Post by Tony Held on Nov 23, 2016 16:29:26 GMT -6
The Stable Grossly Traumatized Patient – Does It Exist?
Street Medicine Sucks – Case Study Series by Anthony Held, NR-P
This case study will lull you to sleep with a run of the mill motorcycle crash and then punch you in the gut with a reminder that your medical knowledge is crucial in not killing trauma patients.
The call: Motorcycle versus car. Caller saw the driver “fly through the air” and had no detailed patient information. Now for the lay people reading, I know that sounds glamorous. A helmeted superman rocketing through the sky that will surely end in horrid injury…. But the reality is most of our motorcycle wrecks just don’t go that way. Usually some scrapes, maybe a concussion here and there, but MOST motorcycle wrecks are benign if the rider was wearing protective gear. Back to the story… Caller states the rider is male, has an obviously broken leg, and the left foot is hanging on by muscles. Well damn… maybe this is a bad wreck after all.
Arrival on scene: I parked to block the scene since I was first EMS provider on scene and noted a pretty hectic scene. One motorcycle in the roadway with heavy damage, several bystanders and police officers around a motorcyclist laying left lateral recumbent, still has his helmet on. Yay! I did an initial patient evaluation as I approached the motorcyclist. Trauma experts need only the smell of blood in the air to know exactly how and when their patient was injured. They can practically rewind time and watch the injury happen to their patient and visualize every injury as it unfolded... That’s not me. I hate trauma. I find it boring, gross, and could go my whole career without another injured patient. We learn to stop bleeding, keep anything broken from breaking worse, and get them to a surgeon. I learned all this MEDICINE to help people and now I’m being reduced to a band-aid station… Ok so some of our band-aids are really big, but I hate trauma. Anyway… The police officer told me he put a tourniquet on the left leg, a bystander was holding a towel on something, and my patient’s left pant leg was really short. Weird…
Initial Assessment: Police were holding C-spine, patient was alert, confused, talking in full sentences, and that left pant leg was still short. What’s the deal? So my patient is awake, breathing, and alive! Hate. Trauma. Boring. Scrapes noted to the helmet which was open face. No trauma to the face, neck, shoulders, chest, abdomen, or upper extremities. Spine was without deformity or pain upon palpation. Pelvis felt stable, but he really started complaining about his leg while pushing on his pelvis. What’s that about? Legs were examined. Right leg exposed and had bruising over knee. Left leg had a CAT tourniquet placed on left thigh that was not appropriately tightened. I could fit my entire arm underneath it. Tourniquet was removed and left leg was exposed. As I moved to examine the lower left extremity, that bystander with the towel was in my way… She was refusing to move. She was pushing this towel or shirt or something down into the street and was shaking. I told her I had it under control and pushed her shoulder backward. As I reached down to lift the cloth she had been holding, a nearly complete amputation distal of left knee was noted with 4-6 inches of exposed tibia. Minimal oozing of blood was noted. THAT’S why his left pant leg is short! Now it makes sense. Amputation was rough and mangled. Tissue behind the left knee was also heavily traumatized. CAT tourniquet was reapplied immediately proximal of left knee. He really started screaming with the tourniquet. Not much you can do in that situation, unfortunately. Tell him to bite his lip and turn the windlass. Man there’s just not much blood around this guy. That’s good I guess.
Treatment: Helmet was removed easily with no trauma noted to skull. Rigid c-collar was placed, patient was rolled onto long backboard and lifted to stretcher, and then he was moved to ambulance. Transport was initiated with immediate report given to trauma center due to short ETA. They asked me for a blood pressure…. I told them I had no idea; he was missing part of his leg but was still awake and alert. I’ll get a blood pressure before I get there. Just call the surgeons, OK? I made my first priority getting IV access on this guy. If he’s awake and alert, he needs pain medicine or this is going to be the worst memory of his life. My EMT partner was grabbing vital signs while I placed an IV. My EMT student did a great patient interview, and no matter how she asked, he denied medical history. Mid 60’s year-old with no medical history? You’re the luckiest guy on Earth! Well except for the missing leg part. Initial vital signs: BP 100/52, HR 68, RR 22, SpO2 97%, GCS 14. Oh buddy, your vitals are GREAT! You get pain medicine like you can’t even imagine! See I’m the candy man on my ambulance. If it hurts, I’ll make it better. No questions asked. I don’t believe in that “you’ve gotta earn it” crap. And if it hurts ME to look at it? Yeah you’re getting the good stuff. 100mcg Fentanyl IV should be a good start. Quick onset, no vasoactive properties. My drug of choice for pretty much everything musculoskeletal. As the Fentanyl is going in, I noted that his hands were cool and moist.
