MVA with entrapment, Pregnant Driver.

[Two-Speed]

This is a secenerio that came up during extrication practice.

You are on your way back to your base from a transfer along a stretch of highway that is not heavily travelled or populated when you are called to check out a reported car accident. , the nearest volunteer Fire Department with extrication equipment is possibly 6 minutes away in the nearest town. The car--a 2-door coupe--is against a rock cut with the driver's side blocked. Pt is complaining of pain in lower abdomen, and informs you that she is 8months pregnant and she thinks her water may be broken.

 

[EMSLaw]

I'm certainly hitting out the FD and PD, and probably ALS. What's the scene situation? Other than the car being pinned against the rocks, am I able to access it? Do I need some sort of heavy or technical rescue because they're at the bottom of a ravine? Is the rockface unstable, and going to come down on me and the patient at any minute?

Try before you pry - so, if the drivers door is not accessable, I'll try the passenger door to access the patient. This is clearly a rapid takedown scenario on the c-spine, so if I can gain access through the other door, I'd probably try to find a way to get her onto the backboard and out through the passenger door, then into the ambulance where I can evaluate her and prepare for delivery if necessary. Incidentally, since she's talking I've got A and B of my ABCs, and I'd look for and take care of any life-threatening bleeds. If the scene is dangerous - because all of a sudden it looks like the rocks are going to come down on my head, or the car starts to smoke, she's getting yanked out, and forget c-spine.

Is she pinned, though? If she is, we have bigger problems, and there's probably no choice but to wait for the FD to arrive and turn the coupe into a convertable. Try to find out if she's had other children, how long labor was, etc. There's a possiblity of miscarriage given the level of trauma, but it'd be nice to know if I have at least a little time.

All in all, if this happens, you're in the s**t.

 

[Two-Speed]

Is she pinned, though? If she is, we have bigger problems, and there's probably no choice but to wait for the FD to arrive and turn the coupe into a convertable. Try to find out if she's had other children, how long labor was, etc. There's a possiblity of miscarriage given the level of trauma, but it'd be nice to know if I have at least a little time.

She's up against the steering wheel, if you have a come-along you could pull it back, otherwise you would be waiting for the fire department to arrive with the Jaws and Ram since hydraulics are required.

 

[atropine]

Well the good news is we have extrication on our engine and it is also als along with and als ambulance with dual role firefighter/medics so this pt would b out in no time and on her way to the appropriate hsopital.

 

[bunkie]

If shes completely trapped I guess all you can do is give her O2 until someone gets her out. You could also feel her belly for contractions. If her water has broken, those contractions will be pretty strong.

 

[rescuepoppy]

We had a case like this several years ago. The woman was pinned by a truck not a rock. The outcome was not good in this one. All you can do in the field is mainly concentrate on keeping the mother alive, if you lose her you lose both. Give rescue a kick-start and unless you are extrication trained try to stay out of the way while still maintaining patient care. O-2 and a couple of large bores would be a good idea, even if you are not flowing a lot of fluid at least run kvo so you will have access if needed.

 

[akflightmedic]

This is clearly a rapid takedown scenario on the c-spine, so if I can gain access through the other door, I'd probably try to find a way to get her onto the backboard and out through the passenger door, then into the ambulance where I can evaluate her and prepare for delivery if necessary.

Are you going to release/remove c-spine precautions if she does start to deliver?

 

[akflightmedic]

If shes completely trapped I guess all you can do is give her O2 until someone gets her out. You could also feel her belly for contractions. If her water has broken, those contractions will be pretty strong.

Are you always going to be able to feel the contractions? How would you differentiate contractions from the mother tensing up due to pain, unless you simply ask her and then you really do not need to feel for them.

Does the water breaking mean that contractions will be present?

Can water break from trauma, therefore no contractions are yet present due to the body not being ready to deliver?

 

[EMSLaw]

Are you going to release/remove c-spine precautions if she does start to deliver?

That depends where we are in the whole process. If she's on the backboard already, I'd have to release her below the waist in order to allow her to deliver. But I really don't think there's a choice - if the baby is coming, it's coming, and it's not going to wait for my c-spine precautions.

 

[Aidey]

One easy thing to do is see if the seat slides back any further. You can always KED her and then tip the seat back all the way too.

 

[akflightmedic]

That depends where we are in the whole process. If she's on the backboard already, I'd have to release her below the waist in order to allow her to deliver. But I really don't think there's a choice - if the baby is coming, it's coming, and it's not going to wait for my c-spine precautions.

So you think it is appropriate if she starts to deliver to only release her below the waist?

Is this doing more harm than good for the two patients?

 

[akflightmedic]

I have to go get on a plane to Ohio now and will not be online for a while, however I figured I would go ahead and post the rest of my questions to lead you down the same path as me.

I like asking questions to assist with those critical thinking development skills, I am not just being an arse.

Anyways, why do we not lay a pregnant woman flat on a backboard without tilting it?

Now with that answer in mind, if we free a woman from the waist below, can we still tilt it? If we do tilt it, do we compromise her cspine?

So if it is going to be compromised already, do we do it to start with?

 

[EMSLaw]

So you think it is appropriate if she starts to deliver to only release her below the waist?

Is this doing more harm than good for the two patients?

I think we can all agree that we can't leave the mother fully restrained to a LBB at the time of delivery, for obvious reasons.

While it is preferable for the mother to sit up during childbirth, to assist in bearing down, it is possible for her to deliver supine, even if that makes a more difficult delivery.

I think it's a valid question as to whether to act of childbirth would cause a compromise to c-spine no matter what we do. But at least by securing the head and shoulders, theres the possiblity of preventing aggrivation of any high fractures that could be life-threatening or cause paraplegia.

 

[reaper]

What happens when you lay a 37 week pregnant woman supine?

How is this fixed, if you have her on a LSB?

What happens when you do the fix, with the lower portion of the body free and the upper portion still attached?

 

[EMSLaw]

What happens when you lay a 37 week pregnant woman supine?

How is this fixed, if you have her on a LSB?

What happens when you do the fix, with the lower portion of the body free and the upper portion still attached?

Gee, this is a fun game. You don't lay them supine because you want to prevent pressure on the inferior vena cava. This is generally fixed by placing a blanket or towel under one side of the board to tilt them slightly to the left. This won't work if the lower part of the body is free. The board will have to be flat on the stretcher.

I don't think there's any perfect solution here. If someone thinks there's an alternative to what I proposed, then that's fine - one possiblity is of course just to let the mother sit up and deliver normally. But in the absence of a way to rule out spinal injury, or in the presence of an actual spinal injury, this is likely to lead to further spinal injury.

 

[Saytuck99]

With no real world experience yet, simply an EMT certification recently received I would suggest this:

Assuming patient removal possible and potential imminent birth with just the facts presented:

KED to extricate, straight onto stretcher, free lower half and secure in fowlers position? Just a thought, It would secure C-Spine, allow for freedom for quick exam for imminent birth, if necessary and would slightly relieve any pressure on in IVC. I don't know, trying to get the best of both worlds...

However, if I could determine whether birth was imminent prior to extrication would completely change my answer. I think, being a witness to the birth of my own child, that the mom in the vehicle, once presented with the options would refuse any treatment which would jeopardize her baby, which may make immobilization irrelevant.