Eviceration

[trauma1534]

Hello Everyone! This is my first day back at EMTlife for a long time. So I guess I am catching up. I would like to share with you a call that I ran about a month ago which really bothered me. I want all of your inputs on it for the scenario as far as tx, and also how you would deal with the aftermath effects of it.

Here goes.

My station was dispatched out for a call for a suicide attempt. The call was approx. 35-40 from our station out in the county. About 5 min. enroute, dispatch advized that PD was on the scene and had advised that patient had a self inflicted knife wound to the abd. with eviceration. They had not gained controle of the scene yet. They were advizing us to stage. We arrived at the area near the scene. We were told to come on down to the house by foot. We started by foot and I advized my crew that I was not confortable with leaving my truck setting. So, we got the truck and took it down as they were asking for med supplies. After getting down to the house, we were told as to what all we needed to bring in. Fire Department medic unit was there also. We brought the supplies down the hill and were asked to wait on the front porch till the officers told us to come it. This was aprox. 50 min after patient had self inflicted. Finally, we gained entrance to the house with the officers inside after they had tackled him down and he was in cuffs on the floore. There was approx. 8 inch verticle eviceration to the abd. The scene was covered with blood all over the walls, all over the floore, etc. He had used an 8 inch butcher knife. Pt was A&Ox4, pale skin, b/p of 60/p. Occlusive dressing was applied, pt loaded.

What would be your next plan of action? Hands are behind back on stretcher, no good visable veins, can't EJ, pt. won't hold head still. Would you RSI? Pt. rapidly loosing blood. Nearest local hospital is aprox. 30 min. eta. How would you handle this? I will tell you what we did after you all tackle it. Is there anything wrong with any part of his call so far, if so what and what would you have done different?

 

[jeepmedic]

Have him sign refusal

 

[Ridryder911]

Have him sign refusal

I agree, however it might be harder to with the handcuffs. ....

Seriously, have them cuff him properly, to the backboard, stretcher.. etc.. Can't find an IV.. time to EZ I/O.. RSI?.. Trouble breathing?.. Sounds like more a shocky syndrome... I will if needed to, but at this time, it appears he is holding his own airway as well most people use Etomidate.. which might lower the BP a little. Again, if it is not broke, don't complicate it.. but keep it in mind.

Time to already have the bird landing.. a known nicked bowel is an automatic surgical candidate. Helicopter should had been dispatched 50 minutes prior to playing at the scene... this is when the patient would had been "knocked down".. (violent patient= RSI or No helicopter) ...This patient needs to be in O.R...

R/r 911

 

[jeepmedic]

Yes I forgot about the Sternal I/O. We do have them here in Va. and are in some of the protocals. If you have been trained on them.

Here in WVEMS we have Haldol in the truck for this. I think Haldol should be in an areosol.B)

 

[RescueRandy]

No doubt he needs the OR, and there's not much you're going to do for him except haul butt.

Don't over complicate things. No doubt that's a frustrating mess, but you can't change that.

Besides, you pump in a bunch of fluid and he'll just bleed more, you aren't going to stop that. All you can do is control that airway and go.

If your service has long transport times and you know you'll be onscene a while the bird needs to be enroute early.

Don't let things not in your control get the best of you.

 

[FFEMT1764]

I have to agree with whats already been said. Of course, you cannot control the fact the the PD couldnt control the scene until almost and hour later, which kinda kilss that whole golden hour thing anyways. IV and O2, RSI is great if he needs it for airway protection or flight crew protection, but if you go by ground and he can maintain his airway leave it alone, unless you want to run the risk of botching the RSI and adding to the patients complicated injuries. And remember that too mach NS is bad also as kool-aid doesnt carry oxygen, only blood can do this!

 

[trauma1534]

Well... here is some more of the story. We called for Life Flight as we left the station and found out what we had. In all reality, Life Flight should have been there, but our command (the fire Department) did not have good communication with the flight crew, so they just kept circleing and circleing. Finally, they passed word through the dispatcher that they were going back to the airport (which is located across the road from our station) to land and stand by for us to transport the patient to them. This was too far out of the way for us to transport. So we decided to divert to the nearest hospital where they have a helipad. They decided to go there to meet us.

This is where it starts to go down hill. ETA to this helipad is approx. 25 min. from the scene. Long time to go with someone pregressively getting shocky. By this point, he is still A&OX4. Airway is still well self-maintained. This guy is doing remarkable for what is going on with him.

