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#57 I Want To Play A Game...


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#1 SerendepitySaki

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Posted 09 July 2012 - 05:56 PM

Attached File  TheSawpuppet.jpg   15.29KB   0 downloads"POP QUIZ! You and your friends are hiking when your friend slips down a 40 foot hill and striking some large rocks on the way down. When you reach him, you call out and get no response, his face is bloody, he's making strange snoring sounds when he breathes and his right upper leg is bent at an odd angle with the femur sticking out and bright red blood is pulsing from the wound into a large pool spreading out beneath him. "

Please list your interventions in order of priority and provide rationales for both the intervention and the priority....

This was posted elsewhere... if you have already seen the case and/or my response, please hold commentary until the end... I am posting it here to informally see how this audience's answers compare and contrast with those given elsewhere...
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#2 Sue

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Posted 10 July 2012 - 01:18 AM

Attached File  TheSawpuppet.jpg   15.29KB   0 downloads"POP QUIZ! You and your friends are hiking when your friend slips down a 40 foot hill and striking some large rocks on the way down. When you reach him, you call out and get no response, his face is bloody, he's making strange snoring sounds when he breathes and his right upper leg is bent at an odd angle with the femur sticking out and bright red blood is pulsing from the wound into a large pool spreading out beneath him. "

Please list your interventions in order of priority and provide rationales for both the intervention and the priority....

This was posted elsewhere... if you have already seen the case and/or my response, please hold commentary until the end... I am posting it here to informally see how this audience's answers compare and contrast with those given elsewhere...


I'll bite....

I am hoping there is more than just me. I would be having someone call for help or go get help, while I open his airway and clear any obvious obstructions. I am still hoping there is more than one of me who can maintain the airway and c-spine while I manage to find a way to stabilize the femur fx and stop the bleeding. I am going right for the tourniquet, either home made or handy dandy in my first-aid kit. I would also splint with a tree branch if need be.

Not sure what kinds of goodies I have with me, so I will stop there. Try to keep this person warm and pray for the rest. It isn't looking too good.

Sue
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Sue Toberman, RN

#3 SerendepitySaki

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Posted 10 July 2012 - 01:35 AM

my apologies, sue... i should have specified.... the scenario was almost word for word, exactly what i quoted...so, we'll use my standard ROE... you can have almost anything you want, within reason.... so, say at least two additional sets of hands, clear comms, and an above average 1st aid kit... the goal here isn't to place obstacles, but quite literally, just to see what this particular audience (Flight Web) prioritizes and why....

I'll bite....

I am hoping there is more than just me. I would be having someone call for help or go get help, while I open his airway and clear any obvious obstructions. I am still hoping there is more than one of me who can maintain the airway and c-spine while I manage to find a way to stabilize the femur fx and stop the bleeding. I am going right for the tourniquet, either home made or handy dandy in my first-aid kit. I would also splint with a tree branch if need be.

Not sure what kinds of goodies I have with me, so I will stop there. Try to keep this person warm and pray for the rest. It isn't looking too good.

Sue


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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#4 ForeverLearning

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Posted 10 July 2012 - 01:43 AM

These usually turn out like fun. I recall medic class scenarios you respond to a residence of a man who fell of a ladder in his garage because he got electrocuted from loose wire and got bit by spider who has a hour glass appearance on his back as he hit the ground, you smell exhaust fumes from an engine as you approach the scene.. (Because this case prepares me for the real job of being a paramedic)


So...Immediate life threats would take precedence, and I am not carrying any bags/kits or gear on me.


1-Call for help
2- Control hemorrhage with T shirt or whatever else I can use for a tourniquet. It's a life threat besides he is still breathing (via snoring resp).
3- Open airway (jaw trust (is by the book) if you cant maintain go to head tilt chin lift)

Hope help comes fast.





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#5 SerendepitySaki

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Posted 10 July 2012 - 01:48 AM

look up, FL...we probably posted at the same time... you are NOT resource poor in this scenario... you can have CATs, etc...

