Check Your Spot (pretty graphic) [Archive]

AngelsSix

03-09-2004, 11:01

This isn't SF related, but I wanted to know how you would treat such a traumatic injury (obviously he is still alive in this picture??)

Since I cannot post pictures to this web site for some reason, I have provided a link to a site that hosts photos.

Thanks to Sacameulas (I think I spelled it wrong, sorry) for helping to try and see if it was a size issue (it was not).

Here is the link to the photo (http://img.villagephotos.com/p/2003-8/354093/BadaccidentEDIT.jpg)

Surgicalcric

03-09-2004, 11:16

Are you sure he is still alive?

NousDefionsDoc

03-09-2004, 11:45

I doubt it.

Sacamuelas

03-09-2004, 11:45

Here it is "ma'am"... (**edited to avoid sexual harassment lawsuit by RL)

Sacamuelas

03-09-2004, 11:52

Alright.. you guys get over your automatic denial about this situation because of the "WOW...that is to painful to think about" this accident stuff. "

Lets do this as if you find a teammate impaled onto an object (fence posts, tree limb). What to do on scene to at least stabilize him for evac. Obviously, this type of impalement may be a little extreme to expect recovery, but a similar situation (less severe) could be important to review. For instance a NIGHT Halo jump into a densely populated or wooded area by mistake.
Anyone want to work out the basics?

HaHa, look at me. I am" Mr. peacemaker and his friend excuse maker" all in one!! LOL
Sir Sacamuelas the honorable

Surgicalcric

03-09-2004, 12:02

There would be no stabiliation of the post necessary. It is being stabilized by the patient's pelvis. Also unless one of the guys has a really good hand saw he will bleed out before getting that post/tree cut.

I am probably going to draw fire for this but;

My treatment for this guy would be an IV and MS to kill the pain and knock out his respiratory drive so he could die without suffereing anymore than he is already. I have seem MANY impaled objects thought the torso. I have yet to see one live to get to the OR. It would be better for him to go as painlessly as possible than to suffer while we screw with an injury not likely to be survivable.

Just my .02

CSB

03-09-2004, 12:37

It certainly is a gruesome photograph, what was the cause?

I know the topic subject implies a parachute landing, but I can't see 10-20 fps having the ability to do that much tissue damage, even for such a grossly obese subject. The post is protruding from the back of the victim.

Angels, do you have a time/place/circumstance?

Eagle5US

03-09-2004, 12:44

at your defeatest attitude there cric...I expected more. Maybe none of yours lived to get to the OR for just that reason...you never gave them a chance to begin with...
Now...back up, regroup, and try again...your narc box was unsecure during the jump and fluttered away in the darkness at about 18000 feet.

Let's go with Sacamuelas' suggestion and push a 4in diameter fencepost a bit inferio/lateral to where this gentleman was impaled. Use the photo to distinguish what the R leg looks like. The fence is still attached to its uprights and his MC-4 is fluttering in the breeze...

So...lets try this again shall we :p

Eagle

Surgicalcric

03-09-2004, 13:46

Defeatest attitude has nothing to do with it Sir. I have just seen quite a few patients with guard rails run thru them. BTW, I have never used my ability to induce respiratory failure to put them out of their misery, but it has crossed my mind on a few instances.

Back to the scenario at hand...

Call for immediate EVAC.

Remove/cut harness and all other gear. Support patient manually with 3 or 4 other team members holding him up; cut 6" x 5' strips from MC-4, pack around entrance and exit with trauma dressings; pad around post with clothing and left over canopy. Use the strips of canopy to secure the impaled object to both torso and lower extremities to prevent movement during extrication and evac. Cut the post at about knee level and lie patient supine on SKEDCO, stretcher, LSB, etc... and secure. (2) IV's and fluid titrated to mentation. MS for pain.

Evac to bright lights and cold steel.

Eagle5US

03-09-2004, 13:56

Originally posted by Surgicalcric
Defeatest attitude has nothing to do with it Sir. I have just seen quite a few patients with guard rails run thru them. BTW, I have never used my ability to induce respiratory failure to put them out of their misery, but it has crossed my mind on a few instances.

touchy touchy...just trying to give you a bit of perspective...not get your tailfeathers all outt whack...

Surgicalcric

03-09-2004, 14:04

I did not take it that way Sir. I was just trying to clarify my position. I think I need some block leave from EMS. lol

Sacamuelas

03-09-2004, 14:18

Assuming it is a fence post of average height of five feet or so.

