First MVA scenario

[Surgicalcric]

During a convoy escort two HMMWV’s at the front of the line are involved in a high-speed rear-end type MVA due to the lead vehicle stopping and the driver of the second vehicle not being attentive.

You, being the only medic, arrive on scene, from the rear of the column after being called up, to find:

The lead vehicle is sitting sideways in the roadway aproximately 30' from point of impact. No skid marks for second vehicle are noted. The lead HMMWV sustained major rear-end damage. The turret gunner is slumped over the M19. The unrestrained driver is sitting up right with his door open and holding his neck, and the front seat passenger is ambulating around the vehicle.

The second vehicle is off the roadside. It has sustained massive drivers side front-end damage and has fluid leaking from whats left of the engine compartment. The driver, unrestrained, is slumped over the steering wheel. The front seat passenger, unrestrained, is slouched down in his seat holding his right hip. And the turret gunner has been thrown clear of the vehicle and is lying prone on the roadway near the rear of the lead vehicle.

A perimeter is being established to provide security to the convoy.

(1) Windshield survey? (This is the initial scene survey prior to dismounting your vehicle.)

(2) What are your vehicle safety/stabilization considerations?

(3) Probable injuries based on impact?

(4) Spinal Immobilization considerations and treatment of the 6 patients onscene?

(5) Transport?

You have Aid bag, collars, collapsible stretchers (5), sandbags(floorboard armor), 100mph tape.

GO.

**This first one is to get you guys thinking in a different frame of mind. I am not looking for indepth treatment, but more things to be considered. Good luck, more to come.**

[Sacamuelas]

I am clueless on the windshield survey. Besides the common sense idea of looking to see which patients will have obvious head trauma and the potential for identifying the impact severity by looking at the glass damage.

Will you run through what you look for and subsequently what that tells you about the victims concerning windshield survey?
Next...
#1- make sure surrounding scene is safe from further incident. I would go to the front end damage vehicle first. Identify the leaking liquid to rule out an environmental danger (fire/explosion) before treatment begins on the actual passengers.

[shadowflyer]

(1) Windshield survey? (This is the initial scene survey prior to dismounting your vehicle.)

Windshield spidered on V1 driver side. Windshield spidered on V2 Driver and Passenger side, due to lack of restraints.

(2) What are your vehicle safety/stabilization considerations?

V1 is stable but would shore up the tires with sandbags or anything heavy. I do not want either of the vehicles moving while I am trying to extricate any PT’s. V2 is leaking fluid possibly gasoline. Get someone on the fire extinguisher and standby ready to put out any fire.

(2.5) Call for help due to large number of PT’s. I will need more medics to be able to get all of those PT’s stable and ready for transport.


(3) Probable injuries based on impact?

V1-Driver- Head injuries, C-spine injury, internal trauma due to impact with steering wheel. Poss. Lower extremity injury.

V1- Passenger- Ambulatory, C-spine injury, head injury if unrestrained, possible LOC.

V1- Gunner- Head inury, C-spine injury, internal injuries, LOC.

V2 - Driver – Head injury, internal injury due to impact with steering column, C-spine injury, lower extremity injuries due to impact with lower dashboard.

V2 – Passenger – Pelvic injury, head injury , C-spine injury, lower extremity injury due to impact with dashboard.

V2 – Gunner – Head inury, internal trauma, C-spine injury and possible T-spine injury due to ejection from V2 at high rate of speed.

(4) Spinal Immobilization considerations and treatment of the 6 patients onscene?

TX—Everyone gets a C-collar. ABC’s

V1 Driver—C-Collar, Extricate onto stretcher. Use 100mph tape and sandbags for stabilization . Assess further and TX as indicated. DCAP-BTLS

V1Passenger – Ambulatory, C-collar. Assess , possible walking wounded.

V1-Gunner- C-collar, Stabilize c-spine, extricate from gun mount. Stretcher and assess. Use tape and sandbags for c-spine stabilization. TX according to assessment. DCAP-BTLS Pri 3

V2- Driver C-Collar, Extricate onto stretcher. Use 100mph tape and sandbags for stabilization of c-spine. Assess further and TX as indicated. DCAP-BTLS

V2- Passenger - C-Collar, Extricate onto stretcher. Use 100mph tape and sandbags for stabilization . Pelvic stabilization or TX due to possible pelvic fracture. IV therapy if pelvic fracture is determined. DCAP-BTLS Pri 2

V2 – Gunner – C-collar, assess for head injury, C-spine and T-spine injury. Stabilization using tape and sandbags. DCAP-BTLS. Pri 1 transport.



(5) Transport?


All 5 stretcher PT’s will need to get to a Med Facility ASAP. Helo medevac. Walking wounded can take a ride back to the hospital.

[Surgicalcric]

Not bad guys for your first MVA.

