# BLS: What would you do in this GSW scenario?



## karantzalis (Oct 29, 2020)

“You are dispatched to a shooting at an university classroom for a female patient with multiple GSW: abdomen, right shoulder, bottom of right foot, and right arm. No exit wounds. Bone is protruding from the arm. 

Scene is still unsafe so you stage nearby. 10 minutes later, scene is declared safe by police. Upon arrival into the building, you are met with the professor who called 911, putting pressure on her abdomen. 

Pt is about 120 lbs, 5’6”, and has lost approximately 20% of blood already. Pt is lying supine and is unconscious but wakes up when you begin to put pressure on her shoulder wound. Her skin is cold and clammy. Decreased BP, Pulse 110 full, RR 32. She complains of pain and being cold. Pt is visibly in extreme pain, is shivering, and seems anxious. Pt responds to your questions, although only after you ask multiple times. She says she is 19 years old, has no allergies, and has mild asthma. Although pt remains conscious throughout your assessment, she is becoming increasingly lethargic and distressed. 

Nearest pediatric trauma center is 30 minutes by ground. Nearest adult trauma center is 40 minutes away by ground. Which hospital and do you decide to call for helicopter?

How do you distract the pt from the visible bone sticking out of their arm since that is what seems to be bothering her the most?

As a BLS unit, how do you take care of the pt in the above scenario?”

>> Here is what I would do: Immediately call for ALS ground support and begin to control bleeding with direct pressure. Check for any bullet holes we don’t already know about. I would pack the shoulder, arm, and foot wounds with hemostatic gauze while maintaining direct pressure on the abdomen. If bleeding doesn’t stop then I would use a tourniquet for her arm. Assist with BVM with high flow oxygen. If her breathing gets worse, maybe give her albuterol due to the asthma history. I’d try to keep her conscious by asking questions so I can continue assessing her status. I know the pain won’t kill her but I’d still try to use words to distract her from the pain and her injuries. Finally, try and keep pt warm using heat packs and blankets. Looks like Class II Hemorrhage so replacing fluid is key and therefore time is the biggest enemy.


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## CCCSD (Oct 29, 2020)

ALS should have been called as soon as you staged.


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## DesertMedic66 (Oct 29, 2020)

Rapid transport. Control bleeding the best you can. 

Have ALS meet you while you are transporting to cut down on your transport time. 

As far as the helicopter, when you start talking about 30-40 minute range a helicopter isn’t always going to save time depending on where they are located and where you are able to set up an LZ at.


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## planetmike (Oct 29, 2020)

Helicopter may have blood options available. You could have requested them when you requested ALS ground support as well.


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## Akulahawk (Oct 30, 2020)

I'm going to use the following constraints in my answer for this particular scenario: No ALS is immediately available, Trauma centers (Pedi and Adult are otherwise equally capable) are in opposite directions (such that going to one negates continuing to the other) and ALS helos aren't also immediately available. 

The answer is actually pretty simple. Which hospital can do the interventions necessary to stabilize this patient? Since both can, you don't mess around on scene. This is a situation where you can scoop and run. You do all interventions en-route. Since transport in this instance is effectively moving the patient toward definitive treatment the entire time, the more time you waste on scene means more time wasted before the patient arrives at definitive care. In effect, all that time during transport is "free time" that you can use to to your interventions because you're not wasting your time on scene doing them. Address any known life-threatening bleeding, move on to less threatening bleeding ASAP and then to minor wounds if you have time. While staging, that's also "free time" so that you can evaluate which facility is the most appropriate one. Once you know which facility is the most appropriate, you go there. Fast, but safely. As soon as you know the extent of the injuries, you relay them to the receiving facility. This allows them to clear beds, open an OR, and even clear a CT scanner if needed. You also tell them you're BLS only so they know you aren't doing anything about volume loss except plugging holes and stopping known external bleeding points. If known, let them know if the injuries are caused by handgun or long gun (basically low energy vs high energy). 

This, quite simply, is one scenario where "thinking like an EMT" is advantageous and the one area where BLS might make a difference over ALS because ALS providers are apt to play on this kind of scene longer than they should.


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## DrParasite (Oct 30, 2020)

CCCSD said:


> ALS should have been called as soon as you staged.


ALS should have been called when you were dispatched to a patient with multiple GSWs.

Scoop and run to the hospital.   Very little you do in the field is going to save this person's live, other than bleeding control.  Maybe deliver supplemental oxygen via a BVM.  Cover her with a blanket or crank up the heat.  I don't care about her asthma, because the bleeding will kill her first.  If you have extra hands (more than just a two-person crew), this would be a great call to have them.  The sooner you are off the scene, the better the patient's chances for survival. 

This patient needs a trauma surgeon to patch the holes, not a paramedic.  Take her to the pediatric trauma center, because a pediatric trauma surgeon typically handles patients under 21.  Adult can too, but many ERs are putting anyone under 21 under the peds side.


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## Bullets (Oct 30, 2020)

What is a paramedic going to do here? Start a line and what? Not giving saline. 

As a paramedic, my concerns are controling bleeding, warming the patient, and driving real fast to the nearest surgeon. Trauma is a BLS call. This trauma, with a patent airway, a broken bone and an ABD injury is a BLS call. Sure, call for ALS, but dont wait for them. Make sure your bring in a moving device like a reeves. Oh and notify the trauma unit


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## medichopeful (Nov 10, 2020)

Bullets said:


> What is a paramedic going to do here? Start a line and what? Not giving saline.
> 
> As a paramedic, my concerns are controling bleeding, warming the patient, and driving real fast to the nearest surgeon. Trauma is a BLS call. This trauma, with a patent airway, a broken bone and an ABD injury is a BLS call. Sure, call for ALS, but dont wait for them. Make sure your bring in a moving device like a reeves. Oh and notify the trauma unit



Start a line and give TXA.


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## RedBlanketRunner (Nov 12, 2020)

Patient called for ambulance herself. (Blunt force trauma plus ecotopic pregnancy rupture later determined). ALS fussed for 15+ minutes trying to get a peritoneal fluid draw. Dispatch to ER ~50 minutes. Brought in comatose, critical - hemorrhagic shock.


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## Carlos Danger (Nov 12, 2020)

RedBlanketRunner said:


> Patient called for ambulance herself. (Blunt force trauma plus ecotopic pregnancy rupture later determined). ALS fussed for 15+ minutes *trying to get a peritoneal fluid draw*. Dispatch to ER ~50 minutes. Brought in comatose, critical - hemorrhagic shock.



wut?

EDIT: Partyin' like a 1987 ATLS class, I suppose.


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## VentMonkey (Nov 12, 2020)

Carlos Danger said:


> wut?
> 
> EDIT: Partyin' like a 1987 ATLS class, I suppose.


Come on now? DPL’s were still a thing in the late 90’s. I just saw one a few weeks back on one of those_ Trauma: Life In The ER_ reruns.


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## RedBlanketRunner (Nov 16, 2020)

Carlos Danger said:


> wut?
> 
> EDIT: Partyin' like a 1987 ATLS class, I suppose.


1986. You're good.

The year I revamped the radio system. Trivia. Nurse friend just retired from that place. I asked her what she thought about the radio tower. What radio tower? She worked there for 44 years and has never seen it. 115 feet tall all of 50 feet away from staff parking. Nobody ever looks up.


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