Accident whilst at sea Thaughts and advice

[UKEMT]

Just want to see what your inital thaughts and actions would be in this case..

Recently whilst at sea we were party to a medical call from a fishing vessel, whom the skipper had an accident which at the time of calling the coast guard for medical evacuation, had left him with one hand partially severed from his forearm.

Bearing in mind that a fishing vessel would not be carrying more than a required basic medical kit what would your actions be, the response time for the helicopter would be 15 mins to lift off and the at least 40 mins til on scene.

 

[Mountain Res-Q]

I can relate to being isolated from more advance medical care. I live in a rural mountian county and am part of the county SAR Team. If I were to translate this to my environment we would have probably even more limite gear and the helo would probably take longer to get there. So...

Stop the bleeding obviously. Direct pressure and elevation are probably not gonna do much on their own. Pressure points along the Brachial Artery would be advised. If avaiable, start a large bore IV. Are pain meds availabel? Go low dose. Oxygen if available and MONITOR ALL VITAL SIGNS!!! Past that nothing comes to mind for treatment.

Wrap the arm (if it is salavagable) in gauze and place it in a seeled plastic bag! Place the bag in an ice bath, but do not allow dirrct contact between flesh and ice!!!

Get the patient ready for rapid transfer to the helo.

 

[akflightmedic]

Vitals signs.

Oxygen if indicated or if pt is anxious.

Tourniquet, if bleeding is not controlled by direct pressure.

Initiate IV site for pain med administration, infuse some normal saline if you wish, no need to dump a liter or two unless indicated by severe hypotension which by your description it was not.

Administer pain medications, be generous. There is no need to do low doses, load the man up as long as he is maintaining his airway.

Since the hand is partially severed, does that mean it is not a complete amputation? It is still attached?

If detached, keep the part cool, does NOT need to be in ice, submerged in ice, or any other variation; it only needs to be kept cool.

Reassess.

 

[Mountain Res-Q]

Vitals signs.

Oxygen if indicated or if pt is anxious.

Tourniquet, if bleeding is not controlled by direct pressure.

Initiate IV site for pain med administration, infuse some normal saline if you wish, no need to dump a liter or two unless indicated by severe hypotension which by your description it was not.

Administer pain medications, be generous. There is no need to do low doses, load the man up as long as he is maintaining his airway.

Since the hand is partially severed, does that mean it is not a complete amputation? It is still attached?

If detached, keep the part cool, does NOT need to be in ice, submerged in ice, or any other variation; it only needs to be kept cool.

Reassess.

A couple interesting variations here. A few thoughts.

There shouldn't be any "Oxygen if..." IMHO, unless there is any hyperventalation everything get's O2. It's one of those basic things almost every level of medical provider can give, so give it. However, in this case, is a fishing vessel going to even have this?

Pain meds. I say go low, because unless there are stadning order or orders from a recieving facility, you do not want to interfer with any other future treatments. In this case of a fishing vessel, the only pain meds avaiable will probably be a prescription of one of the other fishermen. Besides the legalities, giving meds without knowing the patient tollerence or how they will reacte... go low.

IV's. Be careful wiht fluid overloading. In this case you are trying to control bleeding (perhaps major) so while you want to control any hypotension, do you really want to shove so much fluid in that you end up flsuhing it all out the wound and decreasing the amount of blood cells providing the needed oxygen to the brain cells? Once, again... probably not available on a fishing boat anyway.

After reconsidering the part of being on a fishing boat the only thing that I believe is really going to be of use is to control bleeding (dirrect pressure, elevation, preasure points, constricting band, and then -as a last resort- tourniquet - especially when you factor in the delayed response and transport you don't want to use a tourniquet unless rapid treatment in a hospital is anticipated) and confort/supportive measures. Just a thought from a lowly EMT.

 

[JPINFV]

A couple interesting variations here. A few thoughts.

There shouldn't be any "Oxygen if..." IMHO, unless there is any hyperventalation everything get's O2. It's one of those basic things almost every level of medical provider can give, so give it. However, in this case, is a fishing vessel going to even have this?

Then why isn't every patient in the emergency room on oxygen? Probably because not everyone needs supplemental oxygen.

