Another GSW scenario

[zeromedic]

Hey everybody, it's been a while since I've seen a scenario so I figured I'd put up a call I was on a while back. At the time I was an EMT-B (3 years), since then have gone on to EMT-P (2 years in 911 system), now EMT-I as a Deputy Sheriff/SWAT Medic.

Treat it as if it's presenting to you, whatever your level of training/current assignment is...I'm presenting it in civilian EMS.

Call comes out of a subject in a van with a GSW to the face. You are staging around the corner when your dispatch updates you that SO is saying it is safe to come in. You park your rig near the van as the Fire Dept. pulls in behind you, grab your gear and approach it. Looking in the window you see an approximately 40 y/o male in the front passenger seat slumped against the passenger side front window missing the lower half of his face. Copious amounts of blood coming from that area and you are clearly able to see air bubbling from where his mouth used to be. He has visible stippling on the skin around the very large wound, pale skin, and visible but slight rise and fall of chest. No other signs of injury but there is too much blood covering the front of his body to be sure. **A shotgun is visible on the driver's seat** As you are opening the door to access the pt, two SO Deputies start yelling at you to grab him and GTFO as they have located the suspect hiding in a nearby vehicle...how would you treat? What are your priorities? Trauma center was approximately five miles away for us...what if it wasn't?

[11Ber]

As an 18D, I'd eliminate the nearest threat before doing anything. As a EMT type...You see blood flowing, he has a pulse, and bubbles, he's breathing. Get him out of the vehicle, in the recovery position to try to allow him to maintain his own airway, no need to get cric happy. Try to locate any bleeders that aren't say the carotid or jug and try to clamp. If major vessel is involved... Have my junior or assistant start doing a sweep for other injuries or issues and get me some vitals. For conversations sake, lets say I have relative hemostasis. Relative cause some civilians don't mind bleeding if it isn't bright red. He's maintaining an airway in LLR and a trauma room is only 5 mikes out? Get IV access and medicate/resuscitate based on vitals.

[scooter]

If I were you I'd grab him and GTFO. Even with a total airway obstruction (which it doesn't sound like he has) he'll be ok for the 60 seconds it takes to drag him to cover somewhere. Both airway and bleeding are going to be an issue for this guy. It might be easier to cric him then pack his wound with either a hemostatic gauze or just plan gauze. While I'll agree that you dont have to cric every dude with a missing face it Does make managing bleeding a lot easier if you secure his airway first, and then pack to your hearts content. You can clamp if you can ID the vessel, but in a field setting with ugly GSWs that are badly bleeding I have never been able to ID a vessel. At that point he is probably stable enought to get into your rig and start transporting while you start dealing with the rest of his issues.

[adal]

Hmm. I had this guy. Tell SO to provide cover, pull the guy to cover. Intubate (which is fairly easy do to many interfering pieces missing like the pesky tongue) Pack the oropharnyx well, Go ASAP, IV's enroute. My Shotgun to face guy did fine leaning forward on the gurney with stuff dripping into a basin for 20min or so. We intubated him to fly the extra 30min to a level 1 trauma center. He's back on the street now.

[Sonic03svtCobra]

Cric to maintain or improve airway. allows my Jr to apply proper hemostasis without obstructing airway. then get him to ER asap while starting IV therapy.

[Retiredfire]

c-spine (asking for trouble from some ambulance chaser if you dont)
lma/ETI wont know unless you take a look
go to hosp
iv enroute
notify trauma alert

[Old Dog New Trick]

Based on what you posted... you have what appears to be a self-inflicted shotgun wound or a point-blank GSW (the shotgun in the drivers seat would be more indicative of attempted suicide without a current gun battle or reports to sustain that theory.) Why are SD's (SO) concerned about another person, was there a gun fight or a domestic (DV) who sought safety nearby and is not a threat? If there is still a threat why was it cleared? Use the fire apparatus as a shield if possible at this point - you are in the sh!t now.

Since you can't be certain the scene is still safe, you have a tough choice to make. Save the life and risk yours, or back off and possibly lose them. Protocol says you immediately back off to a safe position and wait for the all clear again. (Officer safety rules)

Medically speaking this one is easy... Intubate, pack and transport. C-Spine control is secondary to patent airway and controlling blood loss. Cricothyrotomy is not indicated as the patient has an airway it's just not secure - a tracheostomy is going to be the definitive treatment (Cric only if intubation fails). Packing the wound and wrapping the head around the endotracheal tube is faster and better than trying to identify and clamp individual bleeders. You will still have to pack, why clamp (unless you can see an artery), remember faces bleed a lot but not much blood is lost. If he blew out a carotid you probably don't have a viable patient when the scene is safe.

If you in fact decide to deedee mau with the victim and before treatment is begun, two person under arm carry face down to a safe location then treat as above.


(former 18D/EMT-P now LEO)