Snowmobile vs. tree accident

[LAS46]

This is a call was forwarded to me by a friend.

Dispatch: Snowmobile vs. tree accident. The patient has been taken into the local tavern.

Arrive to find: A 24 y/o female in the one stall bathroom. She is complaining of abdominal pain and vaginal bleeding.

Assessment reveals:
• Airway is open; patient is talking and crying.
• Breathing at 26 times/minute and shallow.
• Pulse is 110, weak and regular.
• Blood pressure 112/88
• Pupils equal
• Lung sounds clear, equal bilaterally
• Skin is pale, cool and clammy.
• History
• S- abdominal pain, vaginal bleeding, nausea
• A- PCN
• M- prenatal vitamins
• P- miscarriage 2 years ago, currently 12 weeks pregnant
• L- pizza and soda 1 hour ago
• E- Lost control of snowmobile going around a corner about 15 MPH.
• O- snowmobile hit the tree; she may have hit handle bars; she has been having cramping and spotting since yesterday
• P- worse when she extends her legs
• Q- cramping abdominal pain
• R- down to pelvis
• S- 6/10 scale; she states “I’m not a baby.”
• T- accident happened ½ hour ago; cramping and spotting since yesterday
• Injuries – Bruise to umbilicus area, gross red blood from vaginal area. Denies neck or back pain.

Treatment:
Basic: Oxygen, prevent further heat loss with blankets. Trauma dressings to genital area for vaginal bleeding. Spinal immobilization with legs flexed. Talk to and calm patient and boyfriend. Monitor patient for hypovolemic shock.

Patient Response: Patient feels better when treated for shock. Nausea continues. Patient continues to compensate:

Vitals:
pulse 118,
respiration rate 30,
BP 110/84.
SpO2 97% on 6 lpm via NC

ALS: Start an IV and titrate to maintain BP. Analgesia for pain if within protocols.

Higher Level Questions or Affective Issues:
B: When and if would you call ALS?
B/A: Would you address the previous miscarriage?
B/A: Would you expose and examine the genital area?
B/A: Would you transport patient on backboard?
B/A: Would you tilt the patient to one side? Which one?
B/A: How would you address the patient’s response to possible miscarriage?
A: What gauge catheter and IV tubing would you use?
A: What rate would you run the IV?
A: What analgesia would you choose to give? Why?

 

[Veneficus]

• Injuries – Bruise to umbilicus area, gross red blood from vaginal area. Denies neck or back pain.

Sounds like a cullen's sign to me.

Bleeding could be multifocal both from the reproductive structures as well as the abdomen. Either or both simultaneously may manifest as vaginal bleeding as well as have considerable occult blood in the abd.
ALS: Start an IV and titrate to maintain BP. Analgesia for pain if within protocols

At 12 weeks of pregnancy, I would attempt to assess fetal heart tones, volume expansion even in light of an uncontrolled bleed may be indicated in this case.

If it were me, I would go with incremental pain control, probably morphine as it is looking like she might be getting a trip to surgery, I would not be surprised if med control denied such a request.

B: When and if would you call ALS?

Yesterday, first rule of medicine, punt on first down.

She is also going right to the highest level of trauma I can find, without passing go or collecting $200. Complicated trauma is what Level Is are for.

B/A: Would you address the previous miscarriage?

I would delve very actively in this, under "normal" circumstances, anyone who has a miscarriage is at risk for more, at 12 weeks the fetus is nonviable, but there may be other historical issues related to this that will complicate or even help with treatment.

B/A: Would you expose and examine the genital area?

Of course. I want to know how mch blood and how fast, I also want to see if she delivers the fetus.

B/A: Would you transport patient on backboard?

Yes, but not for spinal indications. The German surgeons I have met are rather fond retroperitoneal packing to stop an intraperitoneal bleed. It has been my observation in several cases over the years that a spine board creates enough pressure to do something similar, so the spineboard may actually help slow or stop bleeding in such a patient.

B/A: Would you tilt the patient to one side? Which one?