Reassessment: Pain was untouched by the 100mcg Fentanyl. No surprise there. I was just getting started anyway. Trending vital signs: BP 81/32, HR 96, RR 22, SpO2 96%, GCS 14. What the hell? Great vitals before, gave a medication that shouldn’t affect blood pressure, no blood on scene… Whatever I’m at the hospital.
Emergency Department: Patient receives rapid transfusion protocol in ER and is rushed to OR. Hmm… must have just not shown signs of shock until after I gave him the Fentanyl. Glad I’m such a great paramedic. I’m so fast and accurate, I managed to get him pain medicine before he decompensated... Wait, when was he compensating?
Hospital Course: Miraculously, patient receives a below knee amputation in the OR instead of an above knee amputation. Makes a big difference in recovery and prosthetics. Fractured right femur put together with an external fixator. Discharged to inpatient rehab two weeks later.
So what in the world happened?
I honestly thought I rocked this call like a badass. I absolutely hate when people say they didn’t have time to give pain medication when they had a patient with a devastating injury. My patient had no signs of shock and no medical history to indicate he may be taking medications disguising shock. That’s the green light to unload Fentanyl like a model-year clearance event. So if I did that great, why did my patient meet the trauma team with a MAP of 48?
The Big Mystery: Was my patient in compensated shock? Most assuredly. I just missed it. Was he taking a beta-blocker? He said no but maybe. Hell, probably. He was in his 60’s, why was I believing every facet of a patient interview in a confused traumatized patient. But at the end of the day, did it make sense that he was missing part of his leg and had such great vital signs? Absolutely not. Made no sense at all, but I ignored it. Did it make sense that he had a mangled amputation and there was hardly any blood around this guy? Made no sense at all. That leg should have been bleeding like crazy! I completely ignored that my patient’s location at time of injury was 20 yards long and that I had a bystander soaking blood up before I got there. I also ignored that while administering Fentanyl, my patient’s hands were cold and clammy, despite “normal” vital signs. When things don’t make sense, we should pay attention. There’s a reason they don’t make sense.
Lessons Learned: Patients showing signs of compensated hypovolemic shock should receive smaller doses of analgesic medications (Fentanyl should be dosed at 12.5-25mcg) due to their propensity to reduce or eliminate sympathetic response.
How to Avoid This Pitfall: Really evaluate who your patient is in the first place and start assuming some reasonable history if their mental status is compromised. Have a high index of suspicion when things aren’t adding up. Always do a strong trauma assessment before making care decisions.
Street Medicine Sucks – Case Study Series by Anthony Held, NR-P
This case study will lull you to sleep with a run of the mill motorcycle crash and then punch you in the gut with a reminder that your medical knowledge is crucial in not killing trauma patients.
{The Guts - Click Here for the Quick and Dirty}The Patient: Motorcycle versus car. Below left knee nearly complete amputation. Mid 60’s year-old male. Awake and alert, but in a lot of pain. Minimal blood on scene.
Initial Treatment: Tourniquet left leg, c-spine immobilization, transport
Initial Vitals: BP 100/52, HR 68, RR 22, SpO2 97%, GCS 14
Medical Hx: Patient denies
Treatment: 100mcg Fentanyl IV, pale cool extremities during administration.
Trending vitals: BP 81/32, HR 96, RR 22, SpO2 96%, GCS 14
What Happened?: Fentanyl removed sympathetic compensation and dumped blood pressure. Patient more than likely could not self-report beta-blocker usage due to pain and stress response. Dosage of Fentanyl was likely excessive due to decreased blood volume.
Lessons Learned: Compensated shock is not always easily identified. Patient history in a confused patient is not always reliable, and scene information can be confusing. Patient was likely to be taking a beta-blocker, and also was very likely to be volume depleted. Fentanyl administration reduced or negated sympathetic response, resulting in a MAP of 48. Smaller doses of Fentanyl (12.5-25mcg) are more appropriate for patients suspected to be in compensated hypovolemic shock. But you have to suspect it in the first place.
