Trauma Scenario I
 

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?

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.:D So the question is sort of moot.;)

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.

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.

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!

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.

Paper vs. plastic?
 

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?

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.

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!

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

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 ;)