# Train accident



## CW CC (Nov 28, 2022)

Hi been on the forum for a few weeks just looking around and decided to post. I am a critical care/flight paramedic in Tennessee with lifestar and have been with lifestar for about 3years. 

This accident I responded to a while ago was SEMI cab vs TRAIN and a few details may be changed for HIPAA obviously. 

When ALS arrived on scene they activated a medevac with the note pt has severe injuries to the chest and abdomen hemodynamically unstable and needs rapid transport to university  ( 40min drive via ambulance)  so we went and when we landed we followed our protocol the nurse started obtaining information, I start a Rapid assessment, while the doc is listens to me and the nurse then tells us what to try. During my assessment patient is a little cool to the touch and the BP is low while the nurse informs us they were already on a fluid bolus so the whole team agreed presser nurse starts drawing the presser choice that the doctor requested, I started flushing the line and administering while continuing assessment, I notice no breath sounds on the right and severe hypoxia while patient nature of illness was trauma.
The crew once again agreed needle decompression I started the decompress as the doc takes over with ultrasound checking placement and further evaluating while I just listen to breath sounds and continued assessment satisfied with needle decompression. Noticed the voltage on ECG lead was decreasing a little and checked heart sounds which were a little muffled but hard to hear so told the doc who used ultrasound and noted cardiac tamponade so started doc did  Pericardiocentesis while I finished assessment and we started the transport right after noting increase in BP and heart rate normalizing. Transport went uneventful after that. 

The point point of this was to show EMT students that teamwork is key to almost all of your critical calls and even regular calls. Also allows me to ask how many other flight medics and critical care medics are on here? And any questions about me or the call?


----------



## Tigger (Nov 28, 2022)

Why are we giving pressors to chest trauma?


----------



## DesertMedic66 (Nov 28, 2022)

Paramedic, nurse, and a doctor? That’s not a super normal find in US based HEMS. UT Lifestar doesn’t advertise as having any doctors on their flight line. 

Ultrasound and pericardiocentesis but no blood products? Also seems a little weird that you started a pressor before you finished your assessment and identified the tension pneumothorax. 

Did you secure the airway on this patient due to status/clinical course or just let it be?


----------



## E tank (Nov 28, 2022)

Just a couple of things...since the point of this is for learning...

needle decompression of confined cavities like a hemi-thorax or the pericardium, while relieving tamponade physiology, does nothing to fix the reason these conditions developed in the setting of blunt trauma in the first place, ie, aortic dissection and/or coronary artery dissection, atrial/ventricular perforation, pulmonary vascular injury, etc.

Torrential bleeding after the fact is a consideration and you don't specifically mention sewer pipe level vascular access before taking those steps. Leave alone the above comment regarding blood products being on hand. Again, not mentioned doesn't mean not done, but it bears mentioning.

We do rely heavily on Mother Nature and blood clotting does mitigate bleeding from vascular injury, but those clots depend on low shear forces in damaged blood vessels to form, ie, lower blood pressure.

Which brings me to the 'pressor'. What pressor? Do you mean 'inopressor'? 'Inotrope'? Phenylepherine? Vasopressin? Norepi? Epi? Starting any one of these in the setting of hypotension caused by some tamponade condition, specifically a pericardial effusion with tamponade symptoms requires some real foresight and expertise.

If the 'pressor' is phenylephrine or vasopressin, you may temporarily raise the measured BP but the actual cardiac output tanks because you've increased the afterload on an already poorly filling and contracting LV. So that's not a great idea.

So you use epinephrine instead to raise both the cardiac output and BP. There can be a use for this as a bridge to keep the patient alive until you get the blood off of the heart. But what can happen is that once you relieve the tamponade, you now have unopposed inotropic effects, the BP towers and you potentially extend an aortic dissection or some other catastrophic vascular/cardiac injury.

Lots not mentioned in the OP, so maybe you could clarify what really happened.


----------



## CW CC (Nov 28, 2022)

I left a lot of the treatment and assessments out because I wanted the actual case demonstration to be about the compact of the call not the actual patient themselves. I have noticed didn't put a few things in order and there is some clarification needed. UT doesn't always have a doctor on board and that's why it's not advertised but it's common for emergency medical residents at the hospital to be put in our air ambulance at least here. Blood products were given before presser and the presser was only given because we needed to stabilize a little before leaving. We did finish the assessment but I only mentioned the presser because for the most part we already knew we were going to give one. Patient already was RSI before arrival so yes airway was secured. Also we know that the treating the physiology of the tamponade ain't treating the cause but we can't treat the cause in the field it goes to the OR for that what we can do is prevent a cardiac arrest from the causes complications. We did use epi and yes etank the tamponade going away could worsen the situation but it wasn't fully treated it was just enough to balance BP and cardiac output.  Did I miss anything?