I'm obviously out of my league here men. Take this with an understanding that this is not my field. I post to stir debate/correction from knowledgeable members/and learning for myself and others who have no particular expertise in this area.

What I would do:
1. First things first. Detach harness to his chute to prevent it from manipulating his position or causing any more tearing of his tissues from lateral or rotational movement.

2. Have someone radio for immediate and urgent Evac at highest priority

3. Get another soldier to help stabilize his upper body to prevent as much movement as possible.

4. Assuming no active bleeders to clamp (probably not since object is in place), I would get two IV locks started for future pain meds/volume replacement prn.

5. Do not remove soldier from the impaled object. I would actually use ace wraps, any other material available or 100mph tape(if thatâ€™s all I had), etc to stabilize and immobilize his lower extremities to prevent movement.

6. With assistance from your teammates, have some soldier begin to cut the base of the post free from the ground. This is when you hope Reaper is with you. He can whip out one of the 1000 gucci gadgets/knives that he owns to perform the cutting quickly and without to much effort. LOL

7. With help of at least four men, lower the soldier and the post together as one unit onto the ground in a position that places as little pressure to cause movement of the object. His side on a prepositioned stretcher may be the ideal position to facilitate future loading onto a helicopter.

8. Treat for shock and manage pain based on BP/symptoms/breathing. IV Ab woudl be indicated to get the drop on the coming infections after he is stabilized. Reassure patient that James didn't make this jump and he will be fine!! :p LOL

alright James, your turn to blast me for my treatment recs! haha

***edited, I seem to type to slow. James beat me to it.

Smokin Joe

03-09-2004, 14:22

Originally posted by Surgicalcric
There would be no stabiliation of the post necessary. It is being stabilized by the patient's pelvis. Also unless one of the guys has a really good hand saw he will bleed out before getting that post/tree cut.

I am probably going to draw fire for this but;

My treatment for this guy would be an IV and MS to kill the pain and knock out his respiratory drive so he could die without suffereing anymore than he is already. I have seem MANY impaled objects thought the torso. I have yet to see one live to get to the OR. It would be better for him to go as painlessly as possible than to suffer while we screw with an injury not likely to be survivable.

Just my .02

If you find me impaled that bad please do me the favor and provide the above stated treatment.

I know it goes against your morale and ethical code but help a brother out.

Sorry its off Topic Eagle.

NousDefionsDoc

03-09-2004, 14:30

I agree with Sacamuela's TX. I would also try to think of any other supporting measures I could.

In the UWOA, I don't know. You can't leave it indefinitely.

18C/GS 0602

03-09-2004, 14:35

No ABCâ€™s? I canâ€™t tell from the picture but he looks like me might be intubated.

One of the things that was stressed to me during my trauma months was that no matter how spectacular the injury is (i.e. arterial injury with blood spraying everywhere or a knife sticking out of someoneâ€™s head) you always start at what will kill the patients first. No one specifically said what the injury mechanism was but if it was powerful enough to do that it seem like there is a good change there are other injuries that might compromise airway and breathing.

Eagle5US

03-09-2004, 15:15

Just stirring the pot a little here guys...
removal of the post from the ground is a good start, as is letting the post be the tamponadeing element...
NDD has us in the UWOA, accepting the fact that there is only one SGN on these boards, and in a true hospital environment this case would present a significant challenge...
Let's go best case scenario with what we have...

Facts:

-LArge wooden object impaled in the sft tissue of the upper R thigh with entry and exit protrusion.
-circulatory compromise to the R lower extremity
-post removed from its mooring, patient trasnportable to your grass hut clinic
-breathing on his own, shocky, 2 IV's running wide. pain at 7/10 with MS on board, no other significant injuries...

Things to consider:

-how long to leave it in before infection will set in...or has it already begun?
-which antibiotics do you want to load early on?
-how would you go about removal...if you would at all
-what are some anesthesia considerations for the surgical procedure if you wanted to do one.

Kepe in mind some of the parameters...UWOA, no evac for 14+ days, you are it...you have meds...you aren't going to write this guy off...

thoughts???

Eagle

Surgicalcric

03-09-2004, 17:09

Should have paid more attention to Doc T in Trauma ICU... (James kicking own ass).

If infection has not set in yet it will shortly. I would say removal of the post would be needed as soon as viable. You are not going to be able to stop an infection as long as the cause is still in place, correct.

Once back at the UWOA Surgical Suite:

ABX: Begin IV ABX therapy with a broad spectrum abx, 3rd generation cephalosporin?

Anesthesia: Ketamine

Removal:

1.) Scrub and drape the area in normal fashion.

