03-09-2004, 15:15
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#16
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Quiet Professional
Join Date: Jan 2004
Location: Tampa
Posts: 2,531
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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
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Primum non Nocere
"I have hung out in dangerous places a lot over the years, from combat zones to biker bars, and it is the weak, the unaware, or those looking for it, that usually find trouble.
Ain't no one getting out of this world alive. All you can do is try to have some choice in the way you go. Prepare yourself (and your affairs), and when your number is up, die on your feet fighting rather than on your knees. And make the SOBs pay dearly."
The Reaper-3 Sep 04
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Eagle5US is offline
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03-09-2004, 17:09
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#17
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Quiet Professional
Join Date: Jan 2004
Location: Wherever my ruck finds itself
Posts: 2,972
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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.
__________________
"It's better to die on your feet than live on your knees."
"Its not who I am underneath, but what I do that defines me" -Batman
"There are no obstacles, only opportunities for excellence."- NousDefionsDoc
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Surgicalcric is offline
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03-09-2004, 17:11
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#18
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Quiet Professional
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Location: Tampa
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good start...
Sacamuelas??? Anything to add / delete / change?
Eagle
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Primum non Nocere
"I have hung out in dangerous places a lot over the years, from combat zones to biker bars, and it is the weak, the unaware, or those looking for it, that usually find trouble.
Ain't no one getting out of this world alive. All you can do is try to have some choice in the way you go. Prepare yourself (and your affairs), and when your number is up, die on your feet fighting rather than on your knees. And make the SOBs pay dearly."
The Reaper-3 Sep 04
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Eagle5US is offline
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03-09-2004, 17:13
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#19
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Quiet Professional
Join Date: Jan 2004
Location: LA
Posts: 1,653
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Why Ketamine Crip?
__________________
Somewhere a True Believer is training to kill you. He is training with minimal food or water, in austere conditions, training day and night. The only thing clean on him is his weapon and he made his web gear. He doesn't worry about what workout to do - his ruck weighs what it weighs, his runs end when the enemy stops chasing him. This True Believer is not concerned about 'how hard it is;' he knows either he wins or dies. He doesn't go home at 17:00, he is home.
He knows only The Cause.
Still want to quit?
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NousDefionsDoc is offline
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03-09-2004, 17:16
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#20
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Consigliere
Join Date: Jan 2004
Location: Free Pineland (at last)
Posts: 8,841
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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.
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Roguish Lawyer is offline
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03-09-2004, 17:50
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#21
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Quiet Professional
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Quote:
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.
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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
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"It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat." - President Theodore Roosevelt, 1910
De Oppresso Liber 01/20/2025
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The Reaper is offline
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03-09-2004, 17:59
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#22
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JAWBREAKER
Join Date: Jan 2004
Location: Gulf coast
Posts: 1,906
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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?
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"If you live here you better speak the language. This is supposed to be a melting pot not a frigging stew" - Jack Moroney
Last edited by Sacamuelas; 03-09-2004 at 20:34.
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Sacamuelas is offline
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03-09-2004, 20:10
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#23
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Quiet Professional
Join Date: Jan 2004
Location: OCONUS...again
Posts: 4,702
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In a field environment...
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!
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-DE OPPRESSO LIBER-
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Guy is offline
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03-09-2004, 20:16
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#24
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Quiet Professional
Join Date: Jan 2004
Location: Tampa
Posts: 2,531
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in my medicated state...
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
__________________
Primum non Nocere
"I have hung out in dangerous places a lot over the years, from combat zones to biker bars, and it is the weak, the unaware, or those looking for it, that usually find trouble.
Ain't no one getting out of this world alive. All you can do is try to have some choice in the way you go. Prepare yourself (and your affairs), and when your number is up, die on your feet fighting rather than on your knees. And make the SOBs pay dearly."
The Reaper-3 Sep 04
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Eagle5US is offline
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03-09-2004, 20:21
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#25
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Quiet Professional
Join Date: Jan 2004
Location: Free Pineland
Posts: 24,825
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Got Blood?
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
__________________
"It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat." - President Theodore Roosevelt, 1910
De Oppresso Liber 01/20/2025
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The Reaper is offline
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03-09-2004, 20:22
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#26
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Quiet Professional
Join Date: Jan 2004
Location: LA
Posts: 1,653
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LOL - "Hey you, what's with the stick up the ass?"
__________________
Somewhere a True Believer is training to kill you. He is training with minimal food or water, in austere conditions, training day and night. The only thing clean on him is his weapon and he made his web gear. He doesn't worry about what workout to do - his ruck weighs what it weighs, his runs end when the enemy stops chasing him. This True Believer is not concerned about 'how hard it is;' he knows either he wins or dies. He doesn't go home at 17:00, he is home.
He knows only The Cause.
Still want to quit?
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NousDefionsDoc is offline
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03-09-2004, 20:28
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#27
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JAWBREAKER
Join Date: Jan 2004
Location: Gulf coast
Posts: 1,906
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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... 
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"If you live here you better speak the language. This is supposed to be a melting pot not a frigging stew" - Jack Moroney
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Sacamuelas is offline
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03-09-2004, 21:11
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#28
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Guest
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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.
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03-09-2004, 21:15
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#29
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Quiet Professional
Join Date: Jan 2004
Location: LA
Posts: 1,653
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What would the prognosis be where you are Doc T?
__________________
Somewhere a True Believer is training to kill you. He is training with minimal food or water, in austere conditions, training day and night. The only thing clean on him is his weapon and he made his web gear. He doesn't worry about what workout to do - his ruck weighs what it weighs, his runs end when the enemy stops chasing him. This True Believer is not concerned about 'how hard it is;' he knows either he wins or dies. He doesn't go home at 17:00, he is home.
He knows only The Cause.
Still want to quit?
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NousDefionsDoc is offline
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03-09-2004, 21:18
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#30
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Guest
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Quote:
Originally posted by NousDefionsDoc
What;s would the prognosis be where you are Doc T?
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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.
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