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Sdiver
05-30-2013, 22:55
Okay, time to put your thinking caps on.
READ all the information given, don't just focus on the wound in the picture.
Make sure you give a reason for all your actions.

You respond in a Rural area for a "Man laying on the side of the road" on a stormy evening, raining like crazy. You make it on scene at 0313 hours. Upon arrival you find this 20ish year old white male lying face down on the roadside. Responsive only to deep painful stimuli. As you role him you find a black handgun lying underneath him. Breathing appears labored. You cannot obtain any information from him.

You find a bag of what looks like Potpourri falling out of his jacket pocket. Due to weather you only have 1 First Responder on scene, no other available. The small local Sheriff's dept is tied up on a standoff 15 miles away, closest State Police or LEO backup is 20 min away. Closest Level 2 is 10 min away, Level 1 is 15 min.

You HAVE NO OTHER RESOURCES TO RESPOND!!!!

HEENT- Burns around lips
Pupils- 2 mm slow
Neck- Slight JVD, Trach Mid line
Thorax- as you see it.
Lungs- Decreased on left, rails in left lower
Back- Clr
Abd- Appears normal
Pel- Clr
Extrem- Burns to fingers, Cyan in nail beds, nothing else noted
Neuro- Unable to assess

BP- 65/42
HR- 48
RR- 08 Shallow
FSBS- Not assessed
SpO2- 76% on NRB15L via First Responder

What is your treatment plan going to be?
How will you handle the firearm issue?
Any Special concerns or precautions?

Trapper John
05-31-2013, 06:18
Dx: Hypovolemic shock caused by GSW L mid thorax. Rx: Seal exit wound. Start IV Dextran/NS wide open. Drive to Level 2 trauma center. Watch for tension peumo en route. May need a chest tube. Assist breathing with ambu bag and O2.

Manner of Injury: This is not a self-inflicted wound! Suspect that this is related to the stand-off. Patient may be an under-cover DEA or local LEO. Gun is probably his. Carefully bag gun for evidence. Burns on fingers and mouth suggest torture prior to attempted assassination. Keep the potpourri as evidence along with the bagged gun.

Call in the GSW to the Level 2 trauma center (thoracic surgeon on duty). Have them prep an OR immediately. Watch for cardiac arrest en route.

After thought: Don't know if it's permitted in civilian practice, but if this guy were my patient I would try to clamp the bleeders through the exit wound before sealing the chest.

Trapper John
05-31-2013, 06:40
Question: Can you describe his heart sounds? I'm curious about the JVD distention and suspect cardiac tamponade. The force of the bullet may have damaged the myocardium. Obviously missed the heart or we wouldn't be discussing the case. I suspect the shooter was using a low velocity low caliber round. Don't know if I would attempt to treat cardiac tamponade in a moving vehicle on a rural road though.:D So the question is sort of moot.;)

bandaidbrand
05-31-2013, 06:45
As an aside, are chest tubes sometimes in the scope of practice for paramedics? My googlefu shows a lot of "assist only" ones, and I've never worked in a civilian setting.

bandaidbrand
05-31-2013, 06:50
Question: Can you describe his heart sounds? I'm curious about the JVD distention and suspect cardiac tamponade. The force of the bullet may have damaged the myocardium. Obviously missed the heart or we wouldn't be discussing the case. I suspect the shooter was using a low velocity low caliber round. Don't know if I would attempt to treat cardiac tamponade in a moving vehicle on a rural road though.:D So the question is sort of moot.;)

I think you have to evaluate the heart sounds after treating the hemo/pneumo though, could be other reasons for diminished heart sounds. The level 2 is so close anyways!

Paper then plastic the gun in case there's someone else's grubby hands on it.

PedOncoDoc
05-31-2013, 06:52
Dx: Hypovolemic shock caused by GSW L mid thorax. Rx: Seal exit wound. Start IV Dextran/NS wide open. Drive to Level 2 trauma center. Watch for tension peumo en route. May need a chest tube. Assist breathing with ambu bag and O2.