2.) Make incision parallel and over top of impaled object. Fold skin back and suture down.

3.) Clamp and/or cauderize smaller bleeders as they are found and clamp femoral artery and/or vein if either or both is found to be severed in part or in whole.

4.) Remove post in its entirety; thoroughly debriding and irrigating the wound being careful to remove any and all foreign matter.

5.) Repair and suture arteries and veins as possible. Install Penrose Drain and begin suturing the muscles and connecting tissue while closing the wound.

6.) Suture the skin closed.

7.) Dress the wound.

Eagle5US

03-09-2004, 17:11

Sacamuelas??? Anything to add / delete / change?

Eagle

NousDefionsDoc

03-09-2004, 17:13

Why Ketamine Crip?

Roguish Lawyer

03-09-2004, 17:16

If that were me, I would like my medic to prescribe and accurately deliver a .45 round to the brain. Or somewhere else if it would kill me quicker.

I couldn't take the jokes if I survived.

The Reaper

03-09-2004, 17:50

Originally posted by Roguish Lawyer
If that were me, I would like my medic to prescribe and accurately deliver a .45 round to the brain. Or somewhere else if it would kill me quicker.

I couldn't take the jokes if I survived.

As a lawyer, I would think you would be used to the jokes already.

Not a Doc, and have no anatomy classes, but I am almost positive that there would be serious damage to the intestines, and/or renal system, and their transfer mechanisms. Watch for peritonitis after repairs.

Would also try to determine if there is neurological impairment and possible damage to the lower spine or nerves.

Gotta cut him open, he may die, but if you don't, he is going to die soon anyway. Certainly not going to make 14 days with that in him.

Call the Padre for emergency Last Rites on standby.

TR

Sacamuelas

03-09-2004, 17:59

14 days... well, we gotta do something then.

I like what James has said. However, I might change a few things just to be different! LOL

I would do the following:

1.Don't know if I read James's post correctly or not. If he meant an AND in there instead of a comma then I don't disagree. I just don't consider a 3rd generation ceph alone as a broad enough spectrum coverage drug for a penetrating wound.

Initally, I might use a broader spectrum 1st generation ceph or a 3rd generation penicillin like ampicillin. 3rd Cephs have a greatly reduced staph and strep affect and are more selective for gram (-) only and have a little Pseudo. A. coverage.
I was always taught to use broad spectrum unless you know you have something else working. Theother two listed are give good basic gram (-) coverage and still have a good staph/strep efficacy.

2. I would consider this wound "instantly" contaminated and infected. I would remove the object once proper prepping of the wound and anesthesia is provided as James wrote(don't know what general anestetics would be available to you in UWOA).

3. Evaluate the object. I would scrub that object with betadine before removal to prevent further contamination. Also, modification of the end that will be passing back through can be accomplished to remove any projections and decrease its circumference to ease withdrawal.

4. Incise and remove as described.

5. Do as James has listed... particularly noting the likely position of the expected major anatomy that could be further comprimised during removal and suturing. An ounce of prevention concerning the nerves or arteries could be worth its weight in gold.

6. I would close internally (by layers) with resorbable sutures and finish the wound with nylon externally.

I pretty much agree with James. Only a few personal choice differences I think. What did we miss?

What layer(s) in this particular type wound would the drains be placed for maximum effectiveness?

Guy

03-09-2004, 20:10

I would not even consider removing the object unless; I had blood to give him!

The cause of injury is not from a parachute accident...more likely from an extreme height. The force that needs to be generated for penetration of an object that size indicates that!

Eagle5US

03-09-2004, 20:16

I must not be conveying my ideas very well...but there is much good discussion going on nonetheless!!!

INteresting point Guy...do you think this patient would have a chance of survival after having an indwelling fencepost after 2 weeks???
I am interested in your thought process behind it.

We had a similiar incident to this one on a night HALO MTT...the jumper came in downwind and ran a 3in diameter stick through his thigh on impact with a downed tree...

Tell us more Guy!!!

Eagle

The Reaper

03-09-2004, 20:21

Why not? I know people who seem to live for years with a big stick up their asses.

I think Guy means that you will need to line up whole blood or donors before commencing the procedure.

TR

NousDefionsDoc

03-09-2004, 20:22

LOL - "Hey you, what's with the stick up the ass?"

Sacamuelas

03-09-2004, 20:28

Guy-
We decided to go with a modified scenario that Eagel chose in his post at the top of page 2. Check it out.

