Moped Accident

[Bieber]

You are working with your paramedic partner in a small town just outside the big city of the county you work in when you are dispatched to a moped accident. It is around 2300, and you respond lights and sirens to the intersection of a street with no traffic on it where you find the driver of a moped lying supine in the street. The moped is about twenty feet away with no major damage, however from the truck you can see that the patient's face is covered in blood. You are first on scene but can already see the BLS fire units' lights in the distance.

Go!

[Hutsy]

You are working with your paramedic partner in a small town just outside the big city of the county you work in when you are dispatched to a moped accident. It is around 2300, and you respond lights and sirens to the intersection of a street with no traffic on it where you find the driver of a moped lying supine in the street. The moped is about twenty feet away with no major damage, however from the truck you can see that the patient's face is covered in blood. You are first on scene but can already see the BLS fire units' lights in the distance.

Go!

I'll give it a try.

Check his vitals and go from there, is he responsive? Possibly you'd need suction first and then provide respiratory assistance? Reacting/not reacting to pain? Check for cranial trauma... Put a collar on him and depending on his condition get him on a backboard.

Is that what you wanted?

[Bieber]

I'll give it a try.

Check his vitals and go from there, is he responsive? Possibly you'd need suction first and then provide respiratory assistance? Reacting/not reacting to pain? Check for cranial trauma... Put a collar on him and depending on his condition get him on a backboard.

Is that what you wanted?

As you approach the patient, he spits blood in both you and your partner's faces and yells "Get that f'**in' light out of my face!" He speaks appropriately, though he has blood in his mouth, but refuses to respond to your questions. Though he is not cooperative, he is not combative. You and your partner (who had not been wearing face masks) are covered from the waist up in blood spray!

Vitals as noted at this time are:

HR: 88

RR: 22

BP: 110/78

Visible injuries:

HEENT: Massive swelling to the zygomatic processes bilaterally with crepitus felt beneath, lacerations to his mouth and scalp which are bleeding steadily, swelling around his eyes prevents the patient from opening them. No deformity to any other bones of the skull noted. Copious amounts of blood in the mouth, which he continues to spit out without regard for his aim.

Neck: No JVD, retractions, tracheal deviation, subcutaneous emphysema, deformity to the cervical spine (assessing for pain meets the response "F*** you!")

Chest: Patient is wearing an intact T-shirt at this time. No abnormal chest wall movement is noted through the shirt, however.

Abdomen: See above.

Pelvis: Patient is wearing jeans which are intact. Pelvis is stable.

Posterior: Upon log rolling the patient, you lift up his shirt and note no soft tissue injury or deformity to the back or the chest wall or spine.

Extremities: Intact with no deformity noted. You do see a couple of abrasions to the patient's forearms, and his hands are covered in blood. Vascular and motor function are in tact, patient refuses to answer you when questioned about his sensation.

You suction the patient's mouth out and manage to clear it, however you note that it is quickly filling with blood once again. Fire crews arrive and begin to assist you with immobilizing the patient.

EDIT: Also! A bystander is on scene if you'd like to ask him any questions. And as another note, the patient's age is currently indeterminate due to the blood covering his entire face; however he is obviously an adult male.

Edited July 12, 2011 by Bieber

[FireEMT2009]

As you approach the patient, he spits blood in both you and your partner's faces and yells "Get that f'**in' light out of my face!" He speaks appropriately, though he has blood in his mouth, but refuses to respond to your questions. Though he is not cooperative, he is not combative. You and your partner (who had not been wearing face masks) are covered from the waist up in blood spray!

Vitals as noted at this time are:

HR: 88

RR: 22

BP: 110/78

Visible injuries:

HEENT: Massive swelling to the zygomatic processes bilaterally with crepitus felt beneath, lacerations to his mouth and scalp which are bleeding steadily, swelling around his eyes prevents the patient from opening them. No deformity to any other bones of the skull noted. Copious amounts of blood in the mouth, which he continues to spit out without regard for his aim.

Neck: No JVD, retractions, tracheal deviation, subcutaneous emphysema, deformity to the cervical spine (assessing for pain meets the response "F*** you!")

Chest: Patient is wearing an intact T-shirt at this time. No abnormal chest wall movement is noted through the shirt, however.

