Wreck With Entrapment
Attack One receives a call to the scene of a motor vehicle crash with entrapment. The crash occurred at a far corner of the response district, meaning the response time will be fairly long. The dispatcher reports that police have requested a "hurry up" response.
On arrival, the crew finds a single-vehicle accident: a car wrapped around a power pole, with major front-end and passenger-side damage. The victim, a middle-age female, is unresponsive, suspended by her lap and shoulder belt. Extrication will be required: The front-end damage trapped the victim by her legs, and the steering wheel and dash are badly deformed. She is unable to give any history and has no visible medical alert documentation.
She is trapped upright in the driver's seat and accessible through the driver's window. Her airway is patent while upright with her c-spine immobilized, but she is only breathing about eight times a minute. Her right femur is obviously fractured, and her foot is not accessible amid the wreckage of the floorboard. Her pulse is rapid and only palpable in the neck. A pulse oximeter reading cannot be captured on the fingers. Further examination identifies only that the patient is pale and diaphoretic, with large areas of contusion down the right side of her body where the passenger side of the vehicle was crushed into the driver's compartment space.
This patient's critical injuries and ongoing poor perfusion indicate the need for rapid extrication and transport. The Attack One paramedic identifies a "critical patient" to Command and asks for helicopter transport.
Emergency Management
The airway and breathing problems need immediate management, which will have to take place before extrication. The patient is pinned laterally in the remnants of her compact station wagon by the driver's door and the middle console, as well as at her feet. Her airway is easily accessible through the driver's window, and her spine can be stabilized through the back window. However, interventions will require coordination with the extrication crew, as victim movement will also occur through the driver's door. Airway control is needed immediately; then the patient can have oxygen and ventilation support provided through the back window.
The paramedic coordinates with the captain of the extrication crew to time the operation. The Attack One crew will take 2-3 minutes to intubate the patient while the extrication equipment is set up. Once the extrication crew begins work, the medic crew will set up for intravenous access and further packaging. The more difficult and possibly time-consuming extrication of the feet can then be done with the victim's airway captured, ventilation ongoing and IV fluids being infused.
Airway access will be most easily accomplished by nasotracheal intubation, so a tube is prepared, and the larger right nostril lubricated. The tube easily passes through the nose, and on the next inspiration passes into the trachea. Placement is confirmed with a CO2 rapid-confirmation device. An oxygen line is strung through the back window, and the patient can be bagged by access from there. The extrication crew is now prepared and can pop open the front and back driver's-side doors, giving an EMT access into the backseat. That EMT can then continue bagging and maintain spine immobilization from that position, and the extrication crew can work on the steering column, dashboard and remnants of the floor. Between those operations, the paramedic will take the opportunity to cut the clothing off the patient's arms to find the best IV access. The right arm is injured, so the left antecubital vein will be the best available. There is no place to hang the IV bag, and the victim requires pressure infusion, so the liter bag of fluid is arranged in a pressure infuser, all air evacuated from the bag and tubing, and set up for placement in the backseat.
The steering column and dashboard move up easily, and then the trapped right lower leg can be visualized. It is mangled, with an open fracture. While the hydraulic gear is being prepared to spread the areas of the floor, the IV is started with the pressurized line. The victim remains unresponsive and in profound shock.
The paramedic and extrication leader agree that extrication of the right foot should occur as rapidly as possible, or the victim is likely to hemorrhage and die. The paramedic splits the victim's pant leg and shoe open with trauma scissors, and the crew uses the spreaders to open a crack in the floor. The paramedic can then give a good pull and free the leg.
Command has arranged for the helicopter and assigned another engine to provide a landing zone. The helicopter circles the scene as the foot is freed, so the Attack One paramedic requests Command have the helicopter prepare for a "hot load" of the victim, since her extrication will be completed just before the helicopter will be able to land. The lady is fairly small, so her body can be pulled out and packaged quickly once the foot is free.
The crew slides her out quickly, maintaining the airway and spine immobilization and keeping the IV in place, and does a rapid splint of the right femur and lower leg with blanket rolls and tape. Fortunately, the tube was placed and secured before the patient is lowered to the backboard, because her stomach empties as her torso is lowered. The placement of the endotracheal tube is checked again after she is placed on the stretcher, a second pressurized bag of fluid replaces the now-empty first bag, and the leg splint restores gross position of the entire right leg. The pulse oximeter at this point finds a pulse reading on the left and right fingers, but reveals an ongoing rate of about 140 beats per minute.
The helicopter lands, and the radio transmission from the flight crew indicates they are prepared to immediately transfer the patient off the ambulance stretcher to their flight stretcher. The blades will continue to rotate. This is a procedure the crews have both trained on to facilitate the shortest possible scene times. The crew also indicates they want help and could accommodate a paramedic for the transport to the trauma center. The helicopter doors open, and the pilot signals the team to approach. The patient and backboard are taken off the stretcher and carried to the helicopter doors, then slid onto the flight stretcher. That is the first opportunity for the victim to be completely disrobed and checked for further injuries. She has contusions to her right chest wall and flank and on the right side of her head. The chest wall has no crepitation, and the person performing ventilations reports no increase in the pressure required to bag. Her extremities all withdraw slightly to pain, a welcome sign.