Manner of Injury: This is not a self-inflicted wound! Suspect that this is related to the stand-off. Patient may be an under-cover DEA or local LEO. Gun is probably his. Carefully bag gun for evidence. Burns on fingers and mouth suggest torture prior to attempted assassination. Keep the potpourri as evidence along with the bagged gun.

Call in the GSW to the Level 2 trauma center (thoracic surgeon on duty). Have them prep an OR immediately. Watch for cardiac arrest en route.

After thought: Don't know if it's permitted in civilian practice, but if this guy were my patient I would try to clamp the bleeders through the exit wound before sealing the chest...

...Question: Can you describe his heart sounds? I'm curious about the JVD distention and suspect cardiac tamponade. The force of the bullet may have damaged the myocardium. Obviously missed the heart or we wouldn't be discussing the case. I suspect the shooter was using a low velocity low caliber round. Don't know if I would attempt to treat cardiac tamponade in a moving vehicle on a rural road though. So the question is sort of moot.

I was thinking the burns on the mouth and fingers were from a meth pipe, not torture. This guy's likely a user IMO and this was possibly a deal gone bad.

I also worry about tamponade causing the JVD as well as a hemothorax causing the left-sided breath sound abnormalities. Volume expanders may make this worse, but this guy is clearly cyanotic so I would consider supplemental oxygren, but I wouldn't bag him due to concerns about the integrity of his thoracic cavity. My response is to get this guy to a trauma center most ricky-tick!

I'm not a trauma/field guy so my knowledge of field medicine is quite limited. I enjoy reading these scenarios and hearing how they are stabilized prior to coming to the hospital.

Thanks Sdiver!

Trapper John
05-31-2013, 07:01
I was thinking the burns on the mouth and fingers were from a meth pipe, not torture. This guy's likely a user IMO and this was possibly a deal gone bad.

I also worry about tamponade causing the JVD as well as a hemothorax causing the left-sided breath sound abnormalities.

I'm not a trauma/field guy so I'll defer management to those who are. I enjoy reading these scenarios and hearing how they are stabilized prior to coming to the hospital. Thanks Sdiver!

Thanks Doc, meth users and the effects are completely foreign to me. You probably nailed it. Changes my whole thinking on the manner. If this guy's a meth user then the wound is probably self-inflicted (He's not smart enough to do a head shot) and this would account for the bullet trajectory too. He's right handed and the trigger pull forced the barrel to the outside (patient's left). Voila- failed suicide attempt.

MR2
05-31-2013, 08:48
Paper then plastic the gun in case there's someone else's grubby hands on it.

Paper vs. plastic? Not to take away from the thread, but rather expand upon it -

Can anyone explain why paper? And in general terms, explain how much evidence collection training pre-hospital personnel are given, level of expertise is expected, and what are the legal ramifications of such collection?

bandaidbrand
05-31-2013, 10:01
MR2,

Speculation: I think the number of situations where there is literally no law enforcement to respond are probably limited. In most situations you would prefer to avoid collecting evidence so as to not screw up by either contaminating it or the chain of custody.

Fact: Plastic bags retain moisture and heat which incubate bacteria which will then break down cells [and DNA] as food. DNA can also be degraded or by sunlight (think sunlight causes cancer via DNA mutations).
https://www.ncjrs.gov/pdffiles1/jr000249c.pdf is a pretty good summary.

I suggested paper then plastic because your primary mission is patient health, and I don't think the back of an ambulance on a rainy night is helpful for keeping fluids and other contaminants off of the weapon when you are distracted.

Brush Okie
05-31-2013, 10:27
By the book you are supposed to back out and get the cops in to clear the scene to make sure it is safe. Who ever shot him might still be around or come back. Yes I have had it happen to me.

I would stay and treat. First thing I do in this type of situation (been there done that) is secure the weapon and keep control of it.

