Lets see if this will work:
You have a male pt who is trapped beneath a wheel of fork lift at an industrial site. How are you going to get this patient out, and how are you going to treat him. Would your treatment/methods change based on patient condition? (I'm being vague on purpose, I want get as many different perspectives that I can on it)
Lets not look for wrong answers, just discussion points.
1) What part of the body is entrapped? Is it an entanglement or a crush injury?
2) Distance to nearest trauma centre? Is air available for a scene response or modified scene?
3) How well is the patient compensating while entrapped? Conscious? BP, HR?
4) Ensure oxygenation, ventilate as required. Continuous ETCO2 monitoring to alarm falling RR or apnea, especially during extrication.
5) Ensure good vascular access. Ideally two lines. One for fluid and one ready for dopamine is required later. Access should be strongly considered prior to extrication with lines run off of saline locks to cut down on clutter/trip hazards during move.
5) Rapid transport will be key as this pt. will require surgery. Ensure egress routes, vehicle placement and all required personnel ready with assigned tasks for when the extrication is complete.
6) Be ready to control major haemorrhages when forklift removed. Consider large adult BP cuffs to restrict blood flow is thighs/legs are crushed.
7) Expect rapid decompensation following extrication due to crush/compartment syndrome. Remember permissive hypotension to avoid washing out clotting factors and to ensure patient isn't just circulated pink kook-aid.
8) Hypothermia leads to profound coagulopathies and difficulties with perfusion. Error on the side of two warm, especially considering is immobile and in contact with the ground. Heat packs, blankets, blowers bringing in warm arm are all necessary. Ambulance heat should be cranked and doors to patient compartment closed. Ensure blankets in warmer compartment (if equipped) and adequate heat packs.
9) Communicate, communicate, communicate. Whoever is taking lead in directing patient care must also be constantly communicating with personnel leading the extrication and/or IC to ensure everyone is on the same page.
As far as moving the fork lift, at an industrial site the best method I could think of is to actually use a crane. The crane is more than capable of lifting the truck straight off of the patient with minimal invasiveness. I don't think under any circumstance would I ever attempt to push the lift off or drive it off due to the high risk of creating more injuries that don't already exist. Using a crane would ensure a clean lift directly off the patient and would quickly remove any further danger. Prior to lifting the fork lift though I would attempt to have air ambulance either already on scene, or en route. As well as a PCP crew or ACP crew already at the scene to assess the patient.
If a Crane is unavailable at the site then the use of airbags and cribbing would be the next best option, but a very lengthy extrication option in a time sensitive emergency.
Hope this answer is kind of what you were looking for. Hope this forum goes back to being more than just a hiring forum.
I agree, I would never try to push the vehicle off it was going to cause more harm to the patient. But if the patient is dead, whats more harmful? Waiting an extra 5-10mins to get them extricated or pushing the vehicle off? I know, in the grand scheme of things, if they are trauma dead the chances of us getting any kind of favorable outcome is next to zero. But it'd be nice to give the patient the best chance they can get at surviving such a horrific event.
I really don't think there are any right or wrong answers, was just looking for some discussion on the topic, I always like hearing how others think through scenarios like this.
The intentional vagueness of the scenario indicating the patient is trapped "beneath the wheel" of the forklift allows for other entrapment configurations not purely in the vertical axis. Therefore a blanket statement regarding extrication and having the vehicle "lifted off" is perhaps pre-mature.
What options are there after the vehicle is stabilized in place?
1) lift (or separate) the vehicle from the patient
2) lower the patient (remove material from the patient side)
3) remove the wheel (control suspension, remove wheel/tire)
[quote=""HoseA""]At anytime would it be appropriate for the vehicle to be pushed back off of the patient? Does the vehicle ALWAYS have to be lifted off?[/quote]
This is more of a medical risk assessment than technical extrication. Patient centered extrication will strive to extricate in a controlled manner. Balancing the capabilities and resources of the local EMS (wrt managing crush injury and time/distance to trauma centre) is risk management. If the patient crashes and it becomes an immediate release scenario then the risk assessment must balance the time saved from a controlled release against the potential further injury from the vehicle being "pushed off" and what that time buys the patient and EMS for medical intervention.
[quote=""HoseA""]My thoughts are if the patient is either pre-arrest or VSA and I can get the vehicle off quicker, without causing any further harm to the patient by pushing it off of them, I would.[/quote]
Frankly, that pre-conceived choice is easy to state but does not translate to reality. If I can "do something potentially unsafe" with no risk to the patient then it is easy to agree to "do something potentially unsafe", since I have eliminated the risk in my pre-conditions. In reality it is Choice 1/Risk A,B,C and Choice 2/Risk D,E,F both that have advantages and disadvantages for the patient. Choosing either one is rarely straightforward.
[quote=""HoseA""]Would any else just drive/push the vehicle off if they felt that a rapid extrication would be in the best interest of that patient knowing the patient may crash as soon as the weight has been removed.[/quote]Again medical risk management, it is obviously not in the best interests of the patient if they crash after rapid extrication IF local EMS are not in a position (capabilities/resources) to appropriately deal with the crash. How about waiting until an EMS force is gathered that does (air trauma team, doctor from hospital, etc). That means assessing the risk of leaving the load in place until that team is assembled and onscene.
Great points on not limiting the extrication to "lifting" the vehicle off. It takes strong situational awareness and avoidance of tunnel vision, we may get focused on why the patient is in the situation, and focus on only removing the forklift, when maybe there are other options available.
I guess I had in my mind that EMS would be on scene and prepared for the patient. But if they weren't this scenario may be a perfect example where "rapid extrication" may actually be detrimental to the patient.
Thanks for your views.
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