# Priority intervention?



## kirky kirk (Mar 25, 2017)

During one training session, this scenario was given.

Patient arrived at the ER, gunshot wounds to the left chest, left abdomen. Patient is gasping, bleeding profusely and de-saturating fast. What is the priority intervention?


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## Akulahawk (Mar 25, 2017)

kirkyrabbit said:


> During one training session, this scenario was given.
> 
> Patient arrived at the ER, gunshot wounds to the left chest, left abdomen. Patient is gasping, bleeding profusely and de-saturating fast. What is the priority intervention?


Well, my first thought is to throw one of these: 
	

	
	
		
		

		
			





If that's not an option, I'm going to go with the ABC's and take care of B & C as quickly as I can. Patient is gasping so the airway is patent...


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## CALEMT (Mar 25, 2017)

Akulahawk said:


> ABC's and take care of B & C as quickly as I can.



This. Maybe try to find some info on the gsw. Caliber? Entrance/exit wound? Approximate distance from shooter to victim?


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## DesertMedic66 (Mar 25, 2017)

What do you think the priority intervention is?


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## TransportJockey (Mar 25, 2017)

Akulahawk said:


> Well, my first thought is to throw one of these:
> 
> 
> 
> ...


Just make sure to count to three. Four is right out

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## E tank (Mar 25, 2017)

chest tube


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## NomadicMedic (Mar 25, 2017)

Bright lights, cold steel. 

Just prior to that; chest tube, ETI and blood. 

Have someone prophylacticly MFB. (Measure for box.)


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## VFlutter (Mar 25, 2017)

100% NRB to oxygenate the non-existent hemoglobin


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## EpiEMS (Mar 25, 2017)

Chase said:


> 100% NRB to oxygenate the non-existent hemoglobin



Somebody paid good attention to the NREMT's preferences 


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## Akulahawk (Mar 25, 2017)

Chase said:


> 100% NRB to oxygenate the non-existent hemoglobin





EpiEMS said:


> Somebody paid good attention to the NREMT's preferences
> 
> 
> Sent from my iPhone using Tapatalk


That's pretty much what I was hinting at with getting going with B and C... Flood patient with oxygen using an NRB or oxymask (because both can provide high percentage of inhaled oxygen) and then get going with stopping the leaks as much as possible. Ask about GSW info on the way to the ambulance, find way to trauma surgeon who can apply bright lights, cold steel. Maybe along the way, start a couple of medium-to-large bore IV lines and use just enough fluid to maintain a palpable carotid pulse because anything more unnecessarily dilutes what little kool-ade is left. Call hospital so they can bring blood to ED and have it available upon arrival. 

Oh, and 4 really is right out...


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## Gurby (Mar 25, 2017)

"patient is gasping"

Consider poking a needle in their chest.


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## Flying (Mar 25, 2017)

Clamshell him


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## Akulahawk (Mar 25, 2017)

Gurby said:


> "patient is gasping"
> 
> Consider poking a needle in their chest.


That's around step 4 or 5... and since I'm going go be moving rather quickly, that will be considered and perhaps done (if indicated) rather early on as well. It was one of the interventions I had in mind when I read the scenario. However the question was what's the priority intervention. Of course NONE of the answers were provided so we all get to add in our own priority interventions.


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## Jim37F (Mar 25, 2017)

Clearly, the highest priority is full spinal immobilization.....


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## VentMonkey (Mar 25, 2017)

Flying said:


> Clamshell him


Took me a second to figure that one out.


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## VFlutter (Mar 25, 2017)




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## CWATT (Mar 26, 2017)

Chase said:


> 100% NRB to oxygenate the non-existent hemoglobin



Lol!

In all seriousness, gasping indicates the patient is protecting the airway and breathing (although with difficulty) and also confirms presence of circulation.  Check the mouth for blood; there's a high likelyhood with the left abdominal wound.

Now,  I'm going with the ITLS 'find-it fix-it' approach.  If you have the personnalle, get a gloved hand on that left chest wound to prevent tension pneumo.  If the pt. was brought in by EMS I would expect they would have said if there was an exit wound on the back.  If they were a walk-in, then finish the primary survey and check the back.  

It goes without saying, getting the patient on a monitor, throw the pads on, multiple IV access, and prepping for intubation and chest tube is all happening at once, but my 'priority' would be figuring out what I'm dealing with and responding appropriately.


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## SpecialK (Mar 26, 2017)

With the understanding I have never seen or treated a patient who has been shot, nor would 99.9% of ambulance personnel ever see it in their careers, nor would most hospital personnel (except maybe for somebody who has had a slug pellet accidently fired at them) hmm I would hazard a guess at the following:

1) Most importantly, a very early RT call to hospital to have an appropriate doctor who could open his chest in ED if required or at the least, an operating theatre ready upon arrival,
2) Go directly to theatre on arrival if possible and bypass ED all together,
3) Airway by whatever means works (laryngeal mask is fine for now)
4) Compress any external bleeding +/- CAT
5) Blood if available but not waiting at the scene for blood to arrive unless a very few minutes away

I can't say what else I'd do ...


