I think i earned a +1 to all the paramedics in the world today...

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04_edge

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or, at least the ones in this area. I was doing a deep night clinical for school last night/this morning when this happened.

Hx-31yoM single car MVC head on collision at ~65mph into the dividing barrier in the HOV lane. On arrival the medics found the pt. unconscience GCSx3, pt restrained in the vehicle. En route Pt. was being ventilated via bvm and OPA. P110 BP-140's/90's SPAO2 low 90's via bvm and 15lpm RR~10

Long story short, all the doctors involved did their full physical assesment. I then went up to the pt and started doing my own(now that i could actually get near him) assessment. Got through the head/neck and started looking at the chest, low and behold, what do i find? A Flail Segment the size of a softball that everyone had missed. Needless to say the med students/docs werent too happy that they missed it, but the nurses and techs i was with gave me a big thumbs up. Just wanted to share because this made my night, and it just goes to show how important a detailed physical exam is without just paying attention to the obvious.
 
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Glad you found it .... but why did you not perform a secondary survey on this patient while on location or transporting?

Rather than an "attaboy" it screams "deficent assessment"
 
Sounded like he was doing a clinical in the ER, could be wrong and if I am then I agree with brown haha
 
04_edge said:
or, at least the ones in this area. I was doing a deep night clinical for school last night/this morning when this happened.

Hx-31yoM single car MVC head on collision at ~65mph into the dividing barrier in the HOV lane. On arrival the medics found the pt. unconscience GCSx3, pt restrained in the vehicle. En route Pt. was being ventilated via bvm and OPA. P110 BP-140's/90's SPAO2 low 90's via bvm and 15lpm RR~10

Long story short, all the doctors involved did their full physical assesment. I then went up to the pt and started doing my own(now that i could actually get near him) assessment. Got through the head/neck and started looking at the chest, low and behold, what do i find? A Flail Segment the size of a softball that everyone had missed. Needless to say the med students/docs werent too happy that they missed it, but the nurses and techs i was with gave me a big thumbs up. Just wanted to share because this made my night, and it just goes to show how important a detailed physical exam is without just paying attention to the obvious.
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+1 for skilled physical assessment not relying on radiology.
 
MrBrown said:
Glad you found it .... but why did you not perform a secondary survey on this patient while on location or transporting?

Rather than an "attaboy" it screams "deficent assessment"
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I think he was doing a placement at the hospital, so perhaps it ws the attending Paramedics that missed it. If it was the size of a baseball im guessing it would be hard to miss.

On a side note, treatment for a flail segment? i've been told you can wack a defib pad on the area to stabilise it. Would this work?
 
the_negro_puppy said:
On a side note, treatment for a flail segment? i've been told you can wack a defib pad on the area to stabilise it. Would this work?
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That's a new one to me.
 
04_edge said:
or, at least the ones in this area. I was doing a deep night clinical for school last night/this morning when this happened.

Hx-31yoM single car MVC head on collision at ~65mph into the dividing barrier in the HOV lane. On arrival the medics found the pt. unconscience GCSx3, pt restrained in the vehicle. En route Pt. was being ventilated via bvm and OPA. P110 BP-140's/90's SPAO2 low 90's via bvm and 15lpm RR~10

Long story short, all the doctors involved did their full physical assesment. I then went up to the pt and started doing my own(now that i could actually get near him) assessment. Got through the head/neck and started looking at the chest, low and behold, what do i find? A Flail Segment the size of a softball that everyone had missed. Needless to say the med students/docs werent too happy that they missed it, but the nurses and techs i was with gave me a big thumbs up. Just wanted to share because this made my night, and it just goes to show how important a detailed physical exam is without just paying attention to the obvious.
Click to expand...



And this is why you bare look at their skin . AND I'd take that + 1 and add it to the very same reason you listen to breath sounds on the skin, not over the clothes. Either one of those interventions would have found the flail segment. Did they listen to breath sounds at all? i'm sure the patient was on their back on the strecher... how could you not feel that moving ... even just under the shirt. Isn't the rapid trauma assessment where you run your hands over the entire body looking for DCAPBTLS?

Sorry just thinking out loud...
 
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8jimi8 said:
i thought i learned in i class that tx is internal splinting w a bvm?
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yes, for the breathing, however, stabilizing the fx reduces pain, and all the good that comes with it.

In the field, many techniques have come and gone for various reasons.