Finally, we got the PD to get onboard with us and reposition the cuffs so that we could get better access to his veins. Finally, at this point (which is only about 5 min into a 25 min. transport with him quickly bleeding out), we manage to get 4 lines established. One in each hand, and one in each foot. We poored the fluid to him, all 16's and 14's. We went through the first 4 bags of fluid, then we hung the next 4 bags and they were half gone by the time we got him to the helipad. By the time we were about 5 min. out, the patient started to shiver, and say he was very cold. Of course we had him on 15lpm/NRB/02. We had a palp B/P of 50, no peripheral pulses.

Anyone want to continue with other ideas for this guy? Also, still, does anyone see anything at all wrong with the whole beginning of the call? I'm interested to see if anyone will catch the big mistake here.

 

[jeepmedic]

You would not answer your phone.

 

[jeepmedic]

Just kidding. He was cuffed up and violent in the ambulance and where was the SD? Eating a doughnut in his car. ( I can say this because the SD was my cousin.)

 

[Jon]

Ummm.... this is a pet peeve of mine - if the patient is in custody, the LEO belongs in the rig with me, with a key to the restraints "just in case"

 

[MeckRS83]

Hello Everyone! This is my first day back at EMTlife for a long time. So I guess I am catching up. I would like to share with you a call that I ran about a month ago which really bothered me. I want all of your inputs on it for the scenario as far as tx, and also how you would deal with the aftermath effects of it.

Here goes.

My station was dispatched out for a call for a suicide attempt. The call was approx. 35-40 from our station out in the county. About 5 min. enroute, dispatch advized that PD was on the scene and had advised that patient had a self inflicted knife wound to the abd. with eviceration. They had not gained controle of the scene yet. They were advizing us to stage. We arrived at the area near the scene. We were told to come on down to the house by foot. We started by foot and I advized my crew that I was not confortable with leaving my truck setting. So, we got the truck and took it down as they were asking for med supplies. After getting down to the house, we were told as to what all we needed to bring in. Fire Department medic unit was there also. We brought the supplies down the hill and were asked to wait on the front porch till the officers told us to come it. This was aprox. 50 min after patient had self inflicted. Finally, we gained entrance to the house with the officers inside after they had tackled him down and he was in cuffs on the floore. There was approx. 8 inch verticle eviceration to the abd. The scene was covered with blood all over the walls, all over the floore, etc. He had used an 8 inch butcher knife. Pt was A&Ox4, pale skin, b/p of 60/p. Occlusive dressing was applied, pt loaded.

What would be your next plan of action? Hands are behind back on stretcher, no good visable veins, can't EJ, pt. won't hold head still. Would you RSI? Pt. rapidly loosing blood. Nearest local hospital is aprox. 30 min. eta. How would you handle this? I will tell you what we did after you all tackle it. Is there anything wrong with any part of his call so far, if so what and what would you have done different?

Hello people! Where is your scene safety practice at? Why would you continue to the scene if the PD did not have controle over it yet? And on the front porch? BIG NO NO!!!

 

[FFEMT1764]

Wait, you gave this guy 6 liters of fluid? No wonder he was getting worse, you have completely replaced his whole circulating volume...and any blood left in his system is now cool-aid, and useless for carrying oxygen. I think that some fluid is warranted, but overly agressive fluid resuscitation is as bad as the bleeding.
Secondly, why did the FD have anything to do with the helicopter, is it your protocol? Here the FD only sets the LZ up, the EMS supervisor is the ground contact for the helo.

 

[jeepmedic]

Wait, you gave this guy 6 liters of fluid? No wonder he was getting worse, you have completely replaced his whole circulating volume...and any blood left in his system is now cool-aid, and useless for carrying oxygen. I think that some fluid is warranted, but overly agressive fluid resuscitation is as bad as the bleeding.
Secondly, why did the FD have anything to do with the helicopter, is it your protocol? Here the FD only sets the LZ up, the EMS supervisor is the ground contact for the helo.

Ok I know alittle more about this call than most of you. So here goes.

As far as the LZ. Here in VA the Fire Dept is in charge of any LZ that is set up. this is because they have the big hard hats.

As far as the Fluid yes too much of anything is a bad thing. But the Medic on this truck has worked for a level 1 trauma center for years as a flight paramedic. The Hospital is UNC-Chapel Hill TarHeel 1 ( go heels.) It was his call and I stick to the call he made.