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## VentMonkey (Mar 26, 2017)

SpecialK said:


> With the understanding I have never seen or treated a patient who has been shot, nor would 99.9% of ambulance personnel ever see it in their careers, nor would most hospital personnel (except maybe for somebody who has had a slug pellet accidently fired at them)


Ok I have to ask, @SpecialK what are the assault weapons of choice in New Zealand?


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## E tank (Mar 26, 2017)

VentMonkey said:


> Ok I have to ask, @SpecialK what are the assault weapons of choice in New Zealand?



Bowie knife?


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## VentMonkey (Mar 26, 2017)

E tank said:


> Bowie knife?


Who has two thumbs and regrets pulling the trigger on his Dundee knife reference in another thread...this guy.

Back on topic (sort of). I would imagine knife wounds to the the chest to be slightly more of the advantage? when it comes to a traumatically assaulted patients torso.


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## DesertMedic66 (Mar 26, 2017)

SpecialK said:


> With the understanding I have never seen or treated a patient who has been shot, nor would 99.9% of ambulance personnel ever see it in their careers, nor would most hospital personnel (except maybe for somebody who has had a slug pellet accidently fired at them)


Not here in the land of the free and the home of the brave. I'd wager to guess the majority of providers who are in a emergency system for any amount of time. Just in my 2 years on as a medic I have had a handful of patients who have been shot.


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## CWATT (Mar 26, 2017)

DesertMedic66 said:


> Not here in the land of the free and the home of the brave. I'd wager to guess the majority of providers who are in a emergency system for any amount of time. Just in my 2 years on as a medic I have had a handful of patients who have been shot.



I've heard of EMS personnalle doing a rotation through high gun violence areas for experience.  In all honesty, it's something I'd like to do.  I think it's important having someone in the ED who has dealt with such high-velocity/energy penetrating wounds would be a real benefit and I'd argue the same applies for ambulance services.


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## TransportJockey (Mar 26, 2017)

CWATT said:


> I've heard of EMS personnalle doing a rotation through high gun violence areas for experience.  In all honesty, it's something I'd like to do.  I think it's important having someone in the ED who has dealt with such high-velocity/energy penetrating wounds would be a real benefit and I'd argue the same applies for ambulance services.


I know pj students do that but I've never heard of it for field staff. 

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## NomadicMedic (Mar 26, 2017)

It's a rarity to find someone in my area who hasn't run on at least 3 or 4 GSW calls. We have a TON of gun violence here. Savannah gets a shooting or two almost everyday. Even out in the sticks where I work we get a GSW call every few weeks. (Of course we also get snake bites and gator attacks.)


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## Tigger (Mar 26, 2017)

I've run suicides and accidental shootings but nothing related to gun violence in the last four years here. Usually they dead when we get there it seems.


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## StCEMT (Mar 26, 2017)

Hell, here in STL we had 7 people shot at once on Saturday. Last I heard, 4 of our crews responded and then how many ever city EMS folks. North STL is a **** hole, gun shots are not at all uncommon here.


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## VentMonkey (Mar 26, 2017)

CWATT said:


> I've heard of EMS personnalle doing a rotation through high gun violence areas for experience.  In all honesty, it's something I'd like to do.  I think it's important having someone in the ED who has dealt with such high-velocity/energy penetrating wounds would be a real benefit and I'd argue the same applies for ambulance services.


I'm curious to know how this would "benefit" prehospital ambulance personnel? 

In all honesty most GSW's in the field are kept to a very basic approach...keep them alive until they arrive at the trauma center so they can go to OR (theatre?) while employing standard trauam care ALS, BLS, or both. These patients really don't even need a paramedic most of the time, but I digress...

Knowing ballistics and trajectories is all fine and dandy, but does nothing to change their outcomes that the often referenced "lights, and cold hard steel" won't. In short, they're usually a bloody mess, keep them as conscious as relatively possible, and get them to definitive care.

"Seeing" it in real-life doesn't change much of your treatment plan out of the hospital than what's probably already been beat to death via curriculum, and PHTLS/ ITLS. 

If it's one thing EMS buys into, it's the latest "cutting-edge" trauma care, which in all honesty has hardly changed over decades with the exceptions that again, are often brought up.

Oh, and @kirkyrabbit to answer your (homework) question- ABC's as applicable to how they're found, and yes, they're in-hospital and gasping, so they'll probably get cracked.


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## CALEMT (Mar 26, 2017)

Tigger said:


> I've run suicides and accidental shootings but nothing related to gun violence in the last four years here. Usually they dead when we get there it seems.