These usually turn out like fun. I recall medic class scenarios you respond to a residence of a man who fell of a ladder in his garage because he got electrocuted from loose wire and got bit by spider who has a hour glass appearance on his back as he hit the ground, you smell exhaust fumes from an engine as you approach the scene.. (Because this case prepares me for the real job of being a paramedic)


So...Immediate life threats would take precedence, and I am not carrying any bags/kits or gear on me.


1-Call for help
2- Control hemorrhage with T shirt or whatever else I can use for a tourniquet. It's a life threat besides he is still breathing (via snoring resp).
3- Open airway (jaw trust (is by the book) if you cant maintain go to head tilt chin lift)

Hope help comes fast.






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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#6 FlyingScot

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Posted 10 July 2012 - 02:21 AM

1. Scene Safety: Are you going to fall or is something going to fall on you.
2. BSI
3. Primary Survey: ABC's, treat life threats (open airway while protecting C-spine, one helper apply pressure to wound, one
helper calling 911 then applying tourniquet and noting time of application)
4. Secondary survey: Head to toe following DCAP-BTLS. Realign leg and determine if mid-shaft fracture and need for traction.
Treat for shock by covering with jackets, sleeping bags whatever. If you can safely get something under him that's better.
5. If midshaft...lucky me I hike with treking poles and I have an aluminum plate with two holes drilled into it in my pack (I
really do). Find length of pantyhose with butt and foot cut off in pack and slide over poles. Insert tips of poles into
plate and secure with tape. Apply ankle hitch to affected extremity with cravat.Apply gentle manual traction and slide splint
under leg with poles on each side and hose acting as sling for leg. Position splint so there is at least 6 inches between
foot and metal plate. Secure tops of poles to sides of upper leg with cravat. Utilize another cravat to provide traction by
looping through ankle hitch and around metal plate and twisting with the windlass that I also carry. Apply remaining cravats
to legto secure splint. Make sure to check PMS before and after. If no poles available a 3-4 inch diameter tree limb long
enough to go from armpit to 8 inches past foot and notched on both ends will work. Actually, even more lucky for me I carry a
Kendrick device in my pack (again, I really do) which just makes the entire process a whole lot easier.
6. Not midshaft: tree limb or treking pole secured to outside of leg then BOTH legs secured together
7. Of course during all of this ABC's are continually reassessed addressed as needed with an OPA if no gag reflex. Otherwise
it's the good old jaw thrust.

Are those chopper blades I'm hearing?


BTW...for those of you wondering why I carry all that crap. No I'm not an over-zealous crew member. I am a National Ski Patroller and these are the things we carry because we're poor and we don't always have the fancy equipment available. Also, panty hose are the duct tape of a first aid kit
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#7 FlyingScot

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Posted 10 July 2012 - 02:23 AM

These usually turn out like fun. I recall medic class scenarios you respond to a residence of a man who fell of a ladder in his garage because he got electrocuted from loose wire and got bit by spider who has a hour glass appearance on his back as he hit the ground, you smell exhaust fumes from an engine as you approach the scene.. (Because this case prepares me for the real job of being a paramedic


Not nearly as fun as the busload of hemophiliacs hit by a truck full of razor blades!
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#8 SerendepitySaki

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Posted 10 July 2012 - 02:45 AM

YaaaaaaaaaaaaaaaaaaaaaaaaaY! Flying Scot! i have MISSED you! was putting together another neo case for Baby Ann and hoping you'd play there.....getting you here is just uber bonus!!!

going to give it a little longer, just to solicit enough responses for rough statistical comparison before I post my original reply/answer (s).....
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#9 SerendepitySaki

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Posted 11 July 2012 - 01:44 PM

Good Stuff folks... was hoping for more.... reason for posting... quite a few respondents on the original went for airway first....

My Answers:

"1. have other friend call HEMS medevac, preferably w/ hoist capacity...scout/perform safe descent... CAT femoral artery bleed w/ possible fx stabilization to prevent further vascular trauma. rationale... get xport in air ASAP and per Oxyhemoglobin Dissociation Curve, his little red trucks will be all over the canyon floor long before he desats... Then, airway with manual in-line cervical stabilization, followed by femur fx stabilization if not already performed... scalp lac(s) and environmental (heat/cold) last.