No, I doubt she is far enogh along for this to be an issue. Additionally:

There is the possibility that she has a hormone responsive leiomyoma (which could be a substantial mass and possibly palpated on abd exam) which has contributed to her past miscarriages or even this incident that may compress the IVC, but I would need some more history and physical findings to alter my decision to lay her flat. The pressure for stopping the bleeding would be my greatest concern, especially since it may be the uterine artery bleeding. (they retract when severed and are extremely difficult to find and repair surgically in my observations)

B/A: How would you address the patient’s response to possible miscarriage?

I would want to know the history of the events, any prior dx, and any social habits or afflictions. Medically there is nothing to be done for it. If it delivers, I find a suction container works great with a towel wrapped around the outside (to conceal the view) for transport to pathology for examination.

A: What gauge catheter and IV tubing would you use?

Large, preferably 2, with blood tubing if I had it.

A: What rate would you run the IV?

Depends on my assessment of the rate of bleeding as well as potential fetal distress.

A: What analgesia would you choose to give? Why?

Opioids, IV morphine, because it is easily added to and managed if the patient needs to go to surgery.

My response is based largely off of the "gross red blood" but an estimate would be important, included an estimate of loss over the last 24-48 hours.

 

[LAS46]

Thanks for the great answers to my questions... I learned a little bit today!

My response is based largely off of the "gross red blood" but an estimate would be important, included an estimate of loss over the last 24-48 hours.

 

[MrBrown]

B: When and if would you call ALS? No

B/A: Would you address the previous miscarriage? Brown is not an OB, but is wondering whether the bleeding is from a nondelivered foetus and placenta which is now coming out

B/A: Would you expose and examine the genital area? Provided I had a female Ambulance Officer with me, sure.

B/A: Would you transport patient on backboard? Stop smoking crank it is making you embarras yourself

B/A: Would you tilt the patient to one side? Which one? No

B/A: How would you address the patient’s response to possible miscarriage? Brown would be interested in it

A: What gauge catheter and IV tubing would you use? 18 and just put a lock on it, no fluid


A: What rate would you run the IV? No fluid so no rate


A: What analgesia would you choose to give? Why? Methoxyflurane because its good and effective, maybe a little morphine if that didnt work like you know, 2mg to start and see how that works

 

[SerumK]

Spotting is really NBD up to 12 weeks, but post trauma bleeding is! So... really want to know how much "red blood" is coming.

Higher Level Questions or Affective Issues:
B: When and if would you call ALS?
Yes if available. now. If they want to know why, "for IV access" but really, unknown acute abdomen + bleeding r/t trauma in a G2 P0 @ 12wk that could go south at any time!

B/A: Would you address the previous miscarriage?
Absolutely - ask what happened!

B/A: Would you expose and examine the genital area?
Absolutely! (within protocol, patient permission, and preferably with a witness) You NEED to be checking this. Period.

B/A: Would you transport patient on backboard?
If protocol required it...

B/A: Would you tilt the patient to one side? Which one?
Probably unnecessary.

B/A: How would you address the patient’s response to possible miscarriage?
Honest: "This bleeding could be a number of things including a miscarriage. We won't know what it is until after you are at the hospital. We are going to do everything we can to help you and your baby."

A: What gauge catheter and IV tubing would you use?
Bigger is better, 18ga minimum if pt is hard or cold, probably a 16ga or 14ga... I'd warm pack to get it. Buff Cap. Both arms... blood tubing standby.

A: What rate would you run the IV?
Per protocol, but nothing screams fluids RIGHT NOW... yet... but I'd try to figure out the volume lost first, then I'd see where this person was from (you are in CO right? So they could be volume depleted 2* altitude), ask about I/O, etc) but otherwise maintain pressure.

A: What analgesia would you choose to give? Why?
Nothing without calling in first because this lady is pregnant and everything is class C or worse.

 

[MrBrown]

Brown likes your thinking, not.

What is your rationale behind using a big bore cannulae and let us try thinking for ourselves for a minute, how much analgesia would YOU like to give?

 

[Veneficus]

Brown likes your thinking, not.

