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Huggybear
06-20-2008, 09:26
I am currently working in Shindand, Afghanistan (Herat Province) as a contract medic. (At the EMT-P level) This incident actually took place here several months ago. Given the talent pool present here, I'm interested to compare and contrast what my betters would have done against my own actions. In this way, I can hope to improve my own performance.

The scenario:

10 year old local male was out on the perimeter, herding goats as they grazed. One goat got away from the herd. The boy went to retrieve the animal, and as he approached the goat at an approximate distance of 10m, the animal tripped an old APERS mine.

The boy caught a fair amount of shrapnel. Most of it was concentrated in the abdominal area. One piece grazed him a few centimeters north of the hairline, dead center above the nose. No evidence of trauma to c-spine was observed. Objects consistent with shrapnel were palpable in the right upper quadrant (just under the skin), and the boy was guarding that area. Left side of the scrotum was avulsed, the insult was the size of a quarter. Smaller insults were noted to both thighs, bleeding was very minimal at those sites. Lacs present on both hands, superficial lacs to face and scalp.

Initial vitals were BP: 170/P, P:110 and strong, Pupils: EQ&R, Temp 98.5. Patient was alert and oriented to approximate time, date, place, and the nature of his injuries. Breath sounds were clean and clear bilaterally and I could hear no evidence of fluid present. Patient was initially combative secondary to abdominal pain. Patient stated no Hx of drug allergies to terp.

Secondary survey revealed no evidence of exit wounds nor that of further insults to the back of the child's body.

That ought to be enough to get us started. If anyone wants, I can post my patient care report at a later point. The kid lived, by the way. He had a fair-sized internal bleed, though, and we took him to the Spanish hospital at the ISAF base in Herat. The surgeons there worked on him for > 12 hours, though, and did a pretty stellar job fixing him up. I'm grateful to them for taking him.

Doc Dutch
06-21-2008, 23:30
HB,

Good case.

I would be thinking along the lines of,

1) Primary blast injury (Compressed shockwave damage) - bowel, lungs, ears and brain. Since this was outside the shock wave of compressed air would have dissipated.
2) Secondary blast injury (Shrapnel) - penetrating shrapnel gets everything including extremities, torso and head/neck
3) Tertiary blast injury (Patient being thrown back inches, feet, yards) depending on how the patient lands will mean injuries to that area, so think about spine, head and long bone injuries
4) Quaternary ( Miscellaneous) This is a trash can area of diagnoses like burns, asthma/COPD exacerbation from dust, chemical injuries, MI's, etc. Really represents those injuries not cause by the first three. Oh, think about crush injuries, too.

Some have started talking about quininary injures as well but I will investigate that for the site.

Start with the ABC's but if in the military and in the field with life-threatening hemorrhage from an extremity start with "C" then AB. Use a tourniquet. It may be that the limb will die, but the life will be saved. So, it is life or limb . . . always. Reassess "C" once again before going on to D and E.

Good job on saving him. I have seen presentations of those injured by suicide bombers in Israel and what bomb victims look like after presenting from those bombings. The injuries can be horrendous and more like, "Where do I start?" Start at the beginning, of course. This is where one's training kicks in . . . The fact that you saved this child's life lends major kudos to you as the first responder and the physicians caring for him after you rescued him.

Sincerely,

Dutch Matthews, MD