How to Avoid This Pitfall: Make reasonable assumptions about medical history if your patient is unreliable. Have a high index of suspicion when things aren’t adding up. Always do a strong trauma assessment before making care decisions.
Initial Treatment: Tourniquet left leg, c-spine immobilization, transport
Initial Vitals: BP 100/52, HR 68, RR 22, SpO2 97%, GCS 14
Medical Hx: Patient denies
Treatment: 100mcg Fentanyl IV, pale cool extremities during administration.
Trending vitals: BP 81/32, HR 96, RR 22, SpO2 96%, GCS 14
What Happened?: Fentanyl removed sympathetic compensation and dumped blood pressure. Patient more than likely could not self-report beta-blocker usage due to pain and stress response. Dosage of Fentanyl was likely excessive due to decreased blood volume.
Lessons Learned: Compensated shock is not always easily identified. Patient history in a confused patient is not always reliable, and scene information can be confusing. Patient was likely to be taking a beta-blocker, and also was very likely to be volume depleted. Fentanyl administration reduced or negated sympathetic response, resulting in a MAP of 48. Smaller doses of Fentanyl (12.5-25mcg) are more appropriate for patients suspected to be in compensated hypovolemic shock. But you have to suspect it in the first place.
How to Avoid This Pitfall: Make reasonable assumptions about medical history if your patient is unreliable. Have a high index of suspicion when things aren’t adding up. Always do a strong trauma assessment before making care decisions.
The call: Motorcycle versus car. Caller saw the driver “fly through the air” and had no detailed patient information. Now for the lay people reading, I know that sounds glamorous. A helmeted superman rocketing through the sky that will surely end in horrid injury…. But the reality is most of our motorcycle wrecks just don’t go that way. Usually some scrapes, maybe a concussion here and there, but MOST motorcycle wrecks are benign if the rider was wearing protective gear. Back to the story… Caller states the rider is male, has an obviously broken leg, and the left foot is hanging on by muscles. Well damn… maybe this is a bad wreck after all.
Arrival on scene: I parked to block the scene since I was first EMS provider on scene and noted a pretty hectic scene. One motorcycle in the roadway with heavy damage, several bystanders and police officers around a motorcyclist laying left lateral recumbent, still has his helmet on. Yay! I did an initial patient evaluation as I approached the motorcyclist. Trauma experts need only the smell of blood in the air to know exactly how and when their patient was injured. They can practically rewind time and watch the injury happen to their patient and visualize every injury as it unfolded... That’s not me. I hate trauma. I find it boring, gross, and could go my whole career without another injured patient. We learn to stop bleeding, keep anything broken from breaking worse, and get them to a surgeon. I learned all this MEDICINE to help people and now I’m being reduced to a band-aid station… Ok so some of our band-aids are really big, but I hate trauma. Anyway… The police officer told me he put a tourniquet on the left leg, a bystander was holding a towel on something, and my patient’s left pant leg was really short. Weird…
Initial Assessment: Police were holding C-spine, patient was alert, confused, talking in full sentences, and that left pant leg was still short. What’s the deal? So my patient is awake, breathing, and alive! Hate. Trauma. Boring. Scrapes noted to the helmet which was open face. No trauma to the face, neck, shoulders, chest, abdomen, or upper extremities. Spine was without deformity or pain upon palpation. Pelvis felt stable, but he really started complaining about his leg while pushing on his pelvis. What’s that about? Legs were examined. Right leg exposed and had bruising over knee. Left leg had a CAT tourniquet placed on left thigh that was not appropriately tightened. I could fit my entire arm underneath it. Tourniquet was removed and left leg was exposed. As I moved to examine the lower left extremity, that bystander with the towel was in my way… She was refusing to move. She was pushing this towel or shirt or something down into the street and was shaking. I told her I had it under control and pushed her shoulder backward. As I reached down to lift the cloth she had been holding, a nearly complete amputation distal of left knee was noted with 4-6 inches of exposed tibia. Minimal oozing of blood was noted. THAT’S why his left pant leg is short! Now it makes sense. Amputation was rough and mangled. Tissue behind the left knee was also heavily traumatized. CAT tourniquet was reapplied immediately proximal of left knee. He really started screaming with the tourniquet. Not much you can do in that situation, unfortunately. Tell him to bite his lip and turn the windlass. Man there’s just not much blood around this guy. That’s good I guess.
