sladey67 Posted May 10, 2007 Posted May 10, 2007 Ok, this is a real scenario that happened here in Sydney last winter. This was published in our service's Clinical News Vol. 5 Issue 1 Feb '07. I was not present at this job but will reproduce/paraphrase it here for your interest. It is a cold, wet and miserable early winter morning and you are responded to a patient fallen outside a block of units. Nothing unusual here, until further information reveals the patient has fallen from a 2nd storey balcony and has become impaled on a metal fence ... ok we're awake now! 2 cars are responded, a primary care (BLS) vehicle and an intensive care (ALS) vehicle. On arrival you find a slightly built female in her mid 50's, who was lucky enough to have been found by a now very animated neighbour, only minutes after she had fallen from a balcony about 9 metres from the ground. The trajectory of her fall can be traced by the many broken branches of the large tree through which she has plummeted, landing on the fence. Despite the rain, the cold and the time of day, this neighbour heard her fall and got out of bed to investigate, where he found her impaled on two metal poles of the fence surrounding the unit block. She is still in this position on your arrival, with one pole penetrating her right anterior chest and the other her left antero-axillar chest. Neither pole has exited through the other side of her chest, but the pole through the right side of her chest could be palpated under the skin around her right scapula. Her entire weight was still hanging from the poles with only her toes just touching the ground. Her head had fallen forward occluding her airway. Her observations are: GCS = 3, pulse = 0, respirations = 0, pale, cyanosed mucosa, monitored in an idio ventricular rhythm at 40/min. What would you do? 1. Do you call the patient deceased? They have had a considerable fall, is currently in cardiac arrest following trauma, and is still impaled on the fence. (I am unaware of other services protocols but this is permitted under ours). 2. Do you try and treat her while on the fence? Call rescue to cut the poles and transport with them insitu. 3. Do you attempt to remove her from the fence and treat/transport urgently? Going strictly by protocol (ours), impaled objects should not be removed unless intra cardiac and ecm is required! The clock is ticking .... what would you do? Ok, have fun, I'll be back in a few days or so to outline the course of action the officers involved took. You may be surprised what happened!! 8)
Just Plain Ruff Posted May 10, 2007 Posted May 10, 2007 ok this is a toughie but here's what I'd do I'd determine how far out fire was for the tools to cut the poles. I'll ascertain if since shes a trauma code and you cannot kill her any deader, whether the group of us can lift her off the poles and begin cpr. If we can do that then I'll pull her off and start cpr and boogie to the hospital. If I cannot pull her off the poles and fire is more than 10 minutes away then see below - I'll call medical control and tell them what's up. I'm more than likely gonna call her right there because SHE'S DEAD! 0 pulse + 0 resp + a 10 minute response time from fire EQUALS a dead patient.
Ridryder 911 Posted May 10, 2007 Posted May 10, 2007 Dead.. and no I don't hook up traumatic arrest on the monitor. R/r 911
AZCEP Posted May 10, 2007 Posted May 10, 2007 To paraphrase Monty Python, "She has ceased to be, she's an ex-person." There's no clock ticking for this one. She's dead, wait for the law enforcement to secure the scene, don't disturb anymore than absolutely necessary, return to service.
Just Plain Ruff Posted May 10, 2007 Posted May 10, 2007 somehow I think the medics on the scene did something more in depth than just calling her dead. here is how I see it playing out patient on skewers patient removed from skewers patient placed on ground awaiting coroner Patient takes breath they work the patient and she survived
sledogg1 Posted May 10, 2007 Posted May 10, 2007 It's a traumatic arrest, but would be interesting digital intubation, epi, atropine , pace, dopamine or epi gtt. Thats if you had 20 mins on your hands.
brock8024 Posted May 12, 2007 Posted May 12, 2007 I would call her as I found her. Like somone else said, she is dead and it took 10 mins to get there. I would call my ER doctor and get the ok to do so. I mean you could pull her off the poles and work her ,but if the poles are keeping something from bleeding and you pull her off what good are you doing anyway. If you wait for fire to get there to cut her how are you going to do good CPR while she is on the poles? I know you can start a line and push drugs and intubate her , but how are you going to get the drugs to circulate?
brock8024 Posted May 12, 2007 Posted May 12, 2007 I would call her as I found her. Like somone else said, she is dead and it took 10 mins to get there. I would call my ER doctor and get the ok to do so. I mean you could pull her off the poles and work her ,but if the poles are keeping something from bleeding and you pull her off what good are you doing anyway. If you wait for fire to get there to cut her how are you going to do good CPR while she is on the poles? I know you can start a line and push drugs and intubate her , but how are you going to get the drugs to circulate?