1.) Windshield survey
The purpose of the windshield survey is to identify the type of incident(s) you have, immediate needs that may require assistance from other personnel outside of whats immediately available, any hazards on scene, and call for assistance prior to dismounting your vehicle . It is a basic overview or method of reporting back to command before getting busy with the job at hand.

In this case it should go something along the lines of: 2-vehicle rear-end MVA with major damage to both vehicles; one patient ejected; one vehicle leaking unknown fluid, possible fire/HAZMAT; multi-PT's; no apparent entrapment, start MED EVAC coordinates to follow.

2.) Vehicle safety/stabilization considerations
Anytime you are working in or around vehicles that have been involved in an accident make sure they are in Park and the engine is off. If possible set the parking break. (On a civilian EMS note, never stick your head in the drivers compartment between the driver and steering wheel if the airbag has not deployed. It hurts to get hit by one...trust me).

If a vehicle is on its side or top never crawl in or near the vehicle before it is stabilized to the point it will not move or rollover on you. If the vehicle is on a bank/bridge/cliff tie it off to something stable.

Fire hazard/fluid leaking is another hazard that is very real and needs to be dealt with. If its gas/diesel the patients should be removed ASAP. There should idealy be someone with a fire extinguisher standing by. Be sure to protect any patients from the fluids. This is especially a concern with rollovers. If exposed to fuel be sure to wipe the exposed body part(s) off before placing them on the stretcher/LSB. If left on a LSB lying in fuel for a while a patient can, and in many cases will, develop chemical burns.

3.) Probable injuries based on impact
V1: Patients in vehicles struck in the rear are the more susceptible to c-spine (whiplash) and lumbar spine injuries than any other type of injury. From time to time they will suffer an injury from something flying around in the vehicle but generally speaking I would be worried more about spinal injury than anything else.

As the second vehicle struck the patient's his vehicle will have been placed in forward motion. His upper torso will have flexed rearward, at the hips or some other point along the spine, while his lower body moves forward with the vehicle. Due to the impact area, and lack of spinal support that those inside the vehicle are provided by seating, this young trooper is going to have some serious potential for spinal compromise and secondary head trauma from secondary impact with the weapon as the vehicle comes to a stop.

V2 Driver: Unrestrained drivers of vehicles, without airbags, struck in the front end have a high incidence of blunt chest trauma with pneumothorax (paperbag effect) from striking the steering wheel with the chest; head injury and c-spine injury from striking the windshield with their face; knee injury from striking the dashboard; and ankle/tib-fib fx from the peddles.

Passenger: Somewhat the same as the driver with the exception being a lower incidence of blunt chest trauma (no steering wheel) and a higher incidence for hip and pelvic fracture secondary to the passenger’s legs and torso moving forward and their knees sliding under the dash. This pressure is transferred back thru the femurs to the hip/pelvis area most often fracturing the hip or pelvis. This incident is not as high with the driver due to the steering wheel limiting the forward motion of the hips.

Gunner: Having been ejected there are all types of impact injuries he could suffer. His injuries could range from abrasions to fractures, spinal injuries, internal injuries from secondary impact of the organs inside the body, tension pneumo, head injuries, etc... This patient is also the one who will cause you the most alarm.

4, 5) TX & X-port
Everyone gets spinal immob with collar. Sandbags and 100mph tape for H/BID for critical(s).
V-1: Both driver and passenger Priority 3. Walking wounded.

V-1 Gunner: Priority 1 full spinal precautions, IV and rapid EVAC.

V-2 Driver: Priority 1 if unresponsive/ Priority 2 is no LOC, full spinal and EVAC, other TX according to ABC’s and secondary findings.

V-2 Passenger: Priority 3 as long as no other significant injury noted. Full spinal immobilization with precautions taken to immobilize injured hip.

V-2 Gunner: Priority 1 Immediate EVAC, full spinal immobilization, other TX according to findings.


Good job guys. Let me know if you want another.

[Sacamuelas]

James-
I would like to see the actual step by step procedure for the V2 passenger's stabilization. He is the one in the HMMWV with a suspected hip fracture/cervical injuries. Some of us are not used to /trained for getting access to patients "still in a vehicle".
What order, what device/material/technique used, and where on the scene each step is accomplished during the evac.

[Surgicalcric]

Methods of gaining access to patients can vary greatly depending on vehicle, accessability to vehicle, location of patient within vehicle, position of vehicle, and structural integrity of and intrusion into the patient compartment. I am not going to go into all the what if’s and how to's involved with gaining access to the patient, as we could very well be here all day with me throwing out scenarios, circumstances, and talking about all the cool can opener tools I have at my disposal to destroy a vehicle.

On this vehicle access to the patient would be easiest gained thru one of the doors since there is no structural intrusion into patient compartment. The passenger front door would be opened and removed from hinges if possible. If not it would be pushedas far open as it possibly could be.