Abdomen: See above.

Pelvis: Patient is wearing jeans which are intact. Pelvis is stable.

Posterior: Upon log rolling the patient, you lift up his shirt and note no soft tissue injury or deformity to the back or the chest wall or spine.

Extremities: Intact with no deformity noted. You do see a couple of abrasions to the patient's forearms, and his hands are covered in blood. Vascular and motor function are in tact, patient refuses to answer you when questioned about his sensation.

You suction the patient's mouth out and manage to clear it, however you note that it is quickly filling with blood once again. Fire crews arrive and begin to assist you with immobilizing the patient.

EDIT: Also! A bystander is on scene if you'd like to ask him any questions. And as another note, the patient's age is currently indeterminate due to the blood covering his entire face; however he is obviously an adult male.

I will continually suction the mouth and once the BLS crew gets here get them to take over suctioning and get another set of vitals. I also want the bypasser to give me what he knows about what happened and if he knows this guy. I am suspecting a basal skull fracture. Do I note battle signs?

SInce the facial and mouth bleeding are the only ones noted I will get someone to control the bleeding on the head. Is the abdomen tender, nontender, rigid, or soft? I am going to also try and put on a nonrebreather on 15lpm if I can keep the airway open.

I will also get my partner to check on the other patient in the truck if he hasn't already. How far am I away from my nearest trauma center, and if its far off, is HEMS available?

Edit: I am also suspecting a spinal cord injury, possibly brown sequard syndrome. Do I note any ETOH on his breath? I will get one of my assistance to check a BGL as well. I will also get him in a C collar, backboard, and fully trauma packaged as well. How are my pupils?

Edited July 12, 2011 by FireEMT2009

[DwayneEMTP]

First I'm going to retreat and get PPEd for this guy. I don't know if he spit on me on purpose, but with continued bleeding in his mouth it's a fair bet that he is going to continue to spit all over the place. It's just what they do. No fire or volly or police are to approach this patient without a minimum of goggles, mask and gloves. No question that this will be reported later as an exposure so lets try and not have to look any dumber than necessary by having to report more than my partner and I. Also, I am going to report me and my partner for a failure to properly protect ourselves and suggest remediation with BBP (blood borne pathogen) education.

As you go back to your ambulance for PPE, what is the patient doing? How is he behaving? Is he trying to stand? Holding his head up or letting it droop? Trying to speak? Aware of the things going on around him?

What does the bystander say happened?

I want my partner to go ahead and set up the back of the ambulance for a trauma, which for me means meant two 14g IV set ups, one 10ggt, one blood Y, intubation kit set out but not opened, NRB mask attached and running, though it doesn't sound like we'll be using it on this fellow, stethoscope hanging on the grab bars, 3/12 lead ECG set out with patches applied.

While s/he does that I'm going to re approach the patient with the Fire guys with a C collar, long board, soft restraints, suction, and trauma sheers.

We need to get this guy naked, boarded/collared, (leaning on it's side to keep the airway clear) so that we can figure out how badly he's damaged and how we're going to manage it. From your above description is sounds as if we're dealing with mostly cranial trauma. It's possible other than O2, and lines that we may do little more than this depending on the answers to the above question regarding trauma centers. Either way, we need to be moving quickly, though intelligently, towards a higher level of care.

Dwayne

[FireEMT2009]

First I'm going to retreat and get PPEd for this guy. I don't know if he spit on me on purpose, but with continued bleeding in his mouth it's a fair bet that he is going to continue to spit all over the place. It's just what they do. No fire or volly or police are to approach this patient without a minimum of goggles, mask and gloves. No question that this will be reported later as an exposure so lets try and not have to look any dumber than necessary by having to report more than my partner and I. Also, I am going to report me and my partner for a failure to properly protect ourselves and suggest remediation with BBP (blood borne pathogen) education.

As you go back to your ambulance for PPE, what is the patient doing? How is he behaving? Is he trying to stand? Holding his head up or letting it droop? Trying to speak? Aware of the things going on around him?

What does the bystander say happened?

I want my partner to go ahead and set up the back of the ambulance for a trauma, which for me means meant two 14g IV set ups, one 10ggt, one blood Y, intubation kit set out but not opened, NRB mask attached and running, though it doesn't sound like we'll be using it on this fellow, stethoscope hanging on the grab bars, 3/12 lead ECG set out with patches applied.

