Scenario

[EMTelite]

You have a 47 y/o pt that has fallen off his horse, he is not responsive to verbal or painful stimuli, as you approach you notice that his respiratioins are slow and deep he has a hematoma to the occiputal portion of the skull as well as battle signs and racoon eyes and a blown right pupil, your pt has absent breath sounds on the right side of the body as well as paradoxical motion, the pt has no distal pulses and cap refill is at 4 sec. the patient has bruising and distension to his abdomen and crepitus to his pelvic region


This is one my teacher gave me it was out of a ALS section but she decided to give it to me

 

[nomofica]

Well I would immediately break out the c-collar/backboard+headblocks and femoral/pelvic splints, high flow O2 via NRB or BVM, depending (not sure if by "slow" you mean >12 resps/minute or if resps are borderline). standby ready to assist breaths, if AED available set it up. standby ready to perform compressions (unless flail chest is present). call for ALS.

 

[EMTelite]

bascially exactly what i did

 

[nomofica]

what did your instructor say after the scenario?

 

[reaper]

That must be one dam big horse!

 

[nomofica]

That must be one dam big horse!

Hey, maybe he hit a few rocks before stopping. ^_^

 

[EMTelite]

I used a BVM at 15 L/min 1:5 ratio, I used a bulky dressing to fix the paradoxical motion, I used a hip sling to fix the hip, but the only thing that I didnt fix which was stupid on my part was the no distal pulses I forgot to verbalize that we were in rapid transport to the hospital but I knew I was just didnt verbalize it, I also checked and got CSF from the ear so I used the Halo test for that, I cspined which also helped the paradoxical motion with more pressure on the bulky dressing but yes she said that I did everything perfect except for the non verbalization of the transport because of the lack of distal pulses, and I also forgot my head beds on my c-spin *slaps forehead* although she said that I did better than most of her paramedic students which was cool but yea that was the gist of it and when I said deep and slow respirations the respirations were 4 breaths a minute which is characteristic of head trauma, I should have also used an air adjunt but decided not to based on the trauma to the head. But yeah she said that I did very well

 

[nomofica]

i guess i might've thrown in an OPA just to be safe, assuming no facial trauma if i were in that scenario. wouldn't touch the NPA...

but yeah, that's pretty much all I'd do, too.

 

[Mountain Res-Q]

Based upon the numerous severe injuries that you are describing, IMHO while your treatment seems pretty in line with my thoughts, the fact of the matter is that at the BLS level nothing we do is gonna matter. We can't fix cranial trauma, colapsed lungs, flail, crushed pelvis, lose of CSM. We can put a band aid on them, but this fella is gonna need a lot more than BLS or ALS can provide. The one thing missing from your treatments seem to me to be one of the biggies... transport desision. You mentioned rapid transport... and not just for the lose of CSM as their are a few other more important life threatening conditions that need serious help FAST. Considering the fact that this guy was on horse and is likely in a rural area (such as mine) requesting a Helo in additoin to a ground ALS unit would be pretty high on my list. Get them in the air ASAP so that you can quickly treat/transport/and turf to the flight crew. Now, helo might not be the wisest option for some folks in some areas, but if I translated this scenerio over to my county (or several other local counties) this woul have gotten a helo dispatched at the same time as ground crews as rapid transport to the clsest level 1 or 2 trauma center by ground from my county is a minimum of 1 hour (2-3 if they are more remote). Understading what your patient will likely need (cath lab, ortho, burn center, neuro surgeon) and where the closest one is is a big deal in potentially saving this guys life.

And I agree... was this a Clydesdale, because sticks and stones may break some bones, but a 10 foot fall sounds like it will kill y'll!

 

[EMTelite]

Actually I forgot to mention that my teacher placed the scenarion in an area that is around us where people bascially just ride their horses on the main streets and there is a trauma center near by so helo would honestly not be the best choice in my situation and i was not given what type of horse or anything the stuff i told you guys

 

[nomofica]

i would load&go, meet ALS en route, hand over for remaining transport to trauma centre.