What is your rationale behind using a big bore cannulae and let us try thinking for ourselves for a minute, how much analgesia would YOU like to give?

Are you making fun of me?

I would use something large, probably an 18g. If I was concerned about the "gross bleeding" being significant, I would step up to a 14 for a couple of reasons.

First reason being that they work great for autotransfusing (which can be done in most respectable trauma EDs.

Second reason: Sometimes in trauma anesthesia will use a proximally placed 14G in place of a central line.

How much analgesia would I like to give? Titrated to the BP, control of pain, or an increase in fetal distress.

 

[Aidey]

A: What analgesia would you choose to give? Why?
Nothing without calling in first because this lady is pregnant and everything is class C or worse.

Brown likes your thinking, not.

What is your rationale behind using a big bore cannulae and let us try thinking for ourselves for a minute, how much analgesia would YOU like to give?

I think he was making fun of the poster above him (see bolded).

Vene, correct me if I am wrong, but isn't a 16g the preferred gage if the pt is going to receive blood?

 

[Veneficus]

Vene, correct me if I am wrong, but isn't a 16g the preferred gage if the pt is going to receive blood?

You can put blood through just about everything, I have gone as low as a 22 with blood. I have never tried to put blood throgh a 26 guage neonate needle, but I imagine in desperation it is possible.

I am sure you know the larger the bore and shorter the cath the faster the fluid flows. Different facilities and agencies have SOPs for what they want to see in terms of size to pour blood in with. Normally most places like to say "20 guage as minimum," but that is more of a house rule than a scientifically preferred.

As I pointed out, autotransfusing in the ED, because you are using whole blood and running it through a paper filter, I like to use something large (16 or 14) to up the flow and cut down on the backup in the tubing and keep things going.

I really hate having to switch out tubing when blood clots in it, so anything I can do to help keep the line flowing is a good thing in my mind.

 

[firetender]

Dumb Question:

How come no one notes or asks about or even seems to take into consideration how far in time (and secondarily, difficulty) the patient is away from the receiving facility anymore?

 

[Veneficus]

How come no one notes or asks about or even seems to take into consideration how far in time (and secondarily, difficulty) the patient is away from the receiving facility anymore?

Because going to a facility that is not an academic medical center for a major or complicated illness or injury is the same as death. So if you have to chose between death on the road or death in a community hospital, the outcome is the same.

 

[firetender]

Because going to a facility that is not an academic medical center for a major or complicated illness or injury is the same as death. So if you have to chose between death on the road or death in a community hospital, the outcome is the same.

My point is I don't hear anyone asking the question, nor do I hear that being automatically included in choosing what to do and how aggressively to act on the scene.

...and I have brought many a critical patient into a teaching facility only to be met by a gaggle of Rookies, poorly guided in the moment, whose "practice" session results in death.

Human error exists everywhere, but I agree, so much of the work is about doing our best to improve the odds.

 

[MrBrown]

... or death in the air if Brown and Oz from the helicopter emergency medical service come get you

Brown would be interested in evacuating this patient to a tertiary facility with OB and trauma services.

 

[Veneficus]

My point is I don't hear anyone asking the question, nor do I hear that being automatically included in choosing what to do and how aggressively to act on the scene.

...and I have brought many a critical patient into a teaching facility only to be met by a gaggle of Rookies, poorly guided in the moment, whose "practice" session results in death.

Human error exists everywhere, but I agree, so much of the work is about doing our best to improve the odds.

Experience is only part of the equation.

There is the issue of actual equipment and people as well. How much blood can your community hospital get at moments notice? Most I have seen is 2 units on hand and maybe another 2-4 if the blood bank isn't closed for the eve. Can the use Percutaneous ligation to close a pelvic bleed or do they have to open the pelvis?

One of the best trauma surgeons I ever met once said when speaking about EMs doing thorocotomies in outlying facilities:

"Once you get the chest open and save the person, are you planning to close the chest or just transport them out still open?"

