Interesting Trauma I saw as an EMT

[han14tra]

MS-IV and EMT here. Any advice for things I could've done differently? I'm going into EM and I'm always trying to learn.

Patient is a young healthy male. He was attempting to load a piece of machinery (about 44,000 lbs) onto a truck and it slipped and rolled over him. He was not pinned. When we arrived, he was laying on the ground and screaming in pain. He also said he was having trouble breathing (his color was good and he was screaming, but he felt SOB). We immediately immobilized him with a collar and backboard, and got him in the ambulance because we are 45 min away from any hospital (weather made lifeflight a no-go). I also called for a medic because we are BLS. Pt did have T and C spine tenderness, but no step offs. His lung sounds were equal bilaterally, trachea midline, no JVD. His initial SpO2 was 75% with a resp rate of 36. I put him on 15L by non-rebreather. His BP was 140/80 and pulse 96. With high-flow O2, his SpO2 came up to 91%. Both legs were obviously deformed. One leg was shortened and internally rotated, and the other was an obvious tib/fib fx. He had distal pulses, but was not able to wiggle his toes at all. He also had bruising (about the size of my palm) on one flank. There were no other injuries noted. I cranked up the heat and covered him with blankets because he was covered in mud and completely naked.

I had just finished my primary survey and initial vitals, and the medic gets on scene. He balls me out for not splinting his legs on scene. Not only that, he cranks the AC on because he (the medic) was hot. He also yanked off the O2 completely because at that point he was 98% on 15L. He also tells the hospital that the only injury is deformed legs below the knee b/l despite me telling the medic about 10x that he had flank bruising, a shortened and internally rotated leg, and an initial low SpO2. The patient did not get trauma alerted until we hit the ED doors. The doctor took one look at him and there was a Stat Trauma Alert called.

What do you all make of the initial low SpO2? Could really rapid, shallow breathing do it? Once the patient got a bunch of morphine and his rate slowed to about 20, he maintained he sats on room air. I suppose it could also be due to all the dirt on his hands, but I saw the low O2 and just treated it like it was real. The mechanism was there for something bad to be going on, and I didn't want to screw around.

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[Apollyon]

The guy had 22 tons (which, by the way, is 20 megagrams) roll over him and he wasn't 100% smushed, crushed, squeezed, popped dead?

There's more to the story then, as, for example, I saw a 14 year old that went through the back wheels of a fire engine (26000 lbs GVWR, and that is before 1000 gallons of water, which adds 8,300 pounds), and that kid was dead, dead, and dead. He was full-sized, but, irrespective of that, on autopsy, the only thing he didn't do was pop (like if you squeeze a jelly doughnut). His guts, bones, and chest were all goop.

If his hands were cold and blue, that could give an artificially low SpO2.

Now, what kind of weather is it that the helicopter won't fly, but the medic doesn't just have you turn off the heat, but actively put on the A/C? I mean, if the ambient temperature was 75 degrees, and there were thunderstorms, then why turn up the heat even more in the first place? Again, by example, by NY state law, an ambulance must be able to heat and cool the patient compartment to 75 degrees F.

 

[RustedFox]

Medic sounds like a real a$shole.

 

[Apollyon]

Medic sounds like a real a$shole.

Yeah, that too - I should have mentioned. The description is like the definition of a "paragod".

 

[bad virus]

Medic sounds like a real a$shole.

probably one of those super over weight medics that still rocks out nothing but uber tacticool gear like a black hawk murse and a 5.11 overpriced tactical undergarment. They all act military like except for the fact that they haven't actually served.

 

[Arcan57]

What do you all make of the initial low SpO2? Could really rapid, shallow breathing do it? Once the patient got a bunch of morphine and his rate slowed to about 20, he maintained he sats on room air. I suppose it could also be due to all the dirt on his hands, but I saw the low O2 and just treated it like it was real. The mechanism was there for something bad to be going on, and I didn't want to screw around.

Most likely he was splinting like crazy because he had just had his chest wall crushed. If his sat improved with morphine, likely he was able to take deeper breaths without causing soul-destroying agony. That is one case where being able to stare at a waveform would help.