 

[mycrofft]

Not bad for a well-contrived scenario.

I think the horse threw the pt, then came back and beat him with a tire iron.
To critique your teacher: skull hematoma is not a field diagnosis unless the scalp or face are laid back to reveal the skull and you are a neurosurgical professional. (Is that subdural or subarachnoid? Please not that again!). In my experience and that of my coworkers, we agreed that "battle signs" including periorbital and periauricular bleeds are not a rapid finding unless your pt's skull is toast. Or eggshelled. (Saw a fellow who shoved his C spine into his basal skull from a seventy foot fall and he didn't develop signs until hours later, probably too busy bleeding into his gut from the proximal femur fx's).
But it was a good scenario to try and demonstrate multitasking and a variety of skills. Good on you both.
Rancho Murietta?

 

[irish_handgrenade]

blown pupil, paradoxyl movement, absent breath sounds and no distal pulses...proper treatment on that one is: lots and lots of prayer cuz that guy aint livin unless maybe it happened outside the front door of a level 1 trauma facility.

 

[EMTelite]

I am in Murrieta California Riverside hour north of san diego and an hour south of LA

 

[mycrofft]

Familiar with Riverside, old SoCal myself until 1975.

Look up Sapphyre, she'sin the Inland Empire also.
I still say the horse assaulted that rider.

 

[Mountain Res-Q]

Look up Sapphyre, she'sin the Inland Empire also.
I still say the horse assaulted that rider.

"Attention all units... Attention all units... Standby for BOL... All Law Enforcement Units should be on the look out for a Budwiser Clydesdale answereing to the name of Butch. Suspect is described as being as big as a horse and carrying a crowbar. Possible ETOH. Suspect is wanted in conection with a possible gang related assault that left a man with spinal injuries, head injuries, a fractured pelvis, a collapsed lung, broken ribs, abdominal injuries, and possible loss of limbs. Suspect is considered hooved and dangerous... and may be carrying one of the victims limbs. Exercise caution and do not tease suspect with carrots or sugar and to not attempt to mount. <Dispatcher snickers here> Ending BOL at 2146 hours." :unsure:

 

[EMTelite]

^^ best ever:excl:

 

[A140160]

....And people wonder why I keep bringing up the idea of a ambulance mounted machine gun.........

 

[SemiMedic]

"Attention all units... Attention all units... Standby for BOL... All Law Enforcement Units should be on the look out for a Budwiser Clydesdale answereing to the name of Butch. Suspect is described as being as big as a horse and carrying a crowbar. Possible ETOH. Suspect is wanted in conection with a possible gang related assault that left a man with spinal injuries, head injuries, a fractured pelvis, a collapsed lung, broken ribs, abdominal injuries, and possible loss of limbs. Suspect is considered hooved and dangerous... and may be carrying one of the victims limbs. Exercise caution and do not tease suspect with carrots or sugar and to not attempt to mount. <Dispatcher snickers here> Ending BOL at 2146 hours." :unsure:

LMFAO!!!!! :lol::lol::lol::lol::lol::lol::lol:

 

[Seaglass]

"Attention all units... Attention all units... Standby for BOL... All Law Enforcement Units should be on the look out for a Budwiser Clydesdale answereing to the name of Butch. Suspect is described as being as big as a horse and carrying a crowbar. Possible ETOH. Suspect is wanted in conection with a possible gang related assault that left a man with spinal injuries, head injuries, a fractured pelvis, a collapsed lung, broken ribs, abdominal injuries, and possible loss of limbs. Suspect is considered hooved and dangerous... and may be carrying one of the victims limbs. Exercise caution and do not tease suspect with carrots or sugar and to not attempt to mount. <Dispatcher snickers here> Ending BOL at 2146 hours." :unsure:

Classic!

And while the scenario's pretty extreme, there's a reason cross-county riders need to wear their medical histories on an armband...