It is important to also look at the time it will take to assemble things like surgical teams. A general surgeon, while "trained" in trauma can have between 30-90 days out of thier 5 year post doc in trauma depending on how interested in it they are. In that time, they may never see an emergent surgery. Which is vastly different than a presceduled, preselected patient.

I stuck with trauma, but you could use any advanced medical facility, like a PCI lab.

Once you take care of the immediate life threatening issue, are you going to have a properly equipped ICU? Any type of intensivist?

I agree there are rookies and sometimes not the best clinicians ever at the larger facilities, but they are a minority unless you happen to blow yourself up on the 4th of July.

Just imagine the look on a patients face when a a surgeon 10-20 years out of school who does elective procedures all day for years when he says: "I haven't even seen this since my 3rd year of residency."

Wouldn't you rather have the surgeon who says: "yea, we did about 1000 of these last year?"

I agree also that if your initial people do not properly stabilize the patient, then the game ends there. But as you have had the opportunity to witness, it is after the ED that decides the end game.

 

[Melclin]

B: When and if would you call ALS?

I don't think she's likely to get anything from a MICA paramedic than she wouldn't get from me. Except a bucket load of experience and good judgment, which is of course, extremely important, but I think I'd keep this one as long as I can get onto "the clinician" (experienced paramedic) for a consult.

B/A: Would you address the previous miscarriage?

I don't quite get what you mean by address. I would certainly like to hear all about it if that's what you mean.

B/A: Would you expose and examine the genital area?

If I had a female medic with me, I'd prefer she did it.

B/A: Would you transport patient on backboard?

Wouldn't even have considered spinal immobilization. That would be absurd. Although the stuff vene mentions is intriguing.

B/A: Would you tilt the patient to one side? Which one?

As has been mentioned, its a little early to worry about that. Left would be the side you'd go with though.

B/A: How would you address the patient’s response to possible miscarriage?

Do you mean how would I address her concern about her baby? Well in a general sense be honest that I'm concerned about her and baby but that she's going to the best place in Victoria to deal with any problems that might arise. Hopefully a little analgesia helps with the anxiety as well. I'm a big fan of breathing exercises and biofeedback techniques for anxiety in general (only tried it a few times buts its worked a treat) so might give that a shot to if she's receptive.


A: What gauge catheter and IV tubing would you use?

Of course depending on her veins, I'd like a 16. If she's all ropes, then I suppose you may as well get 14.

As far as a second IV goes, I'm not really a big fan of the idea of doing IVs for hospitals. I have more of a 'I'll do one if I have need of one' attitude at this stage of my development. For this pt I feel l only need the one IV and the placement of a second one is just going to be a waste of time. A second IV can be placed concurrently with other assessments in hospital (they are generally cleaner too) but if I do it, we essentially put her care on pause for a few minutes for no particular reason. I wanna give a little fluid and some analgesia. I'm happy with a single 16 for that.


A: What rate would you run the IV?

Boluses. But small and slow ones. I'm pretty concerned about haemodilution on top of pregnancy related haemodilution, although at this early stage I'm not sure all that has kicked off yet. None the less, with potentially uncontrolled haemorrhage, you'd wanna be very judicious. Maybe...5ml/kg first just to see if we get any improvement and to offset the slight drop from the analgesia and repeat based on further assessments and the extent of blood loss.

How easy is it to auscultate a fetal heart rate? Would I be correct in thinking, Vene, that fetal distress would push you further down the fluid path because it indicates that mums having trouble with placental perfusion?

A: What analgesia would you choose to give? Why?

I'd stay away from methoxyflurane in a pregnant pt who may have some troubles with perfusion now or in the near future.

I suppose I'd look at some 25mcg fentanyl boluses after a chat with a more experienced paramedic, because I feel it will drop her BP less than morphine...but we'd have to wait and see what my partner or a clinical support officer thought. May even get in touch with the receiving doctors if we can and have a word with them. If we're doing that, I'd ask their advice RE fluids as well. This seems like a job that a junior paramedic, like young Oz here, should really be asking for help with.