In the hospital, fixation is the treatment of choice.

Stands to reason, if fixation helps in house, it helps outside, the question is how well it is being performed. Back when ships were wood and men were iron, we used to take 1L IV bags to the site. It had great anecdotal effectiveness, then somebody decided that since providers weren't doing it properly, it fell out of favour. Technological devices and bandaging techniques were developed to fill the void. Eventually stabilization was dropped from US prehospital, but is still used other places.
 
8jimi8 said:
And this is why you bare look at their skin . AND I'd take that + 1 and add it to the very same reason you listen to breath sounds on the skin, not over the clothes. Either one of those interventions would have found the flail segment. Did they listen to breath sounds at all? i'm sure the patient was on their back on the strecher... how could you not feel that moving ... even just under the shirt. Isn't the rapid trauma assessment where you run your hands over the entire body looking for DCAPBTLS?

Sorry just thinking out loud...
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Some new providers (at all levels) are so afraid to hurt the patient they do not palpate forcefully enough.

I went through it, I see it happen all the time everyday. Sometimes even with experienced providers.
 
MrBrown said:
Yes we have been taught that for at least the last several years
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I would also like to know the theory behind stabilizing floating rib fragments by an adhesive on the skin.

Are we counting on 2 directional splinting then.... with a bvm and a defib pad being the opposing vectors?


Also... i'd like clarification on the internal splinting via BVM... When is the BVM necessary? only if the patient has severe pain? It seems to me having my breathing assisted by PAP would be very anxiety provoking.
 
X-Ray would have caught it or the patient would exhibit signs of distress that would have drawn attention to it but you did something that is being bred out of medicine; taking the time to do a thorough physical assessment BEFORE employing every machine in the (bank)book.

Sure, you deserve an "Atta Boy!" but what you did should be #1 on everyone's list, and NOT just when the environment is right.
 
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the_negro_puppy said:
On a side note, treatment for a flail segment? i've been told you can wack a defib pad on the area to stabilise it. Would this work?
Click to expand...

I dont think defib pads are X-ray translucent, i know ours have a metal conductor in them. i would not use anything that will obscure the X-ray or CT. here we are taught to tape a folded trauma dressing (10x30 in) and tape tightly over the flail.

isnt PPV discouraged in flail segments due to an increased risk of tension pneumo
 
I feel like in school, flail chest wasn't something that was adequately explained. We were taught bulky dressing over the flail. Can someone explain the actions behind this, and what this action is helping with? Is it just "splinting" or holding in place the flail so it is immobilized.
 
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socalmedic said:
I dont think defib pads are X-ray translucent, i know ours have a metal conductor in them. i would not use anything that will obscure the X-ray or CT. here we are taught to tape a folded trauma dressing (10x30 in) and tape tightly over the flail.

isnt PPV discouraged in flail segments due to an increased risk of tension pneumo
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while I see your point, i very specifically remember PAP splinting as the most current standard of care. (however i'm still looking for clarification on the indications of PAP in regards to a flail segment)

Folded ABD sounds more appropriate to me than a defib pad... plus... how good does that feel when you peel that sucker off? I believe that my instructor claimed that the latest evidence from ITLS as her reference... Can't remember ... that was last year and obviously she did not adequately answer my questions, nor did she actually allow me to visualize a reference on her claims.
 
i will check the ITLS book in the morning.
 
8jimi8 said:
while I see your point, i very specifically remember PAP splinting as the most current standard of care. (however i'm still looking for clarification on the indications of PAP in regards to a flail segment)

Folded ABD sounds more appropriate to me than a defib pad... plus... how good does that feel when you peel that sucker off? I believe that my instructor claimed that the latest evidence from ITLS as her reference... Can't remember ... that was last year and obviously she did not adequately answer my questions, nor did she actually allow me to visualize a reference on her claims.
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Indeed, the only reference to flail chest was from my boss who is an intensive care paramedic with 20+ years on the job, he mentioned defib pad to stabilise, Im not sure how it would work in practice.
 
Congrats on finding something that everyone else missed. Were there any distracting injuries that may have been the reason the paramedics missed the flail segment, or was it just the lack of an good assessment?

Now for me, the fact that this gentleman had a GCS of 3 and an SpO2 of 90% while being bagged, that would have been a major clue for me to inspect the chest as well as intubate the patient. I would have thought that they would have found the flail segment on the rapid trauma assessment, did they not even expose the patient?
 
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