ERDoc Posted May 12, 2007 Posted May 12, 2007 Personally, if I were on the scene I would break out my buff bag. I'd use the acetylene torch in my bag to cut the fence. Once I had her on the ground I would pull out my thoracotomy tray and crack her chest right there on the ground in the mud and rain (yeah, I'd go all Doug Ross on ER style). That's just me. If I took the call at medical control I would tell them to pronounce. I'm going to guess that since this is posted here there is some sort of twist to it. She was probably eating an apple, which she choked on. In an attempt to give herself the heimlich she slammed herself into the railing on the balcony. Getting nervous and overly aggresive she hits the railing too hard and goes over leading to her current predicament. The medics roll up and lift her off. They find the apple and pull it out. She then begins to breathe on her own. One of them puts his hand in her chest to thwart any bleeding that may be trying to take her life. Sorry about the ramblings, but it is 3am and has been a very busy Friday night.
sladey67 Posted May 12, 2007 Author Posted May 12, 2007 Ok, so lets look at the options in my original post, and then lets see what happened ... Option 1 - She's dead seems pretty popular, and honestly if i'd rocked up on scene to find this I'd probably have pronounced her. Not to many cardiac arrests following trauma make it as we all know. Option 2 - Treat her insitu. Not really an option is it? She's in arrest, has no circulation and no way you can do effective cpr with her in this position. Unknown length of time for rescue and even if they were close by her prognosis is v. poor with so long without circulation. Option 3 - Remove her from the fence and transport urgently ... The crews on scene decided with option 3. Their rationale - the patient was already in cardiac arrest and they were not going to make her condition any worse by removing her from the fence. The 4 officers (2 units on scene remember) lifted her off the fence in one smooth movement, while supporting her head and placed her onto their stretcher. Then, the most unexpected turn of events began. Just removing her from the fence and basic airway care (jaw thrust without head tilt for spinal precations) and the patient had the return of a spontaneous palpable carotid pulse of 100. Total scene time was 5 minutes. En-route the patient was intubated, cannulated, C-collar applied, she began to breath on her own with a respiratory rate of 8/min, her perfused improved to pink. Full patient assessment en-route revealed: - Absence of visible trauma to head, face and neck. - Penetrating wounds to right anterior chest and left antero-axillar chest with surrounding contusions and minimal blood loss. - Breath sounds noted to be decreased bilaterally. - Abdomen was soft and non-distended. - Limbs appeared intact. - GCS remained at 3 throughout, no gag during intubation. - Blood pressure was not obtained, they didn't seem to have enough hands/time, however palpable brachial pulse easily felt. - Monitored in sinus tachycardia at 100. - Pupils equal and reactive. - SaO2 not obtained - again other priorities and pt was receiving 100% via the ETT. - Hartmanns tkvo. Transport time 10 minutes to hospital. So would you still call her deceased?? Gives you pause for thought hey. Following full x-rays, bilateral chest drains, infusion with 11 units of packed cells, 2 units of pooled platelets and 6 units of fresh frozen plasma in the ED, on admission to the ICU her total injuries were found to be: - C4/C7 stable #'s of all transverse processes - Left pneumothorax - Right haemothorax - # right clavicle - # right 1st and 2nd ribs - # left 1st rib - Liver contusion - Adrenal haematoma. The only surgery she underwent was an open-reduction internal-fixation (ORIF) of her right clavicle. She was extubated 1 week later and when visited 10 days post fall she was happily feeding herself breakfast. She is neurologically completely intact but (probably fortunately) has no recall of the fall itself. She was on fentanyl PCA. She made a full recovery and was later discharged. Her only problem a decreased range of movement to her right arm following the surgery to her clavicle. You just never know! 8) True story! 8)
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