It's mostly gang violence and officer involved shootings (every once in a while) out here.


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## StCEMT (Mar 26, 2017)

@VentMonkey the main thing that comes to mind is comfort. I don't get serious traumas all that much. I know definitive care is the thing they need, but more experience would be good just so I'd be a bit more comfortable in managing it.


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## VentMonkey (Mar 26, 2017)

StCEMT said:


> @VentMonkey the main thing that comes to mind is comfort. I don't get serious traumas all that much. I know definitive care is the thing they need, but more experience would be good just so I'd be a bit more comfortable in managing it.


It's going to be a whole slew of things that dictate comfort-level, mainly experience.

If you're in the farmlands perhaps tractor incidents, by the highways a lot of MVC's, inner-city ghetto urban blight?--->knife and gun clubs.

What do they all share in common? It's all the same standard approach to trauma care- rapid delivery to the trauma center. Aside from a combative TBI, and a few others that are beyond less means, there aren't many traumas I want to RSI right off the bat, so my "care" is similar to what a brand-new paramedic would/ should be. See what I'm sayin'?...


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## NysEms2117 (Mar 26, 2017)

i agree with mostly everything said above. I've been working in EMS <1 year and i've had about 5 GSW calls. All of them we(my CC-P partner and I) are doing a super rapid trauma assessment, C-spine if needed, Blood sweeps, and we are off scene ASAP. Often times our EMR driver doesn't even get out because he knows how fast we will be off scene and en-route to the hospital. Tbh I as an EMT-B do just about the same things a CC-P would do, aside from potentially giving pain control(which isn't that common here anyway)(also means starting lines obviously). 
My favorite EMS quote: "air goes in and out, blood goes round' and round' any deviation is a problem".


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## VentMonkey (Mar 26, 2017)

NysEms2117 said:


> i agree with mostly everything said above. I've been working in EMS <1 year and i've had about 5 GSW calls. All of them we(my CC-P partner and I) are doing a super rapid trauma assessment, C-spine if needed, Blood sweeps, and we are off scene ASAP. Often times our EMR driver doesn't even get out because he knows how fast we will be off scene and en-route to the hospital. Tbh I as an EMT-B do just about the same things a CC-P would do, aside from potentially giving pain control(which isn't that common here anyway)(also means starting lines obviously).
> My favorite EMS quote: "air goes in and out, blood goes round' and round' any deviation is a problem".


Right, and where would your priorities lie of you dealt with mainly off-road trauma?

I get the comfort-level issue, but if there was ever a rapid learning curve with what we do, trauma care would by far top that list.

Would you--generally speaking--feel the need to do rideouts with your local service in hopes of seeing more ATV accidents?


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## StCEMT (Mar 26, 2017)

VentMonkey said:


> See what I'm sayin'?...



I know exactly what you mean. It isn't a matter of not knowing what to expect or what needs to be done as much as it is ironing out the kinks with the first few that are bound to occur when something new is presented. That mix of being able to filter out unnecessary details, but also having learned little things to pick up on when running through your assessment.


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## VentMonkey (Mar 26, 2017)

StCEMT said:


> I know exactly what you mean. It isn't a matter of not knowing what to expect or what needs to be done as much as it is ironing out the kinks with the first few that are bound to occur when something new is presented. That mix of being able to filter out unnecessary details, but also having learned little things to pick up on when running through your assessment.


I understand exactly where _you're_ coming from as well. I can tell you first hand though that all you can do is prep. For me this includes reviewing current literature, checking all of my gear every day so that when it happens, it's all as fluid as one can possibly hope.

A lot of times we'll get there, and the call these folks will most likely share with their peers, are A) nothing like they've told, and B) most likely not all that exciting.

I'm in no way lecturing you, or insinuating you aren't aware of any of this yourself. The biggest thing I can tell you about making sure to "cross your T's, and dot your I's" is literally just preparing; you'll see (if you haven't already) the all-too-common provider that doesn't. That person: don't do that. 

I haven't RSI-d in who knows how long, but I still like to have all of my stuff laid out where I want it so we're not fumbling through stuff. This includes poking around at the vent in case my partner hasn't in a while.

Everyone gets rattled from time to time regardless of the call. It's healthy, it's normal, without it--as you said--you won't know what _not_ to do next go round unless, again, you're that arrogant prick who "never makes mistakes".


StCEMT said:


> I haven't seen much serious traumas ...yet


Also, this. There's no tricks to training. Complacency kills any good provider, but again, you know that. Don't mind me..."Vent's just being Vent".


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## Jim37F (Mar 26, 2017)

DesertMedic66 said:


> Not here in the land of the free and the home of the brave. I'd wager to guess the majority of providers who are in a emergency system for any amount of time. Just in my 2 years on as a medic I have had a handful of patients who have been shot.


