Proper treatment....read on.

[whitewolf]

Hey guys,

While preparing for my Registration exam with another class mate, she asked me a question that I didn't know how to answer. The question has to do with a crtical patient in a rural setting.

Scenario:

You are in the oilfield making extra cash as an industrial first aid attendant. You are working at EMR/ First responder level, which means no IV's, no meds, etc. You are 2hrs plus away from town/nearest ALS by ground. No nearby air amb.

temps are around -35celcius. And you are in in your shack staying warm when a crew member from the rig runs over to grab you. He informs you that another crew member was pinned under a an approximately 2 ton load when a truck was moving around a piece of equipment.

You arrive on scene, pt's vitals are good, and he is concious but in a crap load of pain. He is pinned under the equipment with both legs around mid femur level. 911 is immediately activated, however it will be minimum 50 minutes before a charter helo with an als crew can arrive, due to no air amb in area.

The consultant on the site says that they have another piece of equipment that can be used to lift the object off the patient, then you can package him and meet ALS enroute.

Now the question is, with the times we are talking about, do you A: stay on scene until ALS can arrive, and treat for shock and constantly evaluate, along with trying to keep the p. wrm, or do you B: take the consultant up on his offer, have the equipment lifted, package, and run.

I've had several people I've talked to go either way on the subject. personally I would stay until ALS arrives due to no ability to replace fluid, as I'm pretty sure he'd bleed out as soon as the load was lifted.

What does anyone else think?

[SC MedicMike]

Yeah, I agree. If you lift the load before ALS arrives, you can pretty much cancel them because you've pretty much canceled the pt.

[crazycat7]

If he is pinned bi laterally @ mid femur level, he is FOR SURE to bleed out if u would attempt to lift the junk off and move him...keep him warm, treat for shock, monitor vitals... unfortunatley, ur a basic crew with basic equipment treating an ALS patient ! wait 4 ALS to arrive or else he is surely to bleed out from the femur Fx's and possible pelvic fx's as well !

[akflightmedic]

Here is some food for thought just to generate some more responses.

Lets look past the immediate care and focus on final outcomes.

If you lift the object and haul arse to meet ALS en route, how much is he actually going to decompensate during that trip? Will he lose a significant amount of blood and go into shock or arrest?

If you leave him pinned for 2 hours to a cold ground and when ALS arrives, then lift the object, have you done him any favors. He has now waited 2 hours and has a 2 hour trip to definitive care.

Also during that time of being pinned, did you consider compartment syndrome? Did you contribute to the patients final outcome actually being worse by leaving him pinned to the ground?

Please discuss.

[AnthonyM83]

I would wonder where exactly I would run to...the nearest hospital is two hours away, which is ample time to bleed out.

I'd rather he spend an hour building up compartment syndrome than two hours bleeding out without ALS (in the back of an ambulance? or how would you ground transport?)

I would keep him pinned and concentrate efforts on keeping him warm and calm with some oxygen. Use the time to get a medical history. Get workers to setup the equipment to free him when air transport arrives. Perhaps, allow him to make some phone calls to his family.

Is your nearest facility a trauma center? If not, could they get the appropriate resources there in that one hour, so you don't have to fly to a hospital farther out?

Ummm...ask for his insurance and billing info? jk jk

[akflightmedic]

There is NO air transportation available.

None....

Does this change any of your decisions?

[JPINFV]

Transport immediately with bilateral tourniquets. Sure, saline would help keep his pressure up, but your going to disrupt clotting and dump his hematocrit at the same time.

Also, wouldn't you be concerned about crush syndrome in a case like this?

[whitewolf]

for argument sake, the ground transport you have is an ETV (emergency transport vehicle) which has the bare minimum it needs to qualify (basically a few splints and bandages, and a full tank of gas) probably a suburban or the like. Nearest hospital is a local small town hospital. Nearest major trauma centre is approx 90 mins from town by fixed wing.

My question next question....a job like this with cf(clusterf***) factor this high......why no onsite ALS?

[JPINFV]

My question next question....a job like this with cf(clusterf***) factor this high......why no onsite ALS?

Same way whole communities get away with not providing paramedics. Money.

[akflightmedic]

Its cheaper to not have ALS and there are endless amounts of EMR willing to do the job for lesser rates.