The medic would direct another soldier to gain access from the rear door-passenger side and educate him on taking C-spine control if not already familiar, while he removes the patient's kevlar. (This is done by opening the hands wide griping the patients head/neck, being sure not to cover the ears so patient’s hearing is not impaired, and hold the head securely and firmly.) Any equipment removal should only be performed after C-spine control is initiated. A Collar should be fitted and placed around the patient’s neck if available. If a Collar is not available a rolled towel in the shape of a yoke can be used as a field expedient collar.

Another assistant would place one end of a folding stretcher(handles), LSB here in the civilian world, on the edge of the patient’s seat and hold the other end securely placing enough pressure inward on the stretcher to keep it from sliding off the seat edge as the patient is moved. The medic, taking hold of the patient’s BDU pants at the front pockets, will lift his butt up. (This is going to cause some discomfort to the patient, but the level of discomfort can be minimized with smooth movements instead of choppy, abrupt ones. The patient should also be advised of any movements prior to making them and to keep their hands and arms across their chest and not try to help.) As the patient is lifted, the stretcher is pushed underneath the patient’s butt. The patient is then lowered onto the stretcher as the body, in whole, is turned facing out the doorway. This should be done in one motion as to minimize stress on the back with twisting and discomfort in the injured extremity.

He would then be slid out and onto the stretcher, while laying him supine, in as smooth a movement as possible. Once onto the stretcher sandbags should be placed on each side of his head to provide immobilization of the cervical spine during movement and transport. The patient's body should be secured to the stretcher with 100 mph tape at the shoulders, hips, and ankles. The head is then taped down. One wrap of tape over the forehead and around the sides of the stretcher should suffice. The head is ALWAYS taped last and once taped down manual C-spine can be released. After patient is immobilized he can then be moved onto the ground or into an Ambulance, or Bird.

The person holding C-spine is in total control of all patient movements prior to immobilization. All movements will be on a three count/command. Movements are made so as the C-spine remains inline with the rest of the spine as a whole and any bending would be done at the hips and not at a point anywhere on the spine. This is easier said than done in the field. If there is not 3 people available the oerson holding C-spine can be omitted but know a Collar is not enough to secure the cervical spine inline whike extricating a patient from a vehiclepatient movement

I am aware it seems time consuming, as I would presume anything would while under fire. It takes much less time to perform than it sounds like though. From first contact to having patient secured onto the stretcher should take no more than 4 minutes. If under fire many of these steps will be omitted, but for discussion and training I think it is important to note all the steps.

HTH

[Eagle5US]

That was great...good job all. Toofmechanic, good on ya for taking a stab at it...

Eagle

[Sacamuelas]

Great post Surgicalcric.

That is exactly what I was looking for in my question. I was unsure whether you would attempt any field fixation method /temp. support of the hip before moving the patient onto a stretcher and out of the vehicle.

I was thinking 100mph tape around the thighs with something in between them (small sandbag/or rolled poncho between the knees) to support and fixate the fractured hip. That way you could help reduce further blood loss from occurring due to an open/displaced pelvic fracture. All this after securing his cervical area with a c collar of course.

Anyway, that is why I see the mouths to fix the teeth and jaws AFTER they have been "saved". Thanks again James

Eagle- You know me. I am not afraid to admit ignorance. I always post a disclaimer when I am "out on a limb" though. We all have specialties... mine are just boring.

[Surgicalcric]

There are many field expedient methods of splinting and immobilizing a Fx hip. Kendrick Extrication Device (KED) in civilian EMS, MAST, and pillows or sandbags and 9' straps are the first few that come to mind.

As for immobilization of the hip while the patient is still inside the vehicle; ain't gonna happen. First off the pelvis cannot be properly assessed and it is much easier and faster once they are out where you have unimpeded access to their loser extremities. Generally speaking hip Fx are splinted against the uninjured extremity with a pillow for support under the knees. This also seems to be the POC for most patients I have come in contact with.

It is easy to succumb to tunnel vision and misdiagnose a pelvic Fx for a hip Fx while the patient is still inside the vehicle, as the patient will complain of pain to the entire hip/pelvis region while in a sitting position. Before splinting what you believe to be a hip Fx be sure to access the patients pelvic stability regardless of associated pain. Here in EMS there have been many instances where the patient was fully immobilized (collar, LSB, straps) and on a stretcher or in the Bus before the pelvis was even given a thought. Only after having unexplained HTPN did the medic think to check it. Having to stop, unstrap the head and body, splint the pelvis and then re-immobilize the entire body is very time consuming and very labor intensive, especially in an ambulance. It is also bad for the patient...lol.

All that to say, be sure to perform a detailed assessment before deciding on an appropriate method of immobilization. If under fire this would definately be a scoop and shoot patient though.

Good job Sacamuelas.

[Eagle5US]

you may consider using a "Cravat Diaper" basically securing a couple of cravats in a diaper like configuration to keep things minimally compressed, but at least not free to totally move around...at least until they are out and can be better immobilized...

Eagle