----------



## akflightmedic (Nov 29, 2022)

Interesting case. You do not speak like an American Flight Medic...weird to say, right? Your whole case presentation has syntax akin to Europe or Australia type flow. Even how you gave deference to the doc and nurse with regards to what care to give, etc. I dunno just seems odd.

Regardless, heck of a call and pretty darn atypical procedurally speaking. Seems like securing the airway would have been performed, no mention of that. If you saved the life, then job done! Keep up the good work!


----------



## CW CC (Nov 29, 2022)

akflightmedic said:


> Interesting case. You do not speak like an American Flight Medic...weird to say, right? Your whole case presentation has syntax akin to Europe or Australia type flow. Even how you gave deference to the doc and nurse with regards to what care to give, etc. I dunno just seems odd.
> 
> Regardless, heck of a call and pretty darn atypical procedurally speaking. Seems like securing the airway would have been performed, no mention of that. If you saved the life, then job done! Keep up the good work!


Yes a lot wasn't mentioned that should have been including patient was RSI with secure airway


----------



## johnrsemt (Dec 5, 2022)

In Indiana one of the helicopter services would fly with an ED or Trauma Resident,  but the bird and crew lived at a Level I hospital.  They would go with Doc and Medic


----------



## silver (Dec 7, 2022)

Interested in hearing what happened at the hospital after. Can't imagine a scenario of "transport went uneventful after" a tension pneumo and tamponade without definitive treatment.


----------



## CW CC (Dec 8, 2022)

silver said:


> Interested in hearing what happened at the hospital after. Can't imagine a scenario of "transport went uneventful after" a tension pneumo and tamponade without definitive treatment.


Patient became more stable


----------



## VentMonkey (Dec 8, 2022)

Early twenties and already on the flight line? Nice job, it took myself and many of my colleagues several years to attain our positions. Definitely worth noting.

I know of at least one base in my region (specifically in our program) that rotates residents through to meet training and educational requirements, so also not unheard of.

As for the original scenario, a bit of friendly advice:

It could have been better worded and articulated in a way that one would typically expect at the level of, say, an advanced field provider.

As you can see from the responses you’ve received, a lot of folks on this forum whether flight, critical care, advanced care or ground providers are well versed and ready to provide feedback in both an engaging and articulate manner.


----------



## DrParasite (Dec 9, 2022)

Interesting... I, too, am not used to MDs being on the helicopter.  Typically it's a flight nurse and a flight medic, with the flight medic taking the lead for scene jobs, and the nurse taking the lead for IFTs.  Having the doc is pretty cool though.  Pressors in a trauma... yeah, the BP goes up, 


CW CC said:


> Noticed the voltage on ECG lead was decreasing a little


My brain is a little foggy on this: why does the voltage on the ECG lead decrease with the cardiac tampenode... is that because the fluid around the heart is making the ECG voltage?


----------



## akflightmedic (Dec 10, 2022)

Agree on nice job with the speed path to the FW. 23 y/o and flying…not crazy impossible, very atypical, expect way better medical jargon, case presentation, etc. 

Anyways, look forward to some more case studies to discuss.


----------



## E tank (Dec 10, 2022)

CW CC said:


> We did use epi and yes etank the tamponade going away could worsen the situation but it wasn't fully treated it was just enough to balance BP and cardiac output.


Bridge inotrope totally defensible. Explain "not fully treating tamponade". What was done and what were the end points of treatment? How did you differentiate the effect of blood administration/inotrope and relieving tension/tamponade physiology? Sounds complex.


----------



## CW CC (Dec 10, 2022)

E tank said:


> Bridge inotrope totally defensible. Explain "not fully treating tamponade". What was done and what were the end points of treatment? How did you differentiate the effect of blood administration/inotrope and relieving tension/tamponade physiology? Sounds complex.


Doc did most of the thinking like differentiating because that's a bit out of my scope


----------



## NomadicMedic (Dec 10, 2022)

I’ll take “things that never happened” for 500 …uhhh Mayim


----------



## VentMonkey (Dec 10, 2022)

NomadicMedic said:


> I’ll take “things that never happened” for 500 …uhhh Mayim


Also plausible.


----------



## akflightmedic (Dec 11, 2022)

CW CC said:


> Doc did most of the thinking like differentiating because that's a bit out of my scope



Nice dodge. In my past flight world and with my current interactions, any provider worth their weight would not answer a question with dumping on the doc. 

Most directly to you as a younger flight medic, my advice is when you do not know something, follow up with, “no I don’t know but can you share some knowledge?”


----------

