In a situation like this, I like to have a primary plan, and then a secondary 4 minute plan. The primary
plan assumes that you can gain control of the patient and the secondary plan is the "salvage what
you can before hypoxia and take the consequences later" plan.
We are now at T+20 mins or so. Two helicopters are now en route, with ETAs of 5 minutes and 20
minutes. The cables are neoprene covered, but 240v. Fire can not yet confirm they are safe, and so
allow no access from the passenger side (top) of cab. A single iv line can be inserted in the right
forearm, and 2 litres of crystalloid are being infused. There is still no evident blood. He is now in
considerable pain and distress. There is now access to the field alongside the cab, and the
ground is hard enough for an ambulance. There is a good helicopter landing site within 100m. The
first (passenger) patient is packaged now, and the crew are happy to look after him.
What should your primary and secondary plans be? (I'll explain what I did as it unfolds, but I'm not
claiming it was right).
> Interesting!
>
> As far as scene safety is concerned, the Fire crew appear to have had a
> fairly close examination of him and lived to tell the tale. This does
> not necessarily mean all is safe, however. I would specifically get the
> Fire Officer to confirm that it WAS safe and then trust him.
>
> You mention the skull contents still work, the neck is sound and the
> chest intact. What is then causing the pressure loss in the system? All
> you have left is belly, pelvis and femurs. You can't assess much of the
> leg, so what can you tell us about belly and pelvis? We may not be
> allowed to see the leg but is there a puddle of red stuff forming below
> it anywhere?
>
> Assuming the leg is the sole injury then the decision has to be made
> whether the probability of the leg being salvagable is worth setting
> against the real risk you lose the patient. Are the Fire Crew right
> when they say it will take so long to free him? Getting a surgical team
> there and then getting them through a mid thigh amputation will take as
> long as many Fire crewws would take to release him. Have we an element
> of crush injury coming in here? Perhaps we could prevent further loss
> of blood by a beefy mid thigh tourniquet. Replace fluids, preferably
> blood from the local hospital, fill with Ketamine and give the crew
> time.
>
> If the leg is not the sole injury though, and he is time critical the
> heroics are needed. I would want another Doctor to agree with me, and
> the decision to be documented by the Police. You say he knows he will
> lose his leg. Tell him he will have to, get his consent recorded by the
> Police. Bicycle clips, two tourniqets, shed loads of Ketamine, Betadine
> all over the Fire Service shears......, and as soon as he is out, run
> with him to hospital. There is no finess to it but he will have no more
> infection risk from that than from a severe open leg injury.
>
> Just hope that when they cut the leg free it wasn't trapped because his
> shoe lace had got caught.....
>
> Vic Calland
> Subject: Taxing case 2 first instalment.
>
Best wishes,
Rowley Cottingham
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