Depends on where you're working. I've been an EMT little over 4 years, last 3 in 911 systems, yet my first 2 years I never saw a single GSW (Torrance and Glendale). Cut to this last year or so working Compton/Compton-adjacent area and I've personally been on at least 3 or 4.



StCEMT said:


> Hell, here in STL we had 7 people shot at once on Saturday. Last I heard, 4 of our crews responded and then how many ever city EMS folks. North STL is a **** hole, gun shots are not at all uncommon here.


Last night we had 4 in our area more or less all right around the same time, including 2 who were walk ins at the local community hospital


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## NysEms2117 (Mar 26, 2017)

VentMonkey said:


> Right, and where would your priorities lie of you dealt with mainly off-road trauma?
> 
> I get the comfort-level issue, but if there was ever a rapid learning curve with what we do, trauma care would by far top that list.
> 
> Would you--generally speaking--feel the need to do rideouts with your local service in hopes of seeing more ATV accidents?



I feel what your aiming at, my only counter would be, ATV/offroading accidents are generally further from a hospital no? Meaning in most cases more care would be provided due to longer tx time? Again I could be completely wrong, I know NYS EMS more importantly REMO EMS. I know where i work GSW's are much closer then knox tractor accidents. Granted I work for a county service so it's a bit larger coverage area. I hope to see nobody get hurt/sick/wounded/breakdown personally, call it lazy or optimistic idc .


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## DesertMedic66 (Mar 26, 2017)

NysEms2117 said:


> I feel what your aiming at, my only counter would be, ATV/offroading accidents are generally further from a hospital no? Meaning in most cases more care would be provided due to longer tx time? Again I could be completely wrong, I know NYS EMS more importantly REMO EMS. I know where i work GSW's are much closer then knox tractor accidents. Granted I work for a county service so it's a bit larger coverage area. I hope to see nobody get hurt/sick/wounded/breakdown personally, call it lazy or optimistic idc .


The issue with trauma is for the majority of EMS our initial treatments are going to be no different than a long transport. Trauma for EMS = Get a patent airway, control/monitor breathing, keep blood going around in circles. 

We treat a Fx leg that is 10 minutes away from the ED the same way we treat a Fx leg that is 3 hours from the ED (just maybe more pain medications).


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## EpiEMS (Mar 26, 2017)

On the point of what is state of the art penetrating trauma care, I would say that the plurality of the studies I've seen (OPALS, the philly PD scoop and run, etc.) provide ample indication that a BLS unit is more than sufficient (and a police car plus hemorrhage control may be better)!


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## VFlutter (Mar 26, 2017)

StCEMT said:


> Hell, here in STL we had 7 people shot at once on Saturday. Last I heard, 4 of our crews responded and then how many ever city EMS folks. North STL is a **** hole, gun shots are not at all uncommon here.



Barnes was on Divert for a little bit because of it. Ended up flying a few patients to the county.


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## StCEMT (Mar 26, 2017)

Come to think of it, that shooting Saturday really highlights what I mean in regards to this. Multiple critical pt's, some with facial gsw's. If I were to be first on scene for that (very possible since I was working and it was .5 miles from one of our post), my 3 month old self would definitely have a couple second pause of "**** me, where do I start?". I think reading post from you and others here definitely helps keep me aware of the right things to focus on and I know I KNOW where to start, but jump that far outside of my comfort zone that fast and I will definitely be living by the phrase fake it til you make it for at least part of the call.


Chase said:


> Barnes was on Divert for a little bit because of it. Ended up flying a few patients to the county.


I know, I called a doc to cover my *** on an OD and the nurse told me to make it quick. That call was right around the time they would have gotten word those folks were inbound. I think the doc said all of 2 words to me.


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## NysEms2117 (Mar 26, 2017)

completely agree with @EpiEMS. In a major city getting places fast requires a few things:
first and foremost: maneuverability. not rocket science, police cars more maneuverable then ambulances
2. getting into the method of travel fast. LEO's wont fiddle around, its drag lay down in seat. slam door, drive super fast. Maybe TQ before moving.
3. clearing lights/ understanding traffic LEO's(that i know) have more training with that then EMT's do. 

Sometimes people just overthink interventions IMO. Sometimes you just have to swallow your pride and say "well fk, sorry pal me as a **insert pre-hospital care provider here** can't do much for you, high flow diesel and cooking to the ER/OR is the best for you, we'll do our best to do that". I do think that is something some paramedics can't quite grasp (from what i can gather everybody on here that knows what they're doing understands that though so +1 to all you guys/gals!)


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## EpiEMS (Mar 26, 2017)

FWIW, the 2011 Philly study showed:



> We are left with the conclusion that police transport of patients with proximal penetrating injuries is not associated with lower survival when compared to EMS-transported patients.



If we cannot show that EMS is superior for penetrating trauma, there really is little reason to not encourage PD to transport urgently. Probably hard to study this with an RCT, but the evidence I've seen is pretty clear.