2. physiology doesn't care who's algorithm it is... we are CLINICIANs ...NOT TECHNICIANs... we know WHY we do WHAT we do.... for example...it doesn't do you ANY good to oxygenate RBCs that are spilling into the dirt... End Organ Perfusion is ALWAYS the correct answer..."


OP's resolution:

"Good answers folks. Just remember, as I'm scanning the victim I'm looking for any life-threatening bleed, which, even though NREMT says airway is king, is going to be my highest priority. You lose enough blood to go into shock and survival rate decreases almost exponentially. We've got to think critically and "outside the box" in this situation in order to give the victim the best outcome. Stay safe."
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#10 FlyingScot

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Posted 11 July 2012 - 05:24 PM

However, with me and two helpers all of what I stated in step 3 can be done simultaneously (because I never hike with civilians lol). Actually, even with civilians it wouldn't be too hard to tell them what and how to do it in a very short period of time (except for my BF who freaks out and can't even dial 911 under stress).
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#11 SerendepitySaki

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Posted 11 July 2012 - 05:30 PM

no doubt in my mind you're wired tight, FS... it would be a pleasure and a privilege to work w/ you!

However, with me and two helpers all of what I stated in step 3 can be done simultaneously (because I never hike with civilians lol). Actually, even with civilians it wouldn't be too hard to tell them what and how to do it in a very short period of time (except for my BF who freaks out and can't even dial 911 under stress).


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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#12 ForeverLearning

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Posted 11 July 2012 - 07:04 PM

In scenarios as such common sense and good BLS care with prompt transport will dictate the terms. With dissociation curve actually going into right shift, the elevation of CO2 from his breathing/tissue demand will drop PO2 pressure lending itself to a better dissociater of O2 to the tissues. My approach would still be the same even with all the toys its call for help, control hemorrhage, airway.


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#13 Medic09

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Posted 15 July 2012 - 07:31 PM

TQ immediately. This is severe bleeding, which can be life threatening pretty quickly.

Adjust airway, assess if more definitive action needed, protect C-spine as much as possible in process. Self-explanatory, I think.

Call for help.

Go on from there.
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Mordechai Y. Scher
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It's all about kind, competent patient care; and getting home safely to tell about it.


#14 Canis doo

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Posted 15 July 2012 - 08:27 PM

Ensure Iím not going to become a victim by playing Cliff Hanger paramedic. Yell/Phone for help.

Honestly, yes this is importantÖbut in real life I would act and then yell in a lot of situations. Have you called your own dispatch centers lately? They canít find the sun when its 12 Noon and the EMD programs ask to tell them when each breaths are. Yes Iím being cynical but I think there are higher priorities at the moment in the woods.

Stop the bleeding with a belt, ripped shirt, shoe lace or whatever means I can subjectively MacGyver. I know the proper means of tourniquet making and Yes, the Windlass methods are important, but not at this time. I just need the squirting to stop for the next five min.

Place the victim in Rescue Recovery Position being mindful of the spine and clear the airway.

Expose the patient for any other injures hidden or life threatening injuries.

Return to the leg deformity. Expose the site and try to identify the bleeding applying direct pressure to site of bleeding. Set the leg in traction method using a branch, belt and or shoe laces then pack and dress the wound with materials at hand.

Pray you donít have AT&T and reception is made to 911. Hopefully GPS works and you have help on the way




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Jason Howard LP, FP-C
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#15 MSDeltaFlt

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Posted 25 July 2012 - 03:17 PM

Hmm. I'm not very well versed on wilderness medicine, but here goes.

If able have one friend call for help with coordinates. This will obviously be a wilderness scene flight with rescue abilities.

Then my friends and I would repel down the slope to the pt. GCS is low. We're stuck on airway with C-Spine. So get a line and tube him. Log roll him and control the airway with C-Spine while another friend straightens the leg. Hopefully it will bring the femur back in and maintain distal pulse. If the bleeding continues, tourniquet the leg.

Find something, if possible, to assist him back up the slope while maintaining C-Spine.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain