A try at some mental gymnastics. Suspension trauma.

[DwayneEMTP]

I've been looking into suspension trauma a bit since I've been back in country as I'v not looked at it for a while and there is a lot of harness work being done on this project. I was a little bit surprised by what I found..

This is meant to be an exercise in memory as well as physiology and treatment logic without reference. I'm asking that you participate, if you choose to do so, without referring to references of any kind. Bring only what's in your head, and we'll hopefully, reason out the correct answers together...(I know, we always seem to have someone that pretends that they just happened to know the exact correct answer from memory despite it matching up closely with the top Google searches, but lets do the best we can.)

If you're already positive that you know the best, most current scientifically supported answers then I ask that you participate in a way that walks everyone else through the logic instead of just stating the answers.

I would like this to be a mental exercise as opposed to, "What is the obvious right answer according to...X"

Ok, enough of that...

You are called to the scene of a 30 year old male that was working at a height of approximately 40 feet when his scaffolding collapsed. For about the first 10 minutes he was laughing and joking with his buddies about how cool it was to get paid to sit in a swing and look at the jungle, but about 3 minutes ago he stopped talking and seems to be sleeping.

The rescue team was quickly on scene, within 5 minutes, but didn't see any reason to call EMS as the patient hadn't suffered any trauma. When you arrive they have lowered him nearly to the ground, he is still in his harness in a sitting position, probably about 30 seconds from touching the ground where the rescue team has set up a collar and long board in preparation.

(For the record, if you're going to ask for hinky ECG readings, blood gasses, etc, I won't be able to provide them. Once I ran into things that surprised me when looking into this I stopped looking and decided to try and reason it out with everyone else. I have no idea as to the right answers here...)

In my opinion this is the most nerve wracking type scenario to participate in (No references, no studies allowed until after completion), as it asks you to hang your ass out and look ignorant because we all seem to believe that we're supposed to have remembered every single thing we've ever learned, even if we've never used it. But you can trust me when I tell you...looking ignorant isn't terminal. If it was I'd've been enbalmed years ago..

What would be your initial interventions? And very specifically, why?

Thanks for playing...I'm really looking forward to this...

[island emt]

On this call we are equipped with the oldest scanning tool known to EMS: The mark 1 eyeball.

What do you see when you walk up to the scene?

Was he in a full harness or sitting on a bosuns chair? Makes a big difference.

How big a drop till the safety life stopped it?

Pulse: regular or thready?

Respirations?

Skin color: face, arms,torso, legs

circulation to above?

pulses to extremities?

I'll reserve tx till we get some more info

[Arctickat]

Hmm, leg straps on the harness too tight? A restriction of venous return could reduce preload to a point of pericarditis resulting in a decrease LOC.

[scubanurse]

I had the same thoughts as Arctic... My first intervention would be to remove the harness, but maybe that wouldn't be right as the shift could cause arrhythmias from excess K in the lower extremities... If the harness was too tight then that was essentially acting as a lower body tourniquet.

Is there discoloration/edema to the lower extremities? Any sign of unstable pelvic fx? The jolt could cause a pelvic/hip injury depending on the type of harness and how it sits on his body....

Just some random thoughts on this case

[DFIB]

I would be initially concerned about the harness not being tight enough. Many workers wear their harness too loose because it is more comfortable but causes functional failure of the equipment in the event of a fall. I think the harness would be more likely to bind if it was originally loose because the weight is less evenly distributed.

Was the safety lanyard attached to a front or dorsal D-ring?

If it was attached to a dorsal D-ring at what level of the back is it positioned before and after the fall? Dis it have a slide capability?

Was the D ring positioned between the shoulders, at the nape of the neck or midsternum?

Did anyone see the fall? Was it a head dive that flipped him around, did he fall supine,prone or feet first?

I am leaning towards a cervical dislocation, herniation or fracture as well as a mild brain injury such as a concussion from the impact of the brain against the skull? All of these could be a result of whiplash.

Do you have any way of measuring ICP?

Hypertension?

Bradicardia?

Breath patterns?

Pupils?

Halo sign?

GCS?

[Curiosity]

Rhabdomyolysis would be my concern based on the mechanics. A decrease in venous return could explain the decreased LOC after the 10 mins.

Pulse, bp, rr, would expect arrhythmia when he is put on the board, IV, bicarb, bolus

[island emt]

Waiting on response from our senior citizen dwayne.

Have answers for how what & why

[DwayneEMTP]

We don't have access to vitals on this guy yet, we're still deciding whether or not we want to lay him down...No reason to suspect any kind of hinky trauma. He saw the scaffolding failing, just sat down into his harness and was laughing and joking up to the time that he became unresponsive.

Curiosity, why would you expect arrhythmias? How much bicarb would you like to give? When? Do you have any concerns about giving the bicarb? A bolus of what? How much? Only one type of fluid?

To the rest, do you want to lay this guy down to assess him? Why, or why not? As to his vitals, what would you expect to find in a patient that presented in this way, with this history?

I have been taught over and over that you ABSOLUTELY don't lay this guy down...looking for reasons for or against, as that would be the very first decision to be made, before considering other interventions...

[chbare]

What kind of safety setup was in place? Was there a setup capable of dynamically responding to loads or was it a simple static safety setup with static rope?

Edited December 24, 2012 by chbare

[DwayneEMTP]

This is a imaginary patient, so I'm not sure. Let's call it static but zero impact issues associated with fall and/or restraints. Trying to limit this to circulation/electrolyte issues, and their associated symptoms/pathologies/treatments.