CASE 44
Incident A
44.1 Briefly discuss how you would plan for this.
After 30 minutes, the team hears gunshots and, shortly after, a police officer is brought to your location by colleagues. He is unconscious and bleeding profusely from a wound in his right loin/lower chest. His colleagues have started CPR. In between cycles you cannot confidently feel a pulse. You are 30 minutes by road from the nearest hospital.
44.2 Discuss further management.
Incident B
You are a military physician providing care to a battalion of soldiers and the surrounding civilian population. The military in which you serve is on a peace-keeping mission in a desert climate overseas.
Military medics (trained to ambulance paramedic standard) are working with you. Medical equipment is limited, is primarily geared towards trauma and is carried in a single rucksack. There is no fixed medical clinic at your location.
You work in an area frequently patrolled by insurgents, which is considered hostile.
You have been asked to accompany a unit of 30 men to designate a new landing site for helicopter rescues near the position. The commander estimates a walk of three hours there and three hours back with an hour on-site. The mission will take place at night and will be through hostile territory.
44.3 How will you plan medically for such a mission?
Two hours into the mission, a soldier activates an anti-personnel device. You are a minute or so behind the explosion and arrive to find:
• Soldier 1: Right below-knee amputation, screaming.
• Soldier 2: Lying supine, abdominal wounds. Partial evisceration. Talking.
• Soldier 3: Rear right-sided chest wounds (multiple). Short of breath.
Your location is a rocky slope; the nearest landing site is 30 minutes downhill. You have two military medics and two stretchers.
The military commander asks you what you need for the medical evacuation.
44.4 How do you answer him. Describe your treatment and evacuation plan.
Discussion
Incident A
44.1 Such incidents are increasingly common in the urban environment and are rarely planned much in advance. The PHR team may only have minutes’ or maybe hours’ notice to prepare. Depending on the nature and frequency of the requests, it may be appropriate for the team to be aware of the operation and its location and only attend if an incident occurs. If the police feel advanced medical attendance is mandatory, they should liaise early with the tasking agency who should ensure that a senior PHR clinician is part of the decision-making process.
If attending, the PHR team should make sure that they have an extra layer of PPE in place (e.g. a ‘stab vest’) and should ask the tasking agency to find details of the emergency services rendezvous point (RVP) (see Case 15). Once at the RVP, the team should stay in contact with the tasking agency and operational police officers. Listening to a police radio may help in this regard. In the event of an incident, the PHR team must not leave the RVP to the head to the scene unless the scene is safe and the team has a police escort. Even then, it is preferable for the casualty to be brought to the RVP if possible.
44.2 Scene safety is still paramount, even in the RVP. It may be appropriate to ask an officer if it is safe to treat the patient in the current location or whether you should move somewhere safer. Do not forget that the officer may be carrying a loaded firearm and other weapons. Never assume these have been made safe and always ask a senior police officer to remove any weapons prior to treatment.
Initial treatment of the pre-hospital traumatic cardiac arrest is as follows:
• Confirm cardiac arrest and note the time.
Treat the immediately reversible conditions and start resuscitation, simultaneously if possible
• Haemorrhage control. In this instance, the blood is coming out of a low chest wall/abdomen defect and will be harder to control. Direct pressure is still the initial option.
• Bilateral needle thoracocentesis for potential tension pneumothoraces.
• Consider thoracotomy. The penetrating wound is low on the right-hand side but, even so, thoracotomy should be considered early on, especially as the patient is in cardiac arrest (see Case 15 and Appendix 1.4).
• CPR should be continued.
Airway
• The patient needs a secure airway and an initial attempt at intubation without drugs should be made. If this is not possible due to the patient gagging or resisting, then the patient may not be in cardiac arrest and rapid-sequence intubation (with a very low dose/no induction agent) may be required.
Breathing
• Bilateral simple thoracostomies are indicated post intubation.
Circulation
• Access to the circulation is required. The quickest route should be used and this may be a long, large-bore catheter in the groin or an intraosseous needle (see Case 7, Case 25 and Appendix 1.2). A generous fluid bolus is required (e.g. 1–2 litres). The first doses of adrenaline should also be given.
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