Tx.
Control bleeding and occlusive dressing over wound. "burp" wound as needed.
ET Tube if gag reflex allows. Assist resperations with O2 if needed. Consider nasal intubation.
If he still has a gag reflex then high flow O2 with mask
C-spine and back board quick as possible.
Transport
2 large bore IV's NS enroute attach blood Y he is going to need it. Draw blood while starting IV to help the hosp get a type and cross match sooner.
Narcan 2mg IV
As mentioned before it may be a heart issue combined with a drug OD along with the obvious. This guy needs a trauma surgeon and fast. He will not make it very long.

If a med evac is available this guy is a good candidate depending on time from hospital on ground vs flight time etc.

You or your partner keep control of the weapon until it can be turned over to LE (chain of custody) Put in paper bag when time allows. Medical care comes first. Cut around any bullet holes not through them for legal reasons.

The best treatment you can give this guy is the gas pedal. Not a lot we can do in the field except buy a little time and PERHAPS help the hemo/pnumo thorax.

bandaidbrand- civilan medics can NOT do chest tubs, just needle thoracotomy.

Trapper John
05-31-2013, 12:49
Okie - Why the Narcan? Do you suspect opiate OD? I'm not challenging you, just curious. Youse guys (notice my Philly dialectic :D) have a lot more and updated experience than mine. I'm trying to wing it on these from memory of my training many moon ago. Right MR2? Richard?

I also have noticed youse guys (there it is again :D) don't like blood volume expanders. This is a new one on me. Do you have any references to why these are contraindicated. My first impulse in hypovolemic shock is to reach for Dextran/NS.

I am hoping to get educated here - so bring it on. :lifter

Not that I am likely to ever use these skills again, but these are FUN. Thanks SDiver!

Trapper John
05-31-2013, 12:59
Paper vs. plastic? Not to take away from the thread, but rather expand upon it -

Can anyone explain why paper? And in general terms, explain how much evidence collection training pre-hospital personnel are given, level of expertise is expected, and what are the legal ramifications of such collection?

I can't refrain any longer - Bro, that avatar is some kinda disgusting :eek:

Brush Okie
05-31-2013, 13:16
Okie - Why the Narcan? Do you suspect opiate OD? I'm not challenging you, just curious. Youse guys (notice my Philly dialectic :D) have a lot more and updated experience than mine. I'm trying to wing it on these from memory of my training many moon ago. Right MR2? Richard?

I also have noticed youse guys (there it is again :D) don't like blood volume expanders. This is a new one on me. Do you have any references to why these are contraindicated. My first impulse in hypovolemic shock is to reach for Dextran/NS.

I am hoping to get educated here - so bring it on. :lifter

Not that I am likely to ever use these skills again, but these are FUN. Thanks SDiver!

He looks like a druggie and with shallow respiration he MAY have opiates on board. Sometimes they smoke heroin, or mix it with meth/crack etc. No telling without a toxicology screen. IF he has them the Narcan will counteract that and MAY help his breathing. Narcan can not do any harm.

As for the blood expander. During the Vietnam war they were all the rage on raising BP, but they found they were actually harmful in trauma for hypovolimic shock. I can't remember all the details but IF I remember correctly they dehydrate at the cellular level and so you are not fixing the problem just moving it to the cells where it is harder to fix. Doc's please help me here I could be all mixed up on this stuff. I know they found that it does more harm than good in the long run, but at first makes the VS look good. Anyone want to pitch in and correct me please do. I would like to review it myself.

From that they went to large volumes of NS or Lactated Ringers. The problem being for every liter of blood lost you had to put in 3 liters of fluid. ie 3:1 ratio. They then figured out that fluid without red blood cells didnt carry more O2 and in fact may be harmful because it dilutes the blood ie red blood cells, and the higher BP actually speeds out the flow of blood, plus diluted blood does not clot as well as non diluted.

