Another Scenario..

[linedoc]

I just got a job as the senior medic on a MiTT team. It's just me and my soldier, a soup can of Iraqi medics and sometimes an Iraqi doctor. I am writing this following sofmed's lead as this type of PT is becoming increasing popular in my AO. Multiple injuries with the capper being severe head injury. I have seen a lot of trauma, but not so much the head injuries. Now that I have a chance I would like to hone my Tx skills in this area, starting with an evaluation of my most recent encounter.

We just happen to be out and about when the IA brings over one of their troopers shot all to hell, he needs immediate evac, we just can't with what we got. I begin by trying to elicit a response, PT is unresponsive.

On initial assessment I notice that PT still bleeding profusely from armpit and ill-placed CAT TQ on L leg. I had my medic place a SOF-T on the leg and I packed the armpit using the arm as leverage to apply pressure. Then I assessed airway, placed King LT, SpO2 @ 95%, R: 10 / full deep breaths, checked pulse- tachy @ L radial and carotid. Gained access via FAST 1, started line NS TKO.


Head: Large lac over R eye found, + crepitus around lac, neg battles sign, no visible brain matter, no spontaneous eye opening, R eye pinpoint and fixed, L eye reactive to light. Swelling around R eye.

Neck: Neg JVD, neg TD, no step offs

Chest: GSW to L chest, mid clavicular just inferior to the clavicle, GSW to R chest mid axillary just superior to 5th ICS, neg crepitus in chest, placed tegaderms on entrance wounds, lung sounds surprisingly clear bilat, chest rise equal bilat.

Abdomen clear of any injuries or abnormalities.

Pelvis/gent. clear.

Legs: L leg: multiple frag injuries, large chunk (50%) of calf missing exposing shattered tib/fib, TQ controlled. R leg entrance wound to upper thigh, not bleeding w/ distal pulse

Arms: L arm multiple frag wounds, packed and wrapped. w/ pulse, R arm: entrance @ deltoid, exit in armpit no distal pulse.

Rolled PT, assessment of back noted no injuries, no rectal bleeding, no spinal abnormalities.

Rolled him back over and worked top to bottom, started w/ airway, still breathing spontaneously, still unresponsive, pulse still tachy, no change in eyes, no new findings as I move down, chest still equal bilat, becoming worked down to the L leg, bandaged and splinted with my high speed MAJ Compton balsa wood contraption. R leg has pulse, bandaged entrance wound.

About this time the evac guys got there so we quickly package the PT as best we can and get him out.

Despite the very low GCS, we still worked on this guy keeping him going till the MEV got there. Please feel free to evaluate my handling of this PT. I know I have much to learn and I would really like to know if my interventions were on point for this type of PT.



I also think this would be a good idea for the medics here to continue to post these situations as they happen. It could be a great learning experience especially with the knowledge and experience base here.

[sofmed]

I just got a job as the senior medic on a MiTT team. It's just me and my soldier, a soup can of Iraqi medics and sometimes an Iraqi doctor. I am writing this following sofmed's lead as this type of PT is becoming increasing popular in my AO. Multiple injuries with the capper being severe head injury. I have seen a lot of trauma, but not so much the head injuries. Now that I have a chance I would like to hone my Tx skills in this area, starting with an evaluation of my most recent encounter.

We just happen to be out and about when the IA brings over one of their troopers shot all to hell, he needs immediate evac, we just can't with what we got. I begin by trying to elicit a response, PT is unresponsive.

On initial assessment I notice that PT still bleeding profusely from armpit and ill-placed CAT TQ on L leg. I had my medic place a SOF-T on the leg and I packed the armpit using the arm as leverage to apply pressure. Then I assessed airway, placed King LT, SpO2 @ 95%, R: 10 / full deep breaths, checked pulse- tachy @ L radial and carotid. Gained access via FAST 1, started line NS TKO.


Head: Large lac over R eye found, + crepitus around lac, neg battles sign, no visible brain matter, no spontaneous eye opening, R eye pinpoint and fixed, L eye reactive to light. Swelling around R eye.

Neck: Neg JVD, neg TD, no step offs

Chest: GSW to L chest, mid clavicular just inferior to the clavicle, GSW to R chest mid axillary just superior to 5th ICS, neg crepitus in chest, placed tegaderms on entrance wounds, lung sounds surprisingly clear bilat, chest rise equal bilat.