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## VentMonkey (Mar 26, 2017)

NysEms2117 said:


> getting into the method of travel fast. LEO's wont fiddle around, its drag lay down in seat. slam door, *drive super fast*. Maybe TQ before moving.


Yeah, no. I love stats, studies, and facts just as much as the next guy, but it's all fine and dandy until it's not...as in a real bad wreck because they're rushing to get the victim, or God forbid, their co-worker to the ED.


NysEms2117 said:


> clearing lights/ understanding traffic LEO's(that i know) have more training with that then EMT's do.


Maybe they're excellent drivers where you're at, I'm not doubting you, but where I am they're more often than not some of thee scariest code three drivers around. I don't think I am alone in my train of thought, but maybe I am...


NysEms2117 said:


> Sometimes people just overthink interventions IMO. Sometimes you just have to swallow your pride and say "well fk, sorry pal me as a **insert pre-hospital care provider here** can't do much for you, *high flow diesel and cooking to the ER/OR is the best for you*, we'll do our best to do that". I do think that is something some paramedics can't quite grasp (from what i can gather everybody on here that knows what they're doing understands that though so +1 to all you guys/gals!)


Again, the "diesel bolus" should be titrated to safely and effectively getting you, your partner(s), and the patient to definitive care.

Should we be flogging around on scene with IV's and the like? Clearly not, but reminding everyone to slow down while moving at a pace that translates into _efficient urgency_ is much different than flinging "GSW Joe" in the back of the meat wagon and driving like a bat out of hell. Sorry, NYS, but that's how your post came across.


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## NysEms2117 (Mar 26, 2017)

Not how it was meant, but I could see how it was interpreted. 
Safety is implied in my posts... No offense but I'm an *******, you as the provider are more important then 2 minutes of time saved. I'm not a fan of not coming home to my fiancé :/


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## Tigger (Mar 26, 2017)

NysEms2117 said:


> completely agree with @EpiEMS. In a major city getting places fast requires a few things:
> first and foremost: maneuverability. not rocket science, police cars more maneuverable then ambulances
> 2. getting into the method of travel fast. LEO's wont fiddle around, its drag lay down in seat. slam door, drive super fast. Maybe TQ before moving.
> 3. clearing lights/ understanding traffic LEO's(that i know) have more training with that then EMT's do.
> ...



Efficiency, not speed matters. Having someone bleed out in a cruiser because no one wanted or knew to put a tourniquet on is a problem. So are tension pneumos. And dying in a wreck. Or showing up to a non a trauma hospital or a trauma hospital that isn't even remotely prepared or otherwise unable to accept the patient. 

PD homeboy ambulance might work in the right place, but there's some luck involved.


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## NysEms2117 (Mar 26, 2017)

Tigger said:


> Efficiency, not speed matters. Having someone bleed out in a cruiser because no one wanted or knew to put a tourniquet on is a problem. So are tension pneumos. And dying in a wreck. Or showing up to a non a trauma hospital or a trauma hospital that isn't even remotely prepared or otherwise unable to accept the patient.
> 
> PD homeboy ambulance might work in the right place, but there's some luck involved.



Well I mean sometimes it's better to be lucky then good? Just kidding!!! 
Again I get both sides. But a bls ambulance vs a cruiser with maneuverability... Bls can't do much for tension pneumo's either. I get where your coming from/aiming at. Where I live if you work county level down. And you get hurt, you're going to Albany med, it's just that simple. If they transfer you to a smaller hospital because they're full that's once you get there. I'd like to hope Leo's can at least say "officer shot en route to Albany med" and somebody would pick up on it. 
I'd also like to hope the same level of common sense would apply to a tq. Again this may be just my thinking since I'm an emt and a Leo, sorry for any confusion. I'm still trying to figure out how to post for the general ems population since I have 0 experience outside of my first and only ems job so far.


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## StCEMT (Mar 27, 2017)

The maneuverability is an advantage up to point. On the main road leading to the big STL hospital, a cruiser won't have any better of a time getting around when traffic is bad due to congestion and roadwork. It has had to be done by PD too at that exact hospital. Their benefit was that transport time was immediate and the hospital was close.

Honestly, I'd say it depends on the part of the city they are in. On the main strip, near by? Go for it. More extended and further North? Or just 1600 and rush hour traffic. At least have us intercept.


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## VentMonkey (Mar 27, 2017)

NysEms2117 said:


> But a bls ambulance vs a cruiser with maneuverability... Bls can't do much for tension pneumo's either.
> *I'd rather have a well-oiled BLS unit cautiously take me to the proper ED than me being flung about in the back of a patrol vehicle; call me crazy.*
> I'm still trying to figure out how to post for the general ems population since I have 0 experience outside of my first and only ems job so far.
> *Perhaps herein lies the disconnect? As an EMS-only provider I can only speak from my experiences.
> ...