In the war on terror they came back with blood expander again to experiment on soldiers. The big thing that killed a lot of soldiers was some medics were giving it for heat casualties and that is the WORST thing you can do since what little water remains in their cells is sucked out. It was contraindicated to give for heat casualties but a prime example of a little knowledge goes a long way.

The way it was explained to me and I used to teach my students. The golden hour means one hour to DEFINITIVE CARE and that is a trauma surgeon, not a medic not an Emergency Room, but a surgeon. There are stop gap measures we can take ie chest decompression, O2 etc but the best treatment for a severe trauma is the gas pedal.

On osmotic diuretics they are still used in head injury cases at times but even less so than they used to be. They found a 72 hour rebound effect may cause more long term harm than good even if short term is good. It works for buying some time to get to a neuro surgeon.

Glad you have the questions. It makes me think as well. Like you I am outdated and out of practice and hope to learn something here as well as have fun myself.

Trapper John
05-31-2013, 14:31
Thanks Okie! Makes sense re: the osmotic effect of Dextran. Would never, never, never use it for rehydration. Still think that its a better choice in acute blood loss than say NS alone. But I may be wrong. Would love to see the evidence. Until then its D10W for me.

Thanks too for the info on Narcan. My guess you see a lot of OD in CONUS civilian EMT work. Not so much on SF teams and MGTs in RVN :D Mostly acute lead poisoning ;)

Brush Okie
05-31-2013, 15:17
Thanks Okie! Makes sense re: the osmotic effect of Dextran. Would never, never, never use it for rehydration. Still think that its a better choice in acute blood loss than say NS alone. But I may be wrong. Would love to see the evidence. Until then its D10W for me.

Thanks too for the info on Narcan. My guess you see a lot of OD in CONUS civilian EMT work. Not so much on SF teams and MGTs in RVN :D Mostly acute lead poisoning ;)

CONUS drugs and lead poisoning go together many times. I have treated my share of both. I will look around for the studies.

MR2
05-31-2013, 15:48
I can't refrain any longer - Bro, that avatar is some kinda disgusting :eek:

That's my sloth face. It happens whenever I do some research on PuffHo or the DailyKok.

Sdiver
06-02-2013, 00:08
Okay guys, I like the way you're thinking.

Brush ... I like the Narcan call. 2mm pupils and slow shallow breathing. Only one thing, would you want to push the full 2mg at once, or space it out 0.4mg (x's 5) or 0.5mg (x's 4)? If you hit him with the full 2.0mg, you might run the risk of completely waking him up. Thinking about spacing out the dosage over time, just enough to bring up his respirations, might be something to consider.

Trapper ... Good call on the Dextran/NS and treatment plan. This guy definitely has some major trauma to deal with.

Bandaid ... I like the call about securing the weapon in a paper bag. As Brush mentioned, the normal route for dealing with a weapon on scene, is letting PD handle it, but in this scenario, PD isn't available to do so, and of course, we wouldn't want to leave it laying around, and as you said, it is evidence.

PediDoc ... You're welcome. :D These are cool to do, and getting everyone else's POV and treatment plan.

Now here's something for everyone ....

Yes we do have a weapon found with the Pt., and a bag of "Potpourri", presumably drugs, but go back and take a look at the photo, and look closely at the wound where the Pts. nipple is supposed to be, and look just laterally of that wound at where the "exit" wound begins.

Remember, it is a "Stormy and rainy" night. ;) :munchin

Brush Okie
06-02-2013, 00:36
Okay guys, I like the way you're thinking.

Brush ... I like the Narcan call. 2mm pupils and slow shallow breathing. Only one thing, would you want to push the full 2mg at once, or space it out 0.4mg (x's 5) or 0.5mg (x's 4)? If you hit him with the full 2.0mg, you might run the risk of completely waking him up. Thinking about spacing out the dosage over time, just enough to bring up his respirations, might be something to consider.

n

Book says .8 to 2 mg titrated to respiration. We usually gave them the full 2mg for a couple of reasons. First the half life of narcan is shorter than of opiates. Second I want this guy awake if possible. If they are out of it lots they can not tell you even if they are pissed you ruined their high. Oh well tough shit. With this guys trauma it is easier to monitor the trauma vs OD and what is going on.

bandaidbrand
06-02-2013, 05:43
Now here's something for everyone ....