 

[Anonymous M4]

Most likely he was splinting like crazy because he had just had his chest wall crushed. If his sat improved with morphine, likely he was able to take deeper breaths without causing soul-destroying agony. That is one case where being able to stare at a waveform would help.

That's what I thought too. Poor guy. Would you elaborate on the role of the waveform in your diagnosis/ management of this patient?

 

[Arcan57]

That's what I thought too. Poor guy. Would you elaborate on the role of the waveform in your diagnosis/ management of this patient?

If the plethysmograph has a poor waveform then the number you are seeing isn't going to be accurate. I've seen the pulse ox not connected still give a sat in the mid 70s but the waveform was all wrong. The number is useful but the waveform helps confirm the accuracy. There are still things that can screw up the reading but it doesn't sound like this guy should have had any of them. Of note, fingernail polish has not been shown to effect accuracy in clinical trials.

 

[Anonymous M4]

Thanks!

 

[jbar]

Best lesson is that you don't need a medic for trauma unless you need:

1: Pain control
2: intubation
3: needle decompression
4: Cric

There is some data that medics may worsen trauma outcomes (likely by delaying scene times.)

Now you are never really wrong to say "I have a really sick person and want some ALS backup." But it sounds like this patient would have been equally (if not better) served by you calling a trauma alert and just going to the hospital without stopping for ALS.

 

[Rendar5]

Best lesson is that you don't need a medic for trauma unless you need:

1: Pain control
2: intubation
3: needle decompression
4: Cric

There is some data that medics may worsen trauma outcomes (likely by delaying scene times.)

Now you are never really wrong to say "I have a really sick person and want some ALS backup." But it sounds like this patient would have been equally (if not better) served by you calling a trauma alert and just going to the hospital without stopping for ALS.

No morphine for 45minutes? severe trauma maybe needing intubation for a long haul? I'd say waiting for medic was probably warranted. Guy needs active resuscitation going if it's that long an ambulance ride.
As for the pulse ox, i'd only trust a read of 75% if there was decreased breath sounds, flail chest. otherwise, make sure his fingers are free of mud before applying it. In the ER I get the beneift of a waveform ot see if it's true or not. If you don't ahve that though I cannot fault you for just throwing a NRB on and letting everyone else do what they will.

 

[BF2BC EMT]

Hey OP did the medic use any IV therapy? Putting on the o2 is the least of this guys problems

 

[joeDO2]

No morphine for 45minutes? severe trauma maybe needing intubation for a long haul? I'd say waiting for medic was probably warranted. Guy needs active resuscitation going if it's that long an ambulance ride.
As for the pulse ox, i'd only trust a read of 75% if there was decreased breath sounds, flail chest. otherwise, make sure his fingers are free of mud before applying it. In the ER I get the beneift of a waveform ot see if it's true or not. If you don't ahve that though I cannot fault you for just throwing a NRB on and letting everyone else do what they will.

ehhhhh, get them to meet you on the way. i wouldn't wait to get some morphine.

 

[Rendar5]

ehhhhh, get them to meet you on the way. i wouldn't wait to get some morphine.

A 45 minute transport time on a major trauma patient with minimal intervention available seems to be riskier than waiting 10 minutes for additional interventional availability. You don't know if this guy is going to crash en route or not. Point 2, if this patient were you, your parent, your wife, your child, would you be that dismissive of morphine? That's simply the added benefit of the medic. Not to mention transporting a screaming thrashing patient seems potentially worse than transporting a more comfortable, more cooperative patient

 

[jbar]

Once the patient is package you shouldn't be waiting. If the medic can intercept you, great. But I've had "they're 10 minutes out" turn into 30. And if there is a problem with the medic (ie they get diverted to a cardiac arrest) you are no closer to the hospital, where if you have started transporting at least you are already on the way.

 

[Rendar5]

Once the patient is package you shouldn't be waiting. If the medic can intercept you, great. But I've had "they're 10 minutes out" turn into 30. And if there is a problem with the medic (ie they get diverted to a cardiac arrest) you are no closer to the hospital, where if you have started transporting at least you are already on the way.

ah didn't realize medics could be diverted. I'm used to only dealing with buses already packaged and rolling. And dealing with very professional crews. If this is the case and your medic ETA's are very far off and they may get diverted, then yes, rolling with medic intercept would be more appropriate.