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View Full Version : Medical scinaro last of 2013


Brush Okie
12-31-2013, 20:52
This is a real call I was on. While it is fairly straight forward I believe it has a couple of learning points especially for the new.

You are called to a shooting. On the way the local volunteer fire department says scene is secure and it was an accidental shooting so you go rolling in. When you arrive you find a 25 y/o male with a single gunshot wound to the left side of the chest just below the left nipple in obvious respiratory distress. When asked what happened the guys friend states the victim was laying on a bed and he was standing at the doorway to the room and accidentally shot him with a .22 long rifle pistol with a two inch barrel. The distance is about ten feet away. Law enforcement is NOT on scene and 30-45 minutes away. Hospital is 45 minutes driving time by ground. Nearest LZ is about a mile away helo is 40 or so minutes from LZ if requested then another 10-15 flight time to hospital otherwise ground would be faster.

What are your options?

What is the first thing you do?

The Reaper
12-31-2013, 23:48
Not a medic, but I know a little bit about bullets.

.22s tend to rattle around quite a bit.

The location of the wound track may not be in a direct line with the entry wound.

Do a good survey, once the weapons are secure and perimeter is safe.

TR

Brush Okie
01-01-2014, 00:21
Good job both of you. Secure the weapon FIRST.

Now does anyone here actually believe it was an accident?

Survey reveals a small puncture wound about an inch below the left nipple. Skin pale cool diapheritic. pupils sluggish. BP is 130/70 HR 130 respiration's rapid and labored. Lung sounds decreased on left side. No JVD trachea is midline. No exit wound. No external bleeding from wound. No sucking chest wound.

DOC. Anything else you might want to do? Think very very basic.

Chest tube gets large amount of blood and relieves breathing issue. (we got 1200cc at the ER)

A couple of things. Scene is not secure is pulling back an option if firearm is not located or the shooter is aggressive?

Reaper very good observation about .22.

bandaidbrand
01-01-2014, 01:58
Seems like fast transport would be my focus here if a thorough check doesn't find an exit wound in a weird spot. If there's that much blood already internally it could be his spleen or a bigger blood vessel. I'd get a line in while his BP is still good with tko LR and may consider switching the bag/rates if he starts to decompensate. I've never done the civilian EMS thing so I don't know how decisions about medevac are made... how do you go about that with a long distance to a hospital?

Is the patient alert and oriented on any level? I'd be asking him or anyone around about allergies/name/blood type... and I always talked to wounded guys even if they were out of it in case they could hear me on some level and to try and control my own breathing if I had been running a lot or moving them.

Can I pistol whip the shooter with his own gun?

Edit: I'd check for breath sounds in his abdomen as well.

Brush Okie
01-01-2014, 17:20
Do as far as the patient? Other than the basic initial trauma stuff mentioned? Uh, I didn't cover 'ensure airway is clear'...

As far as the scene, other than securing it and the weapon? There is no mention of your function or qualifications, so have someone call EMS or do it yourself if the "friend" is unwilling.

Pulling back is definitely an option in the circumstance you mention. If you are dead or detained, there's no one to notify LEOs and EMS, which hastens the victim's dying process. One might also tentatively assume that neither of these gentlemen play well with others.

Ill give you a hint. Where did the bullet go? What did it possibly hit? Remember .22 really bounces around. Level of care is your training ie MD and what you would have in the field. For 18 series then that etc.

swatsurgeon
01-01-2014, 19:02
For the record, .22 doesn't bounce around unless it hits denser tissues that deflect it's trajectory. Have seen plenty go straight with an easy to follow permanent cavity.
ss

Brush Okie
01-01-2014, 19:24
OK how about C-spine and backboard?

Yes or no?

Why?

Brush Okie
01-02-2014, 17:08
Not a lot of response so I will close with my two points and synopsis.

Contrary to a comment this was not a bad neighborhood or druggies. It was a rural area with well to do people and both parties involves were working adult males. No drugs or drinking involved. It occurred on a warm mid afternoon.

Long story short we got the pt to the ER and pulled 1200cc of blood from a hemothorax via chest tube. The bullet was found in his NECK lodged against the C-5 vertebra. He lived after surgery. The shooter was arrested without incident.

My learning points are safety first. It was a upper class area and was reported as accidental so the local volunteer FD took them at their word and we walked into a non accidental shooting. If you are injured or taken hostage instead of being a solution you have made the problem bigger. Don't get lulled into a false sense of safety.

Next, remember the basics. I did a C-spine and backboard on this guy and was glad I did. Bullets are unpredictable so c-spine and backboard bullet wounds, unless you know it is through and through someplace like an arm etc. get full c-spine precautions. While all the advanced procedures are important, the simple basic ones are just as important.

cowboy117
01-18-2014, 10:29
Next, remember the basics. I did a C-spine and backboard on this guy and was glad I did. Bullets are unpredictable so c-spine and backboard bullet wounds, unless you know it is through and through someplace like an arm etc. get full c-spine precautions. While all the advanced procedures are important, the simple basic ones are just as important.

What say you on recent updates on not using spinal motion restriction (SMR) in penetrating wounds?

I wouldn't use SMR in penetrating wounds, ordinarily, unless my assessment revealed a neurological deficit ("I can't feel my legs!" or a priapism) just considering in a time factor for proper application. I like to see forward motion of a patient within 10-12 minutes after contact if possible.

I would have performed a lateral decompression using a 3.25 inch 14ga catheter along the mid-axillary line only after confirming a decrease or loss of lung sounds on the affected side. Even then, depending on the respiratory status of the patient, I may or may not treat, but since distance is an issue in this case, treatment is warranted. Cover with an Asherman seal. My assessment includes simple auscultation with percussion.

As far as IV fluids and trauma resuscitation, I prefer the "hands off" approach. I start a line with a saline hub and keep an eye on mean arterial pressure (our oscillometric NIBP cuffs will display a MAP measurement), but in the absence of a reliable measurement of MAP, A simple blood pressure will suffice. If fluids are required, I use just the amount and flow rate to maintain an alert mentation.

Good basis for a case study, btw. Glad the outcome was positive.