Treatment: Helmet was removed easily with no trauma noted to skull. Rigid c-collar was placed, patient was rolled onto long backboard and lifted to stretcher, and then he was moved to ambulance. Transport was initiated with immediate report given to trauma center due to short ETA. They asked me for a blood pressure…. I told them I had no idea; he was missing part of his leg but was still awake and alert. I’ll get a blood pressure before I get there. Just call the surgeons, OK? I made my first priority getting IV access on this guy. If he’s awake and alert, he needs pain medicine or this is going to be the worst memory of his life. My EMT partner was grabbing vital signs while I placed an IV. My EMT student did a great patient interview, and no matter how she asked, he denied medical history. Mid 60’s year-old with no medical history? You’re the luckiest guy on Earth! Well except for the missing leg part. Initial vital signs: BP 100/52, HR 68, RR 22, SpO2 97%, GCS 14. Oh buddy, your vitals are GREAT! You get pain medicine like you can’t even imagine! See I’m the candy man on my ambulance. If it hurts, I’ll make it better. No questions asked. I don’t believe in that “you’ve gotta earn it” crap. And if it hurts ME to look at it? Yeah you’re getting the good stuff. 100mcg Fentanyl IV should be a good start. Quick onset, no vasoactive properties. My drug of choice for pretty much everything musculoskeletal. As the Fentanyl is going in, I noted that his hands were cool and moist.
Reassessment: Pain was untouched by the 100mcg Fentanyl. No surprise there. I was just getting started anyway. Trending vital signs: BP 81/32, HR 96, RR 22, SpO2 96%, GCS 14. What the hell? Great vitals before, gave a medication that shouldn’t affect blood pressure, no blood on scene… Whatever I’m at the hospital.
Emergency Department: Patient receives rapid transfusion protocol in ER and is rushed to OR. Hmm… must have just not shown signs of shock until after I gave him the Fentanyl. Glad I’m such a great paramedic. I’m so fast and accurate, I managed to get him pain medicine before he decompensated... Wait, when was he compensating?
Hospital Course: Miraculously, patient receives a below knee amputation in the OR instead of an above knee amputation. Makes a big difference in recovery and prosthetics. Fractured right femur put together with an external fixator. Discharged to inpatient rehab two weeks later.
So what in the world happened?
I honestly thought I rocked this call like a badass. I absolutely hate when people say they didn’t have time to give pain medication when they had a patient with a devastating injury. My patient had no signs of shock and no medical history to indicate he may be taking medications disguising shock. That’s the green light to unload Fentanyl like a model-year clearance event. So if I did that great, why did my patient meet the trauma team with a MAP of 48?
The Big Mystery: Was my patient in compensated shock? Most assuredly. I just missed it. Was he taking a beta-blocker? He said no but maybe. Hell, probably. He was in his 60’s, why was I believing every facet of a patient interview in a confused traumatized patient. But at the end of the day, did it make sense that he was missing part of his leg and had such great vital signs? Absolutely not. Made no sense at all, but I ignored it. Did it make sense that he had a mangled amputation and there was hardly any blood around this guy? Made no sense at all. That leg should have been bleeding like crazy! I completely ignored that my patient’s location at time of injury was 20 yards long and that I had a bystander soaking blood up before I got there. I also ignored that while administering Fentanyl, my patient’s hands were cold and clammy, despite “normal” vital signs. When things don’t make sense, we should pay attention. There’s a reason they don’t make sense.
Lessons Learned: Patients showing signs of compensated hypovolemic shock should receive smaller doses of analgesic medications (Fentanyl should be dosed at 12.5-25mcg) due to their propensity to reduce or eliminate sympathetic response.
How to Avoid This Pitfall: Really evaluate who your patient is in the first place and start assuming some reasonable history if their mental status is compromised. Have a high index of suspicion when things aren’t adding up. Always do a strong trauma assessment before making care decisions.