Pain meds. I say go low, because unless there are stadning order or orders from a recieving facility, you do not want to interfer with any other future treatments. In this case of a fishing vessel, the only pain meds avaiable will probably be a prescription of one of the other fishermen. Besides the legalities, giving meds without knowing the patient tollerence or how they will reacte... go low.

So can we cut your hand off and deny pain medications so that the physician can properly assess your hand that's been cut off? Exactly which treatment do you think the pain medication is going to interfere with?



As far as the scenario goes, what AK said plus put the boat in high speed towards the direction the helicopter will be coming from.

 

[Mountain Res-Q]

Then why isn't every patient in the emergency room on oxygen? Probably because not everyone needs supplemental oxygen.

So can we cut your hand off and deny pain medications so that the physician can properly assess your hand that's been cut off? Exactly which treatment do you think the pain medication is going to interfere with?

First, we are talking about the prehospital environment, not a hospital. At my level of care there are few really meaningful things that the law allows me to do. Oxygen is a comfort measure if nothing else and one of the few things I could do in this case that could make a differnce. I give O2 (even if is is 2lpm via canula) to almost everybody for those reasons.

Seconds, remeber what the intial question was. "Bearing in mind that a fishing vessel would not be carrying more than a required basic medical kit what would your actions be, the response time for the helicopter would be 15 mins to lift off and the at least 40 mins til on scene." these are fishermen without any real medical gear or capabilities (probably). If you were the medic on the helo, would you want them doseing the pateint with god knows what before you got there? It would probably be something like oral vicodin. If I were there I would want to give something, even if it would probably only take affect in abouot 45 minutes, just as the helo arrived and they wanted to give something like ms. Is a USCG Medic really gonna be familiar with drug interactions adn be willing to give anyhting on top of that? In hind sight, I would say no to all pain meds, except for the "feel good" measures that oxygen provides (probably not available on a fishing boat". Hall butt towards the helo!!!

 

[VentMedic]

There shouldn't be any "Oxygen if..." IMHO, unless there is any hyperventalation everything get's O2. It's one of those basic things almost every level of medical provider can give, so give it. However, in this case, is a fishing vessel going to even have this?

Hyperventilation?

This person is probably going to have tachypnea since the guy has a nearly amputated hand. However, you are also going to have diminishing carrying capacity depending how much of his Hb is laying on the deck. O2 is more than just comfort. And yes, a fishing boat may have an emergency tank of O2 on board since emergency O2 does not require a script. Many dive and fishing charters do carry emergency O2 as do a few commercial fishing vessels that spend a lot of time off shore.

Get over your "feel good" ideas about oxygen and learn about tissue oxygenation, carrying capacity and appropriate use of oxygen.

 

[Mountain Res-Q]

Get over your "feel good" ideas about oxygen and learn about tissue oxygenation, carrying capacity and appropriate use of oxygen.

I am completely familiar with proper tissue oxygenation, the proper use of oxygen, and the potential phycological attrbutes of oxygen (feel good). Are you saying that oxygen is not needed or that it wouldn't matter one way or another?

 

[VentMedic]

I am completely familiar with proper tissue oxygenation, the proper use of oxygen, and the potential phycological attrbutes of oxygen (feel good). Are you saying that oxygen is not needed or that it wouldn't matter one way or another?

Your words not mine:

Oxygen is a comfort measure if nothing else

except for the "feel good" measures that oxygen provides

unless there is any hyperventalation everything get's O2.

Physiological attributes of oxygen is not just a "feel good". Oxygen does have physiological effects that can affect every system of the body so it is a lttle more than just making the provider "feel good" about giving it.

 

[Mountain Res-Q]

Physiological attributes of oxygen is not just a "feel good". Oxygen does have physiological effects that can affect every system of the body so it is a lttle more than just making the provider "feel good" about giving it.

:wacko: I didn't mean that I feel good about giving it. The patient feels good because of the affects it has on the entire body, including some mild analgesia, which is why I am a advocate of (almost) everything gets o2, even if it is just 2lpm via canula.

 

[akflightmedic]

A couple interesting variations here. A few thoughts.

There shouldn't be any "Oxygen if..." IMHO, unless there is any hyperventalation everything get's O2. It's one of those basic things almost every level of medical provider can give, so give it. However, in this case, is a fishing vessel going to even have this?