Correction for all...
Just noticed that Eagle reported blood flow compromise to the right leg distal to the impalement in this initial scenario. That would be another factor weighing in towards removing the object taking into account the likely hood of 14 days without evac in the UWOA.

INterested to hear your ideas Guy...:cool:

Doc T

03-09-2004, 21:11

the guy in the picture is alive...he is still on the monitor...you can see a EKG tracing in the background.

As for the foreign body.... have seen people live with things inadvertently left behind...a fence post in fact, for upward of 10 days...was finally recognized on XRAY as a fence post and not a spinal rodding (don't laugh.... )...and he had it removed.

The guy in the pic has obviously taken out the vasculature to his left leg as its blue in the photo...and from the looks of where it goes probably his rectum and distal colon...

He wouldn't survive long in the field because of multiple things... but removing the object (as Guy already stated) would most likely lead to a much quicker death.

doc t.

NousDefionsDoc

03-09-2004, 21:15

What would the prognosis be where you are Doc T?

Doc T

03-09-2004, 21:18

Originally posted by NousDefionsDoc
What;s would the prognosis be where you are Doc T?

depends on lots of things you cannot get from the photo.... primarily the injuries and his hemodynamics...

sorry.....know my answer was supposed to be of course he'd survive if I operated on him.... but its been a long week.

doc t.

Doc T

03-09-2004, 21:20

the guy with the retained fence post did well however...but not my patient.

doc t.

NousDefionsDoc

03-09-2004, 21:24

No, I wasn't looking for a pat answer. I'll leave you alone because its been a long week.

:boohoo

NO SNIVELIN' ITS ONLY TUESDAY!

LOL

Doc T

03-09-2004, 21:33

my week started on sunday...that is the way my calender goes...so I have already put in a full weeks work by most people's standards... lol....

as for the guy....blood is hanging so I have to assume he was unstable...

vascular injury remains an independent risk factor for death in a trauma patient with a penetrating injury.... combined with the probable need for a damage control procedure, he has a very poor prognosis. I base my thoughts that he will need damage control on the fact that blood is hanging and I imagine multiple internal injuries... rectum, colon, bladder, pelvis...etc...

NousDefionsDoc

03-09-2004, 21:35

so I have already put in a full weeks work by most people's standards... lol....

nice one.

Note to self - Doc T is sharp even when tired. Leave her alone. LOL

Thanks for the additional comments.

Ok - whoever said "bullet" was right.

NEXT! :munchin

Doc T

03-09-2004, 21:37

bullet?

Sacamuelas

03-09-2004, 21:39

Eagle and I must be on to many medications. Am I crazy or Did anyone else read the change in scenario involving the right thigh only that Eagle suggested we worK?

I am interested to hear GUy and Doc T's ideas about that specific situation as it is a liitle more realistic in prognosis.

Doc T- if you are to tired... by all means ignore my suggestion. BTW, I finally cleared my PM folder. Sorry
:munchin

NousDefionsDoc

03-09-2004, 21:40

If that were me, I would like my medic to prescribe and accurately deliver a .45 round to the brain.

RoguishLawyer. Sorry dude, old habits and all.

ktek01

03-09-2004, 21:45

I am with RL on this one. I also would hope no one was standing around taking pictures, if I lived the .45 round would be for him!

Doc T

03-09-2004, 21:49

nowadays there is a digital camera in most ERs....

as for Eagles scenerio...had missed it.

vascular compromise....no pulse, decreased pulse?

is there bleeding from the wound causing shock or is it just bleeding at the fracture site of the femur as he described a pole going through the upper right thigh...

doc t.

Sacamuelas

03-09-2004, 21:55

Who..Me??

Hey your the mullah in this mosque....how do I know? LOL

I didn't even think to ask those questions. haha
Let's say diminished pulse present... majority of bleeding around the fractured femur internally.

Would you remove the object and do your best if you knew he had to wait a minimum of 14 days before a possible evac out of the grass hut clinic? Or would you sacrifice the leg to maybe save the patient by leaving the object in?

Guy

03-09-2004, 21:59

I'll actually probably dream about this tonight. The prognosis does not look good.

As an operator...

If he were conscious...I would medicate him to the point of no return.
If he were unconscious...I would most likely end it w/o wasting meds.

Doc T

03-09-2004, 22:08

Originally posted by Guy
I'll actually probably dream about this tonight. The prognosis does not look good.

As an operator...

If he were conscious...I would medicate him to the point of no return.
If he were unconscious...I would most likely end it w/o wasting meds.

is this your answer for the guy in the photo or the guy with the post through his leg with a decreased pulse?

for the decreased pulse with bleeding in the fracture I'd hope you'd go all out... May just be an intimal flap or spasm.... Would in that case try to remove the foreign body and hope for the best but be prepared to tourniquet or clamp because no one can hold pressure for two weeks!