We don't know what we don't know, right? Also, aside from Philly, what other LE agencies are doing this, and how have their outcomes held up? I haven't seen, or heard of too many doing this, even in densely populated urban areas. I have to wonder why it hasn't picked up steam by now with the LE community.

Perhaps you know why it hasn't yet?


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## NysEms2117 (Mar 27, 2017)

VentMonkey said:


> We don't know what we don't know, right?



Understood sir , bottom line for me, when **** hits the fan and God forbid I get shot or stabbed or insert *very bad Owwie here* I'd hope that the folks taking care of me made choices that bettered my chances. Ultimately it's getting to the hospital safely. I understand I said "run and gun" with Leo's before, I just meant they can go faster while being safe as well. If my best chances of survival are being jostled in the back of a patrol car for 10 minutes but getting to the hospital sooner (while being safe) so be it. If my chances are to have a paramedic lift me into an ambulance and drive at a slower speed, so be it. Whatever lets me see my family again, whatever lets my patient/partner/ fellow first responder see their family again, that's what i will do. 

If you folks couldn't tell I'm a very results oriented guy, how it happens that's an after thought.

I am safety oriented in real life* don't want you folks thinking I'm a run and gun person, I just assume since we're all here voluntarily safety and precautions are assumed 


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## DrParasite (Mar 27, 2017)

wait, the answer isn't scene safety?


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## DrParasite (Mar 27, 2017)

VentMonkey said:


> We don't know what we don't know, right? Also, aside from Philly, what other LE agencies are doing this, and how have their outcomes held up? I haven't seen, or heard of too many doing this, even in densely populated urban areas. I have to wonder why it hasn't picked up steam by now with the LE community.
> 
> Perhaps you know why it hasn't yet?


Homeboy taxi service has been doing it for years. 

it hasn't caught on in the LEO community because they don't want to always be washing the blood out of the backseats of their patrol cars.  Philly is smart; they have a van where they can just run the hose out of the back. And they have a very poorly managed, understaffed, all ALS system, and historically have extended response times, which is why PPD adopted the scoop and run in the PD van SOP for GSW victims.  After all, why fix the EMS when the cops can just drive really fast to the ER?


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## SpecialK (Mar 27, 2017)

VentMonkey said:


> Ok I have to ask, @SpecialK what are the assault weapons of choice in New Zealand?



Fists, bit of wood, bottles, bat, those sorts of things; mainly blunt trauma with a very low rate of penetrating injuries but mostly from domestics or some blokes have a bit of biffo and somebody picked up a knife but they're usually short kitchen knives.  Every now and then somebody gets shanked with a screwdriver.

The only people I've heard of being attended to who were shot with a handgun is when the police are the ones shooting.  And that's maybe one person a year out of the whole country.  Some of the overseas personnel from London and South Africa reckon it's paradise down here cos of lack of penetrating violent injuries.


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## EpiEMS (Mar 27, 2017)

VentMonkey said:


> Also, aside from Philly, what other LE agencies are doing this, and how have their outcomes held up?



I found an article published in December 2016 that used the National Trauma Databank (this is voluntarily provided data on traumatic injury, and covers over 700 facilities). The authors, in their case-control study, found that:



> Patients transported by police were no more likely to die than those transported by EMS (OR=1.00, 95% CI: 0.69-1.45). Among all police transports, 87.8% occurred in three locations (Philadelphia, Sacramento, and Detroit).



So, that's nearly 90% of police transports in a study of nearly 90,000 patients (covering the 100 most populous trauma systems in the United States) - and only three cities.

More detail on the outcomes:



> Unadjusted mortality rates were higher for police transport than ground EMS for GSWs (26.4% vs. 20.8%, p<0.001) and not significantly different for stab wounds (3.5% vs. 3.3%, p=0.89). Following risk-adjustment*, patients transported by the police department were no more likely to die than those transported by ground EMS (OR=1.01, 95% CI: 0.68-1.50). This held true for GSWs (OR=0.93, 95% CI: 0.62-1.41) and stab wounds (OR=0.32, 95% CI: 0.09-1.14).



*They adjusted for "age, gender, race, ISS, HR, SBP, GCS-Motor, and insurance status."

More conclusive results could be obtained by a RCT, but I doubt that is likely to happen anywhere. (Chicago would be a good candidate city.)


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## MonkeyArrow (Mar 27, 2017)

EpiEMS said:


> More conclusive results could be obtained by a RCT, but I doubt that is likely to happen anywhere. (Chicago would be a good candidate city.)


But is Chicago so understaffed that the EMS vs. LE response times would differ significantly? The only place I see this making sense is somewhere with extended EMS response times due to chronic understaffing like Philly as mentioned, or maybe Detroit?