Pain meds. I say go low, because unless there are stadning order or orders from a recieving facility, you do not want to interfer with any other future treatments. In this case of a fishing vessel, the only pain meds avaiable will probably be a prescription of one of the other fishermen. Besides the legalities, giving meds without knowing the patient tollerence or how they will reacte... go low.

IV's. Be careful wiht fluid overloading. In this case you are trying to control bleeding (perhaps major) so while you want to control any hypotension, do you really want to shove so much fluid in that you end up flsuhing it all out the wound and decreasing the amount of blood cells providing the needed oxygen to the brain cells? Once, again... probably not available on a fishing boat anyway.

After reconsidering the part of being on a fishing boat the only thing that I believe is really going to be of use is to control bleeding (dirrect pressure, elevation, preasure points, constricting band, and then -as a last resort- tourniquet - especially when you factor in the delayed response and transport you don't want to use a tourniquet unless rapid treatment in a hospital is anticipated) and confort/supportive measures. Just a thought from a lowly EMT.

If the oxygen on board is of limited supply (which most likely it is), do you want to use it all up now in the early stages when the patient does not seemingly need it.

Again we are discussing a remote scenario here and potential for complications are high, especially something like the rescuers being delayed, during which time your patient may further decompensate. Conserve your resources, especially when they are not needed and especially when saying you would only give it for comfort if nothing else. Use your words instead of your supplies to comfort the patient if they are anxious.

Your comments in regards to pain management display a lack of current knowledge in pain control practices. You will not interfere with future exams or treatments by giving pain control meds. The rest of your response in regards to this portion inferred a lot of information that was not given by the OP. It was my impression that he was on a medical team responding to a remote fishing vessel until higher level of care could get there. Then again I could have inferred something not there as well.

At what point did you get the impression that I was pushing fluids heavy? Did you not read my response? My first goal for IV therapy was simply a route for pain med administration if available. I then threw the "no need for a liter or two" with a caveat of him being in "severe" decompensation with help so far away. And again we are talking about an amputation or partial one anyways. Most vessels when traumatically amputated retract and self occlude. Yes, there will be bleeding but not movie like bleeding and spurting all over the place, plus we are talking about a hand as opposed to an arm at the shoulder or a leg which would present a much greater blood loss from the initial slice.

Your comments on tourniquet use are also outdated and show a lack of current treatment modalities. Spend much time in Iraq or Afghanistan or read any journals discussing them? The results of their use have been documented and supported (pssst, a little thing called EBM or evidence based medicine). Anyways, all those studies found their way stateside years ago and have been implemented all over the US...or at least I thought it had...hmmm.

Just some thoughts from a lowly paramedic.

 

[Aidey]

I actually worked on a boat as a medic for a while, and if this had been my patient I would not have put him on O2 automatically. I had 2 D cylinders and that was it, and transport times reaching into the hours (if not days). I would have monitored the PT very closely for shock, and for how much blood loss he had sustained, and given O2 at a low dose if he wasn't compensating. Our MD's philosophy was that low dose O2 for longer was better than high dose O2 for not very long at all.

Other than that, I would have done it as AKflightmedic detailed.

 

[Mountain Res-Q]

If the oxygen on board is of limited supply (which most likely it is), do you want to use it all up now in the early stages when the patient does not seemingly need it.

Again we are discussing a remote scenario here and potential for complications are high, especially something like the rescuers being delayed, during which time your patient may further decompensate. Conserve your resources, especially when they are not needed and especially when saying you would only give it for comfort if nothing else. Use your words instead of your supplies to comfort the patient if they are anxious.

Your comments in regards to pain management display a lack of current knowledge in pain control practices. You will not interfere with future exams or treatments by giving pain control meds. The rest of your response in regards to this portion inferred a lot of information that was not given by the OP. It was my impression that he was on a medical team responding to a remote fishing vessel until higher level of care could get there. Then again I could have inferred something not there as well.

At what point did you get the impression that I was pushing fluids heavy? Did you not read my response? My first goal for IV therapy was simply a route for pain med administration if available. I then threw the "no need for a liter or two" with a caveat of him being in "severe" decompensation with help so far away. And again we are talking about an amputation or partial one anyways. Most vessels when traumatically amputated retract and self occlude. Yes, there will be bleeding but not movie like bleeding and spurting all over the place, plus we are talking about a hand as opposed to an arm at the shoulder or a leg which would present a much greater blood loss from the initial slice.

Your comments on tourniquet use are also outdated and show a lack of current treatment modalities. Spend much time in Iraq or Afghanistan or read any journals discussing them? The results of their use have been documented and supported (pssst, a little thing called EBM or evidence based medicine). Anyways, all those studies found their way stateside years ago and have been implemented all over the US...or at least I thought it had...hmmm.

Just some thoughts from a lowly paramedic.

Interesting thoughts. I was under the assumption that there was a push toward being fluid conservative, providing what is needed wtihout complicating things, which is where that thought comes from. I do not expect there to be blood spurting everywhere like in the movies, I have enought time out there to know that.

As far a pain meds go, my experience in that doesnt come so much from my 8 years in EMS (as a lowly EMT in California can't give any), but from my 6 years in Veterinary Medicine where pain management is fully understood by anyone worth a damn. My arguments there go more towards non-experience fishermen giving whatever meds that they have at hand. A trained flight medic or medic on a boat could do whatever worked to help as long as it is based on their knowledge, for which they take full resposibility.

As far as the tourniquet thing goes, I was under the impression that it was still discouraged. I don;t now what teh accepted standard is out in teh rest of teh world, but in California we have been experiencing what I would call a lag in conforming with the rest of the world. Do you, in your experience, have any problems advocating that a fisherman places a tourniquet on this patient from the beginning; bearing in mind that the helo might go down enroute or that other help might be unavailable and that it might take hours for the fishing boat to reach dock, much less a hospital? I know you are speaking as if you were the one on teh fishing boat, but I am looking at this more from a "what if I was jsut a fisherman with no meical training."

These questions are serious. I AM NOT being an *** or trying to argue. I really want to know; exchange ideas and learn from your experiences. I just fled another forum when the entire site became place for the chil-like to argue and name call.

 

[UKEMT]

I am based on a rescue ship, but at the time we were not in a position to attend the fishing vessel, otherwise we would have having dedicated medical staff and medical supplies beyond that of a normal vessel, the standard for oxygen is still to have 2 D cylinders on board for a normal ship, and increased for rescue ships due to having to treat what we would class as critical (1-1 care) patients. As for pain medication on the fishing vessels without digging through the Coastguard regs im unable ton say exactly what they should have had on board.

but otherwise thanks for the interesting and somewhat different inital care.

 

[Aidey]

Interesting thoughts. I was under the assumption that there was a push toward being fluid conservative, providing what is needed wtihout complicating things, which is where that thought comes from. I do not expect there to be blood spurting everywhere like in the movies, I have enought time out there to know that.

There has been a push towards being fluid conservative, but you still want vascular access early while you have a better chance of getting it. This is why hep locks are so useful. You don't have to worry about giving the patient extra fluid, or messing with any clotting factors, but you have immediate vascular access if things go down hill, or you want to give a bolus.

As far as the tourniquet thing goes, I was under the impression that it was still discouraged. I don;t now what teh accepted standard is out in teh rest of teh world, but in California we have been experiencing what I would call a lag in conforming with the rest of the world. Do you, in your experience, have any problems advocating that a fisherman places a tourniquet on this patient from the beginning; bearing in mind that the helo might go down enroute or that other help might be unavailable and that it might take hours for the fishing boat to reach dock, much less a hospital? I know you are speaking as if you were the one on teh fishing boat, but I am looking at this more from a "what if I was jsut a fisherman with no meical training."

I know this isn't addressed to me, but I'm going to answer anyway.

I would rather that if someone is unsure if a patient needs a tourniquet or not that they use one. It is possible that the tourniquet will be improperly applied, but I would rather loose a patient's hand than loose a patient. The fact that the heilo may be delayed, or that it may be several hours just enforces the need to definitive hemorrhage control.

Hopefully in this situation someone on the ship can contact an advanced medical provider (ie an ED) and be talked through what they need to look for and what they need to do. In this specific situation a tourniquet may not be needed because of the vessels ability to constrict when severed across. (Rather than lengthwise, where the vessels can't really occlude themselves). If the bleeding doesn't slow though, a tourniquet may be necessary. It's one of those things that is very hard to judge unless you can see what is going on.

Yes prolonged use of a tourniquet can cause complications, but studies coming out of Iraq and Afghanistan are have been showing that when tourniquets are properly used these affects don't start causing serious complications until hours after the tourniquet is applied. The studies have also consistently been showing that tourniquets are reducing mortality in penetrating trauma injuries.

Specific to this scenario, a tourniquet also frees up hands. When you are the lone medical provider somewhere you can't tie yourself up with one task. If you stick your hands in a wound to stop the bleeding, you are stuck there. This is where deputizing people can help, but it's still very impractical to ask one person to hold pressure on a wound for 6 hours while you work on medevacing someone out of a difficult situation.

If you are using a Heilo for a medevac it is also very likely there will be a limited amount of space for extra people, or a weight restriction that limits the number of people on the helicopter. A tourniquet weighs nothing; someone holding pressure is an extra 200lbs.

 

[Mountain Res-Q]

I know this isn't addressed to me, but I'm going to answer anyway.

I would rather that if someone is unsure if a patient needs a tourniquet or not that they use one. It is possible that the tourniquet will be improperly applied, but I would rather loose a patient's hand than loose a patient. The fact that the heilo may be delayed, or that it may be several hours just enforces the need to definitive hemorrhage control.

Hopefully in this situation someone on the ship can contact an advanced medical provider (ie an ED) and be talked through what they need to look for and what they need to do. In this specific situation a tourniquet may not be needed because of the vessels ability to constrict when severed across. (Rather than lengthwise, where the vessels can't really occlude themselves). If the bleeding doesn't slow though, a tourniquet may be necessary. It's one of those things that is very hard to judge unless you can see what is going on.

Yes prolonged use of a tourniquet can cause complications, but studies coming out of Iraq and Afghanistan are have been showing that when tourniquets are properly used these affects don't start causing serious complications until hours after the tourniquet is applied. The studies have also consistently been showing that tourniquets are reducing mortality in penetrating trauma injuries.

Specific to this scenario, a tourniquet also frees up hands. When you are the lone medical provider somewhere you can't tie yourself up with one task. If you stick your hands in a wound to stop the bleeding, you are stuck there. This is where deputizing people can help, but it's still very impractical to ask one person to hold pressure on a wound for 6 hours while you work on medevacing someone out of a difficult situation.

If you are using a Heilo for a medevac it is also very likely there will be a limited amount of space for extra people, or a weight restriction that limits the number of people on the helicopter. A tourniquet weighs nothing; someone holding pressure is an extra 200lbs.

I guess my rea question is what is accepted now, on a national level? My training, and protocol in my area, is: Dirrect Pressure, Elevate, Pressure Points, and then a tourniquet as a last resort. Yes, losing a limb is far more acceptable to losing a life, but the way it was presented here the tourniquet is the gold standard and should have been immediately slapped on this patient. Maybe I am reading into it, but that's how I interpreted it. In my case I am the Medical Team Leader for my SAR Team and I could never imagine immediately slapping on a tourniquet on a patient deep in the wilderness even if he lost a limb without trying everything else first.

As far as the fluid thing goes, that was my point. IV access early, but the need for fluids should be balanced; no need to give a massiv amount just because the patient lost a limb. At least that would be thought as a lowly EMT.

 

[Aidey]

We all agreed on the IV fluids point, I think there was just a misunderstanding somewhere in there.

Ambulance protocols on hemorrhage control are going to probably be different than remote location protocols. Ambulance protocols aren't going to rely on tourniquets as much because its easier to employ the other methods of bleeding control, and transport times tend to be a lot shorter. In the ambulance system where I work now our protocol is similar to what you described, with the tourniquet as the last option.

There is a lot of room for individual judgment though also in our protocol. Sometimes you see a wound and just by looking at it you know a tourniquet is needed. On the scene of a 5 person MVA you may use a tourniquet to control bleeding you would ordinarily use a pressure point on, but since you have more patients than you do resources you need to employ a "hands off" treatment method.

I wouldn't go as far as to call them a "gold standard" but they are a very definative method of controling bleeding. The biggest thing with them is knowing when it's appropriate to use them, and how to properly do it.

One of the other things that needs to be looked at also is how much time are you willing to spend trying alternative bleeding control methods before switching? Or, in other words, how much blood are you comfortable with that patient loosing? Closer to the hospital that amount may be a bit higher. The further away you are, the lower that number gets (at least for me).

So to answer your question in a more succinct manner; Tourniquets have their uses, and should always been considered as an option when appropriate. The further away from definitive care you are, the better an option they are when talking about a severe wound. Things such as transport time, transport method, number of skilled personnel available, amount of resources such as IV fluid and O2, blood loss already sustained, and MOI are all going to affect how likely I am to apply a tourniquet to control bleeding. The longer times you have, and the less resources you have, and the sicker the patient is all increase the likelihood that a tourniquet is going to be needed.

Does that make sense? (Sorry about the long-winded post. Maybe AKflightmedic can come by and summarize better for me).

 

[Mountain Res-Q]

We all agreed on the IV fluids point, I think there was just a misunderstanding somewhere in there.

Ambulance protocols on hemorrhage control are going to probably be different than remote location protocols. Ambulance protocols aren't going to rely on tourniquets as much because its easier to employ the other methods of bleeding control, and transport times tend to be a lot shorter. In the ambulance system where I work now our protocol is similar to what you described, with the tourniquet as the last option.

There is a lot of room for individual judgment though also in our protocol. Sometimes you see a wound and just by looking at it you know a tourniquet is needed. On the scene of a 5 person MVA you may use a tourniquet to control bleeding you would ordinarily use a pressure point on, but since you have more patients than you do resources you need to employ a "hands off" treatment method.

I wouldn't go as far as to call them a "gold standard" but they are a very definative method of controling bleeding. The biggest thing with them is knowing when it's appropriate to use them, and how to properly do it.

One of the other things that needs to be looked at also is how much time are you willing to spend trying alternative bleeding control methods before switching? Or, in other words, how much blood are you comfortable with that patient loosing? Closer to the hospital that amount may be a bit higher. The further away you are, the lower that number gets (at least for me).

So to answer your question in a more succinct manner; Tourniquets have their uses, and should always been considered as an option when appropriate. The further away from definitive care you are, the better an option they are when talking about a severe wound. Things such as transport time, transport method, number of skilled personnel available, amount of resources such as IV fluid and O2, blood loss already sustained, and MOI are all going to affect how likely I am to apply a tourniquet to control bleeding. The longer times you have, and the less resources you have, and the sicker the patient is all increase the likelihood that a tourniquet is going to be needed.

Does that make sense? (Sorry about the long-winded post. Maybe AKflightmedic can come by and summarize better for me).

PERFECT. That was basicly my thoughts, but the way it was worded by AKflightmedic made it sound like the tourniquet HAS TO BE USED and that anyone who didn't use it ASAP was behind the times in EMS. If that is the case, I just wqanted to know the research and maybe get a better understanding on what others are trained to do. In my 8 years of Ambulance, SAR, and Snow Park Medicine I have never used a tourniquet; always found other ways, but then again, the only amputation I have personally dealt with was a fingure. Thanks for your thoughts. Pretty much as I saw it, was trained to operate, and what my protocols say.

 

[Aidey]

It doesn't have to be used, but they should be considered as just another option, not as a last ditch, scary, "oh-no-my-patient-is-going-to-die", do everything you can to avoid using them alternative.

The attitude that everything should be done to avoid using them is an outdated one that has been disproved by studies and evidence based medicine, and I think that is more of what AK was getting at. (Please correct me if I'm wrong AK).

 

[mycrofft]

I think tourniquets need a new viewing by EMS, and seperate thread.

To rewind to the original post and request:
1. ABC's first, along with safety.
2. Get on radio, then to shore or get the Coasties or Air Guard Rescue Wing to "drop" by with their medics and possible airlift.
3. Cool the affected part to lower O2 demand and slow lactate production.
4. Oh, yeah, see if an EMTLIFE subscriber is on board with her/his whacker kit!