving him pain med could in fact make matters worse, but if he insists ( and I assume he is competent to make the life choices) I would try some fentanyl. I tend to lean away from MSO4 in traumas anyways. As caregivers we have to be prepared for what might happen once his wife is at the scene and things go bad.

This was not easy for me or Lindsey to sit an wait doing only what we could to keep him alert and orientated, but unfortunately this is a fact of what we have chosen as our careers, you CANNOT save everyone, but everyone gets the best I have, the best the crew has and then some. I hate to loose, I have since day 1.

This is how it ended….
We dosed pt with increments of 100 of fentanyl. They also gave boluses of 200 cc of NS to keep the patient conscious. The wife was able to arrive and they had a moment alone to say goodbye.

The whole crew was very honest with the pt and the wife. They were told he would probably die when the compression of the vehicle was released. They appreciated this candor and spent his last moments holding each other saying goodbye.

When he passed out the extrication crew finished the job (they prepped the car while wife was en route). On extrication, the pt went into PEA -> A systole.

His pelvis was crushed severely. The second the compression was gone his blood volume dumped into his pelvis and he died.

We flew Pt. wife to hospital to await the body being ground transported. I sat with her through the flight and during the wait. She asked I accompany her to the morgue for viewing, I did so. I told her I would be in the flight office when she was done if there was anything else needed
After the preliminaries were done, she returned to the flight office, hugged us all and kissed Lindsey and I on the cheek whispering to all a sorrowful “thank you”

In a subsequent letter from the wife, she stated:
“I could not say enough good things about this crew. Especially Lindsey and the one they called “Angel” Truly, those 4 are amazing providers who put the QUALITY of life before QUANTITY, something often forgotten in the rush of emergency medicine.

after a 5 day grounding I was reprieved and vinicated, will post the dieciplinary hearing findings after some discussion on the events first.

She was grounded for calling the wife, in short. But thoroughly vindicated for being above and beyond her call of duty.

I would hope that, if I was ever in that situation, either as the crash victim or the spouse, that the EMT's would have the presence of mind and the soul to contact my loved one or myself.
My other feeling on this is that it should never have even been up for review, but should be protocol-if you know your victim will die once extricated, why would you NOT call next of kin to arrive?
Was she right in what she did? Should she have been disciplined? If you found yourself in a life or death situation, would you want her there? And, if you are an EMT or police officer, are you allowed to take this action? Would you?