Yes we do have a weapon found with the Pt., and a bag of "Potpourri", presumably drugs, but go back and take a look at the photo, and look closely at the wound where the Pts. nipple is supposed to be, and look just laterally of that wound at where the "exit" wound begins.

Remember, it is a "Stormy and rainy" night. ;) :munchin

Oh wow, this is a lightning strike? :munchin

Trapper John
06-02-2013, 08:02
Oh wow, this is a lightning strike? :munchin

Yup :cool: I'm wondering if this guy was wearing a shoulder holster and the gun was the conductor?

Good one SDiver!:lifter I initially thought the "charring" of tissue was necrotic tissue from the GSW and the "charring" around the "entrance wound" were "powder burns". Totally consistent with a lightning strike. This guy was some kinda lucky. If he wasn't carrying he'd be dead at the scene.

Was the gun even fired?

PedOncoDoc
06-02-2013, 08:32
Thanks for throwing us the huge bone, Sdiver.

Was a nipple ring, bychance, the conductor? :confused:

Sdiver
06-02-2013, 09:29
Thanks for throwing us the huge bone, Sdiver.

Was a nipple ring, bychance, the conductor? :confused:

Yep !!!!! ..... It was either a nipple ring or stud or something definitely metallic that was the conductor.

The gun, was never fired or used. He just carried it in his left inside jacket pocket (sorry Trap, no shoulder holster. :) it was just loosely carried in there). It just happened to fall out and land underneath him after he got struck by the lightning.

People see/read about the gun and that type of wound and immediately think GSW, when in fact, lightning hit the nipple ring/stud and exited out his side, striking the gun in his jacket pocket. None of the rounds in the gun were discharged or went off, in fact the gun was wholly intact, that cavitation was caused just by the lighting alone.

Thanks for playing folks .... we have some nice parting gifts for ya. :lifter

Brush Okie
06-02-2013, 09:35
Yep !!!!! ..... It was either a nipple ring or stud or something definitely metallic that was the conductor.

The gun, was never fired or used. He just carried it in his left inside jacket pocket (sorry Trap, no shoulder holster. :) it was just loosely carried in there). It just happened to fall out and land underneath him after he got struck by the lightning.

People see/read about the gun and that type of wound and immediately think GSW, when in fact, lightning hit the nipple ring/stud and exited out his side, striking the gun in his jacket pocket. None of the rounds in the gun were discharged or went off, in fact the gun was wholly intact, that cavitation was caused just by the lighting alone.

Thanks for playing folks .... we have some nice parting gifts for ya. :lifter

Good one.

Can I have the gun as a parting gift? Trapper can have the nipple ring. :p

MR2
06-02-2013, 11:25
;)

Trapper John
06-02-2013, 13:57
Good one.

Can I have the gun as a parting gift? Trapper can have the nipple ring. :p

Now WTF would I do with a nipple ring? :p

This was fun SDiver. Can we do it again, huh? Can we? Can we?

Priest
06-03-2013, 11:07
Okie, not sharpshooting here, but delivering narcan in a GSW case just to relieve respiratory depression (which, from the vitals and pt's mental status suggest that intubation would be no problem) seems counter intuitive due to the fact that when this guy does come around, you've filled up his opiate receptors with NARCAN and now you've increased the mental and physical trauma this guy is going to get. Now, as a military medic I don't see the drug OD as much, but is this the typical treatment for such a patient in a pre-hospital setting?

Brush Okie
06-03-2013, 17:38
Okie, not sharpshooting here, but delivering narcan in a GSW case just to relieve respiratory depression (which, from the vitals and pt's mental status suggest that intubation would be no problem) seems counter intuitive due to the fact that when this guy does come around, you've filled up his opiate receptors with NARCAN and now you've increased the mental and physical trauma this guy is going to get. Now, as a military medic I don't see the drug OD as much, but is this the typical treatment for such a patient in a pre-hospital setting?

I don't take it as sharpshooting. Good questions.

Yes. Typically you give the Narcan first if you suspect drug OD. It isn't going to hurt anything. If they are intubated you can extibate them if needed. Many times you will run across a multi problem issue such as a car wreak caused by someone having a heart attack that blacked out for a second so you have to treat both. Typically a gun shot wound here involves someone using drugs ie two druggies shooting it out, cops shoot druggie etc etc. I am NOT saying give narcan to every shooting victim, but in this case the circumstance called for it.

We didn't give pain killers ie morphine to MAJOR trauma like this guy. It can hide clues about his vitals, mask his LOC dropping (is it the meds or the trauma) and suppress his respiratory system and we are trying to give them more O2 not less. IF and that is IF he had opiates on board it is suppressing his respiratory system and that narcan may be the difference between him making it to the hospital and dying in the back of the rig. The Narcan is NOT going to hurt him if he does not have any opiates on board. The half life is shorter than Morphine.

Quick tip. To check if someone has a gag reflex left run your fingers across their eye lashes and see if they react. That reflex goes out about the same time the gag reflex does so it is a good indicator.

Every situation is different and understanding what is going may mean that the book is not right in certain situations. We used to call it cook book medicine and it is dangerous. Remember METT-TC it applies to everything in life.

Whiplash
06-03-2013, 23:10
Sdiver, what website do you get these off of? I took this scenario into my aid station today to see what some of the other medics thought and they enjoyed it thoroughly.

JMART5
06-04-2013, 17:15
I'm not a medical professional but I do enjoy reading these scenarios.

Don't know if it matters, but is it possible that he was smoking the potpourri (the kids call it spice). I have a friend whose son had a stroke smoking that shit. Maybe that's why he was wandering around in a rain storm. Several stores around Fort Lee are of limits because of it.

Sdiver
06-04-2013, 17:47
I'm not a medical professional but I do enjoy reading these scenarios.

Don't know if it matters, but is it possible that he was smoking the potpourri (the kids call it spice). I have a friend whose son had a stroke smoking that shit. Maybe that's why he was wandering around in a rain storm. Several stores around Fort Lee are of limits because of it.

Unknown if this is what happened, but it most likely is.
"Spice" and now "Bath Salts" are showing up with more frequency and is something that we're having to train up on, on how to handle and it's turing out to be some scary ass shit.

Sdiver, what website do you get these off of? I took this scenario into my aid station today to see what some of the other medics thought and they enjoyed it thoroughly.

Awwww Man ...... A good fisherman never tells others where his good fishing holes are, that is, until he's ready to hang up his fishing pole. :D

Priest
06-04-2013, 18:38
I don't take it as sharpshooting. Good questions.

Yes. Typically you give the Narcan first if you suspect drug OD. It isn't going to hurt anything. If they are intubated you can extibate them if needed. Many times you will run across a multi problem issue such as a car wreak caused by someone having a heart attack that blacked out for a second so you have to treat both. Typically a gun shot wound here involves someone using drugs ie two druggies shooting it out, cops shoot druggie etc etc. I am NOT saying give narcan to every shooting victim, but in this case the circumstance called for it.

We didn't give pain killers ie morphine to MAJOR trauma like this guy. It can hide clues about his vitals, mask his LOC dropping (is it the meds or the trauma) and suppress his respiratory system and we are trying to give them more O2 not less. IF and that is IF he had opiates on board it is suppressing his respiratory system and that narcan may be the difference between him making it to the hospital and dying in the back of the rig. The Narcan is NOT going to hurt him if he does not have any opiates on board. The half life is shorter than Morphine.
.

Thanks for the info