Broad spectrum antibiotics....you guys are all utd on tetanus... never close skin on a dirty wound...irrigate and debride what looks dirty...you'll be pulling wood splinters out for a while .... dressing changes a few times a day into the cavity.

doc t.

Sacamuelas

03-09-2004, 22:11

Thank you Doc T.

I was wondering about my decision to suture verses pack the wound. I had a feeling I was wrong on that. :o

Guy

03-09-2004, 22:22

I was talking about the picture.

Surgicalcric

03-09-2004, 22:29

Originally posted by NousDefionsDoc
Why Ketamine Crip?

Just a guess NDD. Am I wrong?

I dont have much experience with anesthesia other than NO2, and the common RSI drugs.

Doc T

03-09-2004, 22:34

Originally posted by Guy
I was talking about the picture.

i thought as much...the timing was just off.

Cannot imagine having to make those types of decisions for teammates.... I try to distance myself from my patients although that is obviously not the case always. Withdrawals on awake, alert patients who have chosen to refuse care (ie. withdrawal of ventilation in quadraplegic patients) is always a very difficult thing for me and thankfully does not happen often.

Surgicalcric

03-09-2004, 22:39

As for my ABX choice, I do not have any formal training in treatment of infectious tissue. I only know of what I have read so my choice of Abx therapy is only as a SWAG, nothing more.

Is there a chance one of you more experienced in ABX therapy could go over the highlights of ABX therapy for field admin. Thanks.

Doc T

03-09-2004, 22:41

what do the SF medics carry antibiotic-wise? I'll be happy to go over some of the stuff tomorrow.... will start a new post.

doc t.

AngelsSix

03-09-2004, 22:58

Thanks for taking care of that for me Sacamuelas, appreciate it. I can't figure out if it's just the two weeks of continued lack of sleep or what.

Interesting case. I have to admit that I got the photo in the email from someone else, no idea what the case was. The "check your spot" was my sick sense of humor coming through. Although as some of the other have mentioned, it does happen.

My guess is that this was possibly a case of someone running into a vehicle with this pole protruding from the back of it. Much like the logger trucks you see all the time up and down the highway. I am trying to see if the angle would be right for a passenger vehicle. Considering that it definitely went through from front to rear (note jeans pushed through in front) I have to guess MVA or something even weirder than that. Possibly a MC, but that would be truly amazing.

I like the thought process on treatment. If agree that if it were me I say drug me to the hilt until my heart stops. I wouldn't want to survive that.

I would have to think the massive blood loss would lead to heart failure. I see the blood pooled in his left leg (livor mortis??)
I am not a doc, but one of the things I would consider was to get the leg off and remove the object. Then the time comes when we decide if the damage to the internal organs has been too bad. I wonder how much or how many were affected here??

I think we are spot on in saying that even if by some stretch of the imagination he survived, the massive infection/toxic shock syndrome would probably kill him.

I hate to say this, but I am thinking that they might just be keeping him alive long enough for the family to get there. I would never want to see my loved one like this. Ever.

DoctorDoom

03-10-2004, 03:25

Roguish Lawyer

03-10-2004, 11:57

Originally posted by The Reaper
Why not? I know people who seem to live for years with a big stick up their asses.

Nice!

Roguish Lawyer

03-10-2004, 11:58

Originally posted by NousDefionsDoc
Ok - whoever said "bullet" was right.

NEXT!

Duh! :D

Sigi

03-10-2004, 12:01

This guy could be some sort of lumberjack or tree trimmer. I had a friend who cut trees and one of his workers had tied a rope to one of the limbs to guide it down after he had cut it. The rope got away from the ground person and it swung back and struck the man up top square in the chest. Like putting your finger into a jelly donut. He of course died before EMS arrived.

Maybe this guy fell from his harness and struck a limb.

Anyway you look at it, this entire thread made my groin hurt. I don't know how all of you in the medical profession do it, but thank you.

ktek01

03-10-2004, 17:58

Originally posted by Doc T
nowadays there is a digital camera in most ERs....

Yes Ma'am, I'm sure there are. I was talking about in the field, with the guys in my unit. With an injury that serious I doubt any of them would be taking pictures, but you never know. My first room mate in the Army had pictures of his PL and PSG lying on the ground with GSWs to the 4th point of contact. They both made full recovery's, and he had the pictures hanging up on his wall locker.