While s/he does that I'm going to re approach the patient with the Fire guys with a C collar, long board, soft restraints, suction, and trauma sheers.

We need to get this guy naked, boarded/collared, (leaning on it's side to keep the airway clear) so that we can figure out how badly he's damaged and how we're going to manage it. From your above description is sounds as if we're dealing with mostly cranial trauma. It's possible other than O2, and lines that we may do little more than this depending on the answers to the above question regarding trauma centers. Either way, we need to be moving quickly, though intelligently, towards a higher level of care.

Dwayne

Who looked lke the dumba** that forgot the PPE and indangered all the crews around? THIS GUY!!!!! Thanks for commenting on the PPE Dwayne.

[Bieber]

FireEMT, you successfully suction out the patient's airway again, but I bet by now you know what's gonna keep happening, don't you?

Bystander states he is the patient's son and that the patient was consuming ETOH tonight (the smell of which is evident on his breath) when he drove down the street on his moped at sixty miles per hour and "wiped out". Oh, and he also mentions that the patient has a "heart history" and takes something that starts with "warf".

You note no battle signs, however the patient's face is still completely covered in blood. If you didn't know better, you'd almost say someone had torn off the epidermis on his face. You also successfully put on the NRB, and the patient is pretty much able to maintain his own airway, though he continuously turns his head to the side and spits or demands you suction him out. Once you get in the back of the truck, one of the fire guys offers to drive you in so you and Dwayne can dual medic it in the back. You are between fifteen and twenty minutes away from the nearest trauma center (closer to fifteen, thanks to the low traffic at night). HEMS is available.

Dwayne, GOOD PLAN! You get masked up and get your truck set up. The patient just lies there. He moves his head to turn it on the side to spit, and moves his hands around emphatically, even when you tell him to stop, but he's not combative--just uncooperative. When you try to tell him what happened and that you're there to help and take him into the hospital, he responds with a "F*** you!" and also rants about you and FireEMT being assholes, but otherwise refuses to answer any questions.

Once you get him in the back of the truck, you guys get him naked and note the following:

HEENT: Eyes are swollen shut, and you are unable to assess his pupils. The blood is making his eyelids too slippery to raise. Everything else is as before, and if not for the fact that you can see the rest of his body you would have no clue what color his skin was. Attempts at mopping up the blood seem futile, and his facial wounds continue to bleed slow but steady.

Neck: Same as before.

Chest: No soft tissue injuries or deformity of the chest wall noted. No subcutaneous emphysema.

Abdomen: Upper left and right quadrants are soft, with no bruising, distention or guarding. Upper and lower right quadrants are rigid, with bruising noted and guarding present.

Pelvis: Patient is incontinent of urine, no priapism or soft tissue injuries present. Pelvis is still stable.

Posterior: Same as before.

Extremities: Patient continues to demonstrate normal motor function with no gross deficits, vascular function is intact in all extremities. Significant bruising is noted to the right knee, and patient has multiple small abrasions on both lower extremities. Upper extremities are the same.

Also note patient's skin feels very cool to the touch and appears pale. You get your lines, and you're easily able to restrain the patient with the soft restraints. EKG shows a sinus tachycardia with no ectopy. With constant suctioning, you're able to maintain a patent airway.

Vital signs now:

HR: 100

RR: 24

BP: 108/76

[FireEMT2009]

FireEMT, you successfully suction out the patient's airway again, but I bet by now you know what's gonna keep happening, don't you?

Bystander states he is the patient's son and that the patient was consuming ETOH tonight (the smell of which is evident on his breath) when he drove down the street on his moped at sixty miles per hour and "wiped out". Oh, and he also mentions that the patient has a "heart history" and takes something that starts with "warf".

You note no battle signs, however the patient's face is still completely covered in blood. If you didn't know better, you'd almost say someone had torn off the epidermis on his face. You also successfully put on the NRB, and the patient is pretty much able to maintain his own airway, though he continuously turns his head to the side and spits or demands you suction him out. Once you get in the back of the truck, one of the fire guys offers to drive you in so you and Dwayne can dual medic it in the back. You are between fifteen and twenty minutes away from the nearest trauma center (closer to fifteen, thanks to the low traffic at night). HEMS is available.