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## EpiEMS (Mar 27, 2017)

@MonkeyArrow, I think that anywhere with high rates of penetrating trauma would be a reasonable place to study it. Based on the Philly data, PD transport is strictly preferable under certain conditions, and I don't think it really matters whether there are extended EMS response times under those constraints (e.g. penetrating trauma to the torso).


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## kirky kirk (Mar 28, 2017)

Wow, the wealth of information I got from you guys.


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## phideux (Mar 29, 2017)

kirkyrabbit said:


> During one training session, this scenario was given.
> 
> Patient arrived at the ER, gunshot wounds to the left chest, left abdomen. Patient is gasping, bleeding profusely and de-saturating fast. What is the priority intervention?



Back to this, I'm going with IV or IO, RSI, slow the bleeding and get blood going in, Maybe dart the chest while the Doc sets up the chest tube tray and puts in a tube, CT to see what's actually going on, and take it from there.

StCEMT, I was working triage at the ER one night when a car pulls up with 5 people with multi-GSWs. One was DRT, the other 4 made it. We had 2 GSWs walk in through triage last weekend. We see a bunch of that here.


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## CoraElizabeth (Mar 31, 2017)

Trying to figure out an "exit wound" is a waste of time. Just count the holes, it makes ZERO impact on our care, and quite frankly, if someone is gasping for breaths, I just have bigger priorities. I once heard a trauma surgeon talking, apparently, they aren't even allowed to document an entrance/exit wound, because they aren't medical examiners. All the trauma surgeons document is number of holes. Apparently, if they do document entrance or exit, the could be completely
I'm also not HUGELY concerned about things like distance. Most of our GSWs are street violence, so no one around knows, or is willing to talk, so I don't even ask. The reality is, regardless of how far away the person was or was not...the wounds are still the wounds, and that's all that's needed to know in the emergency setting. 


CALEMT said:


> This. Maybe try to find some info on the gsw. Caliber? Entrance/exit wound? Approximate distance from shooter to victim?


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## VentMonkey (Mar 31, 2017)

CoraElizabeth said:


> Trying to figure out an "exit wound" is a waste of time. Just count the holes, it makes ZERO impact on our care, and quite frankly, if someone is gasping for breaths, I just have bigger priorities. I once heard a trauma surgeon talking, apparently, they aren't even allowed to document an entrance/exit wound, because they aren't medical examiners. All the trauma surgeons document is number of holes. Apparently, if they do document entrance or exit, the could be completely.


Eh, I don't know about all of that. The "Bullet Rule" still holds value to many-a-trauma surgeons I have encountered. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3255182/#!po=70.4545


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## E tank (Mar 31, 2017)

Brain Teaser time: 

Had a guy with 4 self inflicted bullet wounds in his belly. .38 special. One in each quadrant, pretty symmetrical pattern. No exit wounds on his back. No bullets visible on KUB, AP chest or lower extremity films. Negative FAST.

What happened?


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## Akulahawk (Mar 31, 2017)

E tank said:


> Brain Teaser time:
> 
> Had a guy with 4 self inflicted bullet wounds in his belly. .38 special. One in each quadrant, pretty symmetrical pattern. No exit wounds on his back. No bullets visible on KUB, AP chest or lower extremity films. Negative FAST.
> 
> What happened?


He lost a fight with an industrial-size staple remover.


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## Akulahawk (Mar 31, 2017)

E tank said:


> Brain Teaser time:
> 
> Had a guy with 4 self inflicted bullet wounds in his belly. .38 special. One in each quadrant, pretty symmetrical pattern. No exit wounds on his back. No bullets visible on KUB, AP chest or lower extremity films. Negative FAST.
> 
> What happened?


If the patient was a bit portly (shall we say?), I suspect the revolver discharged twice, with the bullets travelling through the abdomen and exiting without impacting (literally) any organs.


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## E tank (Mar 31, 2017)

Akulahawk said:


> He lost a fight with an industrial-size staple remover.


Nope...he was really shot with a .38. That does remind me of the guy that was seeking sexual gratification with a belt sander though...


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## E tank (Mar 31, 2017)

Akulahawk said:


> If the patient was a bit portly (shall we say?), I suspect the revolver discharged twice, with the bullets travelling through the abdomen and exiting without impacting (literally) any organs.



Exactly...He actually grabbed a handful of fat and shot across his belly...twice. Surgeon figured it out pretty quickly by running a probe through the holes. The guy was shocked he had been figured out so fast.


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## Akulahawk (Mar 31, 2017)

E tank said:


> Nope...he was really shot with a .38. That does remind me of the guy that was seeking sexual gratification with a belt sander though...


I imagine he was a bit raw after that...


E tank said:


> Exactly...He actually grabbed a handful of fat and shot across his belly...twice. Surgeon figured it out pretty quickly by running a probe through the holes. The guy was shocked he had been figured out so fast.