Transport wise, again it would decided on after a consult with the clinician. Obviously she's going to a level 1 trauma centre but rurally it is worth consulting as to whether or not to stop off at a regional trauma centre for some assessment or blood and whatnot, and have the Adult Retrieval team come and get her, or whether it would be better to put her straight on the chopper.

 

[RNL]

If it would happened in Poland
B: When and if would you call ALS?

No. I would be the ALS.

B/A: Would you address the previous miscarriage?

Taking history is crucial. But that's all. Just to know.

B/A: Would you expose and examine the genital area?

Yes. At least to asses the severity of bleeding. And I agree with the statement: "If I had a female medic with me, I'd prefer she did it"

B/A: Would you transport patient on backboard?

Yes. Veneficus has already said why.

B/A: Would you tilt the patient to one side? Which one?

Doesn't matter in low pregnancy.

B/A: How would you address the patient’s response to possible miscarriage?

I would try to calm her down verbally. I woludn't give any tranquilizers or sedatives.

A: What gauge catheter and IV tubing would you use?

Green or grey


A: What rate would you run the IV?
Depending on her general condition, BP and HR.

"How easy is it to auscultate a fetal heart rate? Would I be correct in thinking, Vene, that fetal distress would push you further down the fluid path because it indicates that mums having trouble with placental perfusion?"

Very difficult at 12-th week. Honestly, in case of suffering traumtic patient IMO impossible, and pointless.

A: What analgesia would you choose to give? Why?

How long would it take to transport her?

Transport wise

In Poland, usually, patient is transported to the closest hospital, and than if necessary and possible, referred to the specialized hospital.

 

[Veneficus]

"How easy is it to auscultate a fetal heart rate? Would I be correct in thinking, Vene, that fetal distress would push you further down the fluid path because it indicates that mums having trouble with placental perfusion?"

Very difficult at 12-th week. Honestly, in case of suffering traumtic patient IMO impossible, and pointless.

If could?

Just my opinion, but I think attempting an assessment is always worth a try. Though like you said, I wouldn't expect it would always or even usually yield anything.

The problem I see with fluid is the problem with hemostasis. I think it is very easy to use crystalloid to maintain pressures, but to what end?

If you impede clotting, you lose more blood. Because the placenta perfuses with pressure, in the event of a placental disruption as cause of bleeding, it can not only increase bleeding, but create enough pressure to further seperate an incomplete abruption. Which in the field is impossible to assess.

I don't think it does any good to maintain numbers with water.

But the whole scenario is based on a variable amount of blood that is unknown. That also makes any attempt to evalate the bleeding control and the effectiveness of any treatment impossible to speculate.

Depending on the presentation, we may have to make a decision to do what is in the best interest of the mother and call the baby a loss. I know that sounds cold, but at 12 weeks, there is really nothing that can be done for it, so it doesn't even allow the question of which one we can try to do the best for.

 

[Aidey]

If could?

Just my opinion, but I think attempting an assessment is always worth a try. Though like you said, I wouldn't expect it would always or even usually yield anything.

While I agree with you that a proper assessment is worth a try, there is the question of what happens when you can't find the FHT. All we have are stethoscopes, and I know that I don't have enough pregnant patients to be proficient at auscultating FHTs, especially on anyone that isn't in the 3rd trimester.

Even when I've explained to patients that it is an art, and if I don't find anything it doesn't mean anything they still get freaked out.

 

[Veneficus]

While I agree with you that a proper assessment is worth a try, there is the question of what happens when you can't find the FHT. All we have are stethoscopes, and I know that I don't have enough pregnant patients to be proficient at auscultating FHTs, especially on anyone that isn't in the 3rd trimester.

Nobody can ever expect more than your best from you.

Even when I've explained to patients that it is an art, and if I don't find anything it doesn't mean anything they still get freaked out.

Why tell them everything?

Here is my perspective: in the few moments it takes for the attempt, you lose nothing.

If you find something you have another piece of data to plug into your equation for making a decision.

If you find nothing, as you said, you must realize that it is an inconclusive finding, not a negative finding.

So as long as you realize what it is you have or have not found, you stand to lose nothing, and might gain something.