Abdomen clear of any injuries or abnormalities.

Pelvis/gent. clear.

Legs: L leg: multiple frag injuries, large chunk (50%) of calf missing exposing shattered tib/fib, TQ controlled. R leg entrance wound to upper thigh, not bleeding w/ distal pulse

Arms: L arm multiple frag wounds, packed and wrapped. w/ pulse, R arm: entrance @ deltoid, exit in armpit no distal pulse.

Rolled PT, assessment of back noted no injuries, no rectal bleeding, no spinal abnormalities.

Rolled him back over and worked top to bottom, started w/ airway, still breathing spontaneously, still unresponsive, pulse still tachy, no change in eyes, no new findings as I move down, chest still equal bilat, becoming worked down to the L leg, bandaged and splinted with my high speed MAJ Compton balsa wood contraption. R leg has pulse, bandaged entrance wound.

About this time the evac guys got there so we quickly package the PT as best we can and get him out.

Despite the very low GCS, we still worked on this guy keeping him going till the MEV got there. Please feel free to evaluate my handling of this PT. I know I have much to learn and I would really like to know if my interventions were on point for this type of PT.



I also think this would be a good idea for the medics here to continue to post these situations as they happen. It could be a great learning experience especially with the knowledge and experience base here.

Sounds like you had your hands full. I know many of the young medics here did not know about opposing pressure using the arm/limb as pressure to stop the bleeding in the armpit like that. I run scenario based training on a regular basis and throw that one in quite often when we have new boots on the ground. Gets them every time.

I appreciate your post. It was a learning experience. Now I have a couple more ideas/tools in my kit.

I hope we can keep this going. It's most definitely good for us all.

Cheers!

Mick

[linedoc]

Thanks, the opposing pressure was taught to me much like I teach it to my soldiers, much like you teach it to yours. It's not in the school-house so it's up to the NCO's to pass these pearls down.

I saw that wound and was actually excited to put the technique to work. It was actually the first time it was presented in such a clear cut manner.



I have a set of CDs retrieved from TCMC. On them is a plethora of bandaging, splinting, and tq skills discussed and demonstrated. It's a great tool that I use to get the idea juices flowing in the new guys and to refresh my ideas from time to time.


On a further note, a little past my echelon but what are the chances of someone coming back from an initial GCS of say 3 or 4? Also, what are some key Tx to help this type of PT down the road? My gut tells me chances are not so good, but I am curious.

[sofmed]

On a further note, a little past my echelon but what are the chances of someone coming back from an initial GCS of say 3 or 4? Also, what are some key Tx to help this type of PT down the road? My gut tells me chances are not so good, but I am curious.


I have my GCS right in front of me and I'm getting more info directly from a trauma nurse sitting right beside me at the moment. Great guy!

I can say that in my experience of the casualties I've dealt with having a score of 3 to 4, the prognosis of survival was not good. At this level they don't even withdraw from pain...say a deep fingernail/toenail-bed roll with a pen...between 5 and 7 I've seen withdrawal from pain, and the survivability was increased, but everything is going to be scenario and injury based as well as how quickly can you get them to an advanced care facility?

The trauma nurse is saying that at a score of 5 or less intubate immediately. Usually they will expire within a matter of hours or days, at a 3 or 4, depending on the expertise of the medical team taking care in ICU, etc. Hours or days.

Everyone's physiology is so different and with the LN's they're already so dehydrated and under nourished, etc. they go into shock a whole lot faster than one of us would from a comperable wound(s).

I dealt with a strangulation case not too long ago...No pulse, had to intubate immediately, pink frothy sputum coming out the combi., and this guy was at a 3. NO RESPONSE whatsoever. I don't remember what the SPO2 was, just that it was way too low for a live person. We performed all the right steps immedately beginning CPR, all the way to the hospital which took all of 5 minutes. If you've ever been to Bucca, you'll understand. I personally performed chest compressions on this guy for at least six or seven minutes before handing off to trade places and bvm.

Short of it, 20 minutes later after numerous meds and three compression switchoffs, the Doc called it. Strangulation was his only injury too. Multiple injuries complicate things way off the charts.

Beyond that, I'll wait for someone else with more experience and expertise to put their .02 in because I don't want to sound like a know-it-all here.

Little help here, guys.