Dwayne, GOOD PLAN! You get masked up and get your truck set up. The patient just lies there. He moves his head to turn it on the side to spit, and moves his hands around emphatically, even when you tell him to stop, but he's not combative--just uncooperative. When you try to tell him what happened and that you're there to help and take him into the hospital, he responds with a "F*** you!" and also rants about you and FireEMT being assholes, but otherwise refuses to answer any questions.

Once you get him in the back of the truck, you guys get him naked and note the following:

HEENT: Eyes are swollen shut, and you are unable to assess his pupils. The blood is making his eyelids too slippery to raise. Everything else is as before, and if not for the fact that you can see the rest of his body you would have no clue what color his skin was. Attempts at mopping up the blood seem futile, and his facial wounds continue to bleed slow but steady.

Neck: Same as before.

Chest: No soft tissue injuries or deformity of the chest wall noted. No subcutaneous emphysema.

Abdomen: Upper left and right quadrants are soft, with no bruising, distention or guarding. Upper and lower right quadrants are rigid, with bruising noted and guarding present.

Pelvis: Patient is incontinent of urine, no priapism or soft tissue injuries present. Pelvis is still stable.

Posterior: Same as before.

Extremities: Patient continues to demonstrate normal motor function with no gross deficits, vascular function is intact in all extremities. Significant bruising is noted to the right knee, and patient has multiple small abrasions on both lower extremities. Upper extremities are the same.

Also note patient's skin feels very cool to the touch and appears pale. You get your lines, and you're easily able to restrain the patient with the soft restraints. EKG shows a sinus tachycardia with no ectopy. With constant suctioning, you're able to maintain a patent airway.

Vital signs now:

HR: 100

RR: 24

BP: 108/76

Beiber,

Well I am definately gonnna start two 14 gauge IVs like you said. The patient seems to becoming more and more unstable and is gonna start decompensating soon due to the fact that is lower quadrants are rigid and his blood pressure has dropped over 10 points since we got the first set. I would set my lines TKO until his blood pressure really starts to fall faster. I will also do a 12 lead just to verify that he has not had a heart episode in another part of heart. I will also cover him up with a blanket to prevent hypothermia. What was the temperature outside? I would roll lights and sirens. How is my capillary refill? I would like a repeat of my vital signs every 5 minutes. Can the son give us anymore SAMPLE?

[Bieber]

Beiber,

Well I am definately gonnna start two 14 gauge IVs like you said. The patient seems to becoming more and more unstable and is gonna start decompensating soon due to the fact that is lower quadrants are rigid and his blood pressure has dropped over 10 points since we got the first set. I would set my lines TKO until his blood pressure really starts to fall faster. I will also do a 12 lead just to verify that he has not had a heart episode in another part of heart. I will also cover him up with a blanket to prevent hypothermia. What was the temperature outside? I would roll lights and sirens. How is my capillary refill? I would like a repeat of my vital signs every 5 minutes. Can the son give us anymore SAMPLE?

12 lead shows a sinus tachycardia, no ST elevation/depression or T-wave inversion or any other appreciable abnormalities. The temperature outside is in the high 80's, low 90's. Cap refill is about 3 sec. Son says his father is allergic to penicillin, has an unknown cardiac history, doesn't know any other medications besides something that starts with "warf". He doesn't know anything else aside from the fact that the patient's been consuming copious amounts of ETOH tonight.

[FireEMT2009]

12 lead shows a sinus tachycardia, no ST elevation/depression or T-wave inversion or any other appreciable abnormalities. The temperature outside is in the high 80's, low 90's. Cap refill is about 3 sec. Son says his father is allergic to penicillin, has an unknown cardiac history, doesn't know any other medications besides something that starts with "warf". He doesn't know anything else aside from the fact that the patient's been consuming copious amounts of ETOH tonight.

Well I am going to keep the blanket on him anyway because since he is bleeding in copious amounts and the rigidity in the stomach and the dropping BP means that he will become susceptable to hypovolemic shock and will become easily hypothermic. I am also gonna get another set of vitals.

FireEMT2009