The flight crew defers any further physical examination because of the profound shock and obvious trauma. With the paramedic on board, the remainder of the crew withdraws, and the helicopter goes airborne. Total scene time of the helicopter was four minutes; extrication had taken 15.
Hospital Course
The patient is removed from the helicopter at the trauma center and taken directly to the operating room. The paramedic is asked to accompany the team, as there has not been adequate time to communicate the history of the incident or even identify the victim. The anesthesia and surgical teams prepare the victim quickly and soon have her abdomen open. She is bleeding profusely from her liver and has damage to her right kidney. After relaying information to the surgical team, the paramedic leaves the OR and accompanies the flight crew to the ED. There they can all collect further information and begin patient care documentation.
The paramedic contacts dispatch to request any further information available on the scene or through law enforcement. Dispatch contacts Command, and a link is made to the patient's information. Her husband had arrived on scene as the helicopter lifted off. His identification confirmed the information from the purse found in the car, and he provided information regarding her health history. She is pregnant and healthy, though she has a history of life-threatening allergic reactions to penicillin.
That is critical information, and a flight crew member goes immediately back to the operating room to relay it.
The husband is being transported to the hospital by law enforcement, and dispatch coordinates to have him met by the other flight crew member and paramedic as he arrives.
The patient has a positive pregnancy test. She survives the operation, and bleeding is controlled. She had a significant bleed into the right side of her head, but neurosurgery is able to evacuate it before she leaves the operating room. Orthopedic surgery does initial stabilization of the right leg injuries, but corrective surgeries will have to wait until she is more stable.
The patient survives and awakes in a few days. Through multiple injuries and surgeries, she does well and goes on to have a healthy baby.
Customer Service Priorities for This Case
What other scene or patient presentation details could have improved care?
The mechanism was not apparent, with a single-vehicle accident on dry pavement. Were there precipitating factors? Was the victim having a medical event (seizure, dysrhythmia, hypoglycemia) that precipitated her losing control and wrapping the vehicle around the tree? All major injuries could be identified or anticipated through mechanism of injury and limited physical assessment.
Was the optimal treatment path followed?
Victim management was optimized by careful coordination of medical care and extrication operations. This allowed rapid assessment, appropriate packaging and extrication to occur as quickly as possible. The airway intervention had to be performed with the victim still trapped and upright. A simple bag-valve mask allowed the crew to support ventilation. Pressure-infusing fluids stabilized the victim during rapid removal without delaying extrication.
What communications were critical for incident management?
The most critical communication was that carried out between the paramedic in charge of victim care and the extrication leader. It allowed rapid extrication, performed safely for victim and rescuer. The landing zone team coordinated victim removal with helicopter availability so that a "hot load" could be performed.
What were the customer service priorities in this incident?
The patient's family members and/or friends are likely to come to an emergency medical scene. This crash occurred in an area and at a time where work and school commutes are predominant, so the patient's family was likely to be somewhere close by. Command staff and law enforcement personnel were prepared for their arrival and communications with them.
The severe damage to the car scattered the victim's belongings across the ground. Some of them may be very important to her and her family-especially her purse. It is always good procedure to treat all belongings carefully and respectfully for the victim and family.
An important point in customer care is the exchange of information with hospital caregivers and family who were not present when the event took place. The Attack One crew was split for victim transport, but then proceeded to the hospital to finalize information exchange with the trauma team. The Attack One paramedic accompanied the victim in the helicopter and as she was moved to the operating room. The other team members drove to the ED to complete documentation, pick up their colleague and meet and support the family. The ED staff in this case was short on information regarding the accident, the victim and where she was in the hospital, as she had bypassed the ED. As a routine matter, it is great customer service to have the EMS crew (if possible) meet the family at the hospital, arrange for them to communicate with the department as necessary, and inform them what law enforcement agency is handling the investigation and the car and patient belongings.
Case Analysis
This victim survived due to rapid work by the medical and extrication teams and a timely movement into the OR at the trauma center. Any of the steps in assessment, treatment, extrication, transfer to the helicopter and movement into the hospital could have consumed time this victim could not afford. There are some critical trauma and medical patients that require such rapid movement through the system.
An additional point in the management of this patient is that communication pathways and preplans will facilitate outstanding delivery in time-sensitive incidents. This department had an excellent training relationship with the air ambulance team, and prior education shaved minutes off the ground time of the helicopter. The paramedic was prepared to accompany the patient and continue the communication chain from incident site to trauma team and then to family. Two critical pieces of medical information were delivered through dispatch. Documentation could be completed at the appropriate time.
Jim Augustine, MD, FACEP, serves on the clinical faculty in the Department of Emergency Medicine at Emory University, Atlanta, GA. He also serves as Medical Director for the Atlanta Fire Department, which includes operations at Hartsfield-Jackson Atlanta International Airport. He has served 23 years as a firefighter and EMT-A, and is a member of EMS Magazine's editorial advisory board. Contact him at jaugust@emory.edu.
James Augustine is a featured speaker at EMS EXPO, October 11-13, in Orlando, FL. For more information, visit www.emsexpo2007.com.