Think about Shock. You have one of three things going on. Pump failure, Fluid Loss, or Dilated Space. In this case you had Fluid Loss. They were behind the 8 ball to start and had to catch up.

Dopamine? Nope it is a trauma and bleeding involved would have made things worse. increased bleeding with out replacing volume.

The only other choice we here in Va have is to give high flow o2 and fluid replacement with NS. If you have no blood to go round and round then you need to get some fluid in there to help out. Now I agree that Blood or some Blood product would have been better. But once again we do not carry that kind of stuff on our trucks this is why the Bird was called. Mean while back in the truck you have a combative pt. that is going to die no questions ask if you do not do something so you work with what you have. NS at WAO get the pressure up to a mangeable level and cut it back. Which is what the medic did. The pt lived long enough to get to the Level 1 trauma center and into surg. and as far as I know is still alive today.

Now for the record the Medic who was on this truck is one of the Best in this area. which includes anything from Richmond VA to Durham/Chapel Hill NC. He has taught classes and has a Masters in ES.

 

[trauma1534]

Thanks Jeep for breaking all that down for them!

 

[FFEMT1764]

As far as the patient being combative, does the agency not have RSI. That takes care of all combative patients. If not then its a different story. I still think 6 liters of NS is far too much...but hey I wasn't there so who knows. I personally would not have given him that much fluid, mainly because the trauma surgeons here would have killed me, and my med control and system director would prolly suspend me for doing more harm than good...but I agree something circulating with the blood is better than not, I just believe that if you replace the complete circulating volume with saline there is nothing left to carry the oxygen to the organs which is the ultimate goal.

 

[trauma1534]

As far as the patient being combative, does the agency not have RSI. That takes care of all combative patients. If not then its a different story. I still think 6 liters of NS is far too much...but hey I wasn't there so who knows. I personally would not have given him that much fluid, mainly because the trauma surgeons here would have killed me, and my med control and system director would prolly suspend me for doing more harm than good...but I agree something circulating with the blood is better than not, I just believe that if you replace the complete circulating volume with saline there is nothing left to carry the oxygen to the organs which is the ultimate goal.

At that time of the call, the whole area under our medical director was under temp RSI disable, due to an upgrade to the RSI kit. All RSI kits were pulled off every truck untill the OMD decided which drug he wanted to take out and replace.

 

[jeepmedic]

As far as the patient being combative, does the agency not have RSI. That takes care of all combative patients. If not then its a different story.

Did you miss the combative part? Pt. would not let them get an IV. So how you going to RSI even if you can. There are other drugs that can help you gain control of the Pt. but they were not on the truck due to protocol.

 

[FFEMT1764]

Finally, at this point (which is only about 5 min into a 25 min. transport with him quickly bleeding out), we manage to get 4 lines established. One in each hand, and one in each foot.

I don't see how this means there is no IV? Looks like there are plenty of IV's to push the RSI drugs...but hey, if you think he needs more than 4 IV's to RSI him...

 

[Ridryder911]

If a Paramedic administers 6 liters of fluid to a "shock" patient they need to re-learn shock treatment. I don't care if they work in a Level I , then shame on them they should know better. Wash-out theory has been recognized for the past 12 years, in fact after 2 liters of fluid, you have met your "fluid challenge". Saline lock those 3 others and infuse NSS about 200/hr to maintain fluid level.

This is taught from every trauma course from ATLS to PHTLS/BTLS. The patient needed the red stuff and rapid transport. RSI or even sedating would had at least decreased activity and decreased the work load and possibly lowered the bleeding level from increased activity. As well, if one can initiate lines in peripheral-distal apparently circulation was better than appeared. Peripheral vasculature usually collapses distally then caudally.

Call sounds like a cluster.. and poorly handled. We all have been on them, and hopefully we can all chalk it up to experience, where it won't re-occur again. Yes, it is easy for all to play arm chair quarterback.. and personally, as the Paramedic I would review the call with "higher beings" so I would not be in this predicament again.

R/r 911

 

[jeepmedic]

I don't see how this means there is no IV? Looks like there are plenty of IV's to push the RSI drugs...but hey, if you think he needs more than 4 IV's to RSI him...

These IV's were well into the call. After the Pt. had lost alot of blood and at this time he was CTD. No need to RSI. You need to look at the whole picture not just the parts you want to pick apart. The OMD has no problem with the call.