While I've never had a patient like that, nor have I heard of such a patient until now, given the findings that you typed, I pretty much figured out what happened and it took me longer to type it up than to figure out. Let me guess, he also had unilateral signs of perhaps muzzle contact with his abdomen? He may have also had some very minor wounds from debris spitting out of the cylinder gap.


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## E tank (Mar 31, 2017)

Akulahawk said:


> Let me guess, he also had unilateral signs of perhaps muzzle contact with his abdomen? He may have also had some very minor wounds from debris spitting out of the cylinder gap.



Smart guy, you are....all the above...I guess. That was around 27 years ago. He might have been wearing a clown suit too, I don't remember.


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## StCEMT (Mar 31, 2017)

E tank said:


> That does remind me of the guy that was seeking sexual gratification with a belt sander though...


What? I know some people have their kinks, but for ****s sake....


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## Akulahawk (Mar 31, 2017)

E tank said:


> Smart guy, you are....all the above...I guess. That was around 27 years ago. He might have been wearing a clown suit too, I don't remember.


I don't consider myself to be _that_ smart... I just used the data you provided and my knowledge of firearms and figured the rest out. The cylinder gap wounds would have probably been either overlooked or been written off as some minor abrasions or some similar thing. Guy likely had some more spectacular wounds on the entry side just due to either direct or very close to direct muzzle contact with the body.


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## Jim37F (Mar 31, 2017)

This reminds me of a story from Band of Brothers, guy gets shot in his 4th point of contact.. 1 bullet, 4 holes....


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## phideux (Mar 31, 2017)

A buddy of mine playing quick draw with a 45 Colt, luckily he was sort of bow-legged. Just as he cleared leather, Bang. Bullet went in his upper thigh came out above the knee went into the calf came out just above the ankle. Left a hell of a mark.


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## E tank (Mar 31, 2017)

Akulahawk said:


> I don't consider myself to be _that_ smart... I just used the data you provided and my knowledge of firearms and figured the rest out. The cylinder gap wounds would have probably been either overlooked or been written off as some minor abrasions or some similar thing. Guy likely had some more spectacular wounds on the entry side just due to either direct or very close to direct muzzle contact with the body.



Now that I stretch my memory and think about it, after it was established that these where through and through across the abdominal fat/fascia, the powder burns around the right hand wounds  magically became visible to everyone for the "Aha" moment.


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## CWATT (Mar 31, 2017)

@E tank , did he give a reason for his actions?


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## E tank (Mar 31, 2017)

CWATT said:


> @E tank , did he give a reason for his actions?


He was crazy... in need of some serious psychiatric help.


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## LaAranda (Apr 8, 2017)

Interesting hearing others' experiences treating GSWs. As a half-time paramedic (straight nights) in a large but not particularly dangerous American city, I personally run about two a year. The hospital (L1) I work at receives probably one or two a week. There are two other hospitals in town that also receive major trauma.


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## Medic27 (Aug 11, 2017)

BSI ofc, Scene Safety ofc, Spinal Stablization /Full Trauma assessment

1.) ABC's Airway, Breathing, Circulation
2.) Direct pressure
3.) 15 liters non-rebreather, initiate shock management elevation of feet, and ensuring warmth
3.) Contact hospital and notify the ED you are inbound with a priority patient.


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## bakertaylor28 (Aug 12, 2017)

LaAranda said:


> Interesting hearing others' experiences treating GSWs. As a half-time paramedic (straight nights) in a large but not particularly dangerous American city, I personally run about two a year. The hospital (L1) I work at receives probably one or two a week. There are two other hospitals in town that also receive major trauma.



Only Two a year? Lucky you. I once went two weeks seeing nothing but heroin overdoses, GSWs, and a couple Psych Hobos. Its about the only time in history I can imagine one praying for the powers that be to move someone's STEMI up two weeks, oh, and praying to and/or for Madonna to get hit by a MAC truck.


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## bakertaylor28 (Aug 12, 2017)

StCEMT said:


> What? I know some people have their kinks, but for ****s sake....



Does not necessarily mean what you think it means. I've seen people use a belt sander and how should I say....attach a apparatus to the motor without how should we say considering the sheer velocity involved, resulting in significant rectal trauma.


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## Tigger (Aug 12, 2017)

bakertaylor28 said:


> Only Two a year? Lucky you. I once went two weeks seeing nothing but heroin overdoses, GSWs, and a couple Psych Hobos. Its about the only time in history I can imagine one praying for the powers that be to move someone's STEMI up two weeks, oh, and praying to and/or for Madonna to get hit by a MAC truck.


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## bakertaylor28 (Aug 12, 2017)

Tigger said:


>



Tiger, seriously dude, I'm going to have to remember to take you out to a Frisha's sometime. ;-) Where HAVE you BEEN?


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