View Full Version : Airway case management - Scenario #1
This will be a question and answer thread. A "what would you do" in this scenario approach.
#1--Plane crash in the back country
You are part of a 3 man SAR/medic team. You are activated for a plane crash in a remote mountainous back country canyon. The downed aircraft has been located by a spotter plane but due to terrain he can't get close enough to spot any activity. He reports the crash is about 10 miles due east of the nearest road through fairly rugged terrain. Helicopter insertion is possible from a ridge about 500 yards north of the location but the approach to the crash site is extremely steep and rocky.
Time: 1630H - Helicopter is on standby with rotors turning.
Question: What sort of airway equipment do you have in your go-bag? What is your plan for deployment/assignments?
This is going to be fun guys, mainly because you don't have to do it real!
Jag
Update:
1637H
Incoming data-Plane is a Cessna 172
pilot filed a flight plan lists 4 souls on board- 2 adults, 2 children.
Weather forecast-short term, temperature daytime 65F, dropping to 30 tonight. Mild wind out of the northwest at 10 - 15 mph. Slight overcast with a ceiling of 13,000 ft, visibility 10 - 15 miles. Tonight a low pressure system will bring increasing clouds and high winds 35-45 mph and chance of rain turning to sleet in the mountains.
County Sheriff is activating local SAR team with horseback capability. Estimated response time - 0500H tommorrow am.
US Coast Guard helo/SAR team available to respond if requested. Estimated response time 2 hours to scene.
Helo is ready to go, any last minute items you want to throw in, requests?
hmmm... I'd go with the coast guard... but from an airway perspective, by the time anyone reaches them anyone with serious airway complications is going to be dead, OTOH, collapsed lung, flail chest or something like that is possible. maybe bring basic airway equipment and O2? (esp considering the altitude) Don't forget pedi sizes!
Reasonable Rascal
03-01-02, 13:47
Hmmm, interesting scenarion indeed! I'll give it a whirl any way. Thus showing my lack of exeperience in wilderness mecicine. ;-)
I am going to assume I have at least 1 Paramedic or similar in the 3-person team, the others trained as EMT-W's (Wilderness EMT's). That's my team.
Coast Guard? Looking at the time of day, then factor in an overnight stay, as many as 4 viable victims, I'd say make the request. But in all likelihood they aren't equipped for an overnight stay in the mountains with weather coming in. Have them on standby for the extraction to come tomorrow.
The primary go bag carries ET equipment enough to intubate a child and adult without resorting to less-than-optimal tube sizes, oral airways, nasal airways, perhaps a Combitube also.
Anyone with a seriously compromised airway will likely expire before we reach the crash site, so I'm looking at managing lung injury instead. Keep them alive and ventilated until we can get them out.
I have at my disposal ambu bags and a transport vent also (Ambumatic). Looks like we are going to have to sit overnight at least with these folks.
Oxygen is going to be a jumbo D cylinder as well as a couple regular D bottles, aluminum of course in all cases. So I have ummm umpteen hours of O2 at low flow. When that runs out it's ambient air via the ambu bag.
So it'd be reserved for the worst case patient. Coasties requested to bring additional O2 with them, ideally aluminum cylinders if they have them, or perhaps pick up supplies from my basing area on the way.
I can rig a cric okay if need be, 10 ga needle with an adapter.
Just random thoughts thus far, not a cohesive plan of action - yet.
RR
I want to play too. My go bag has the following airway equip:
1 - adult BVM (bag valve mask)
1 - pocket mask
2 - 28mm combitubes
2 - 32mm combitubes
1 - eischmann stylet
1 - adult "cook" cricothyrotomy kit
1 - ped "cook" cricothyrotomy kit
5 - oral airways, assorted sizes ped-adult
2 - nasal airways, 28mm and 32mm
Update:
US Coast guard is responding with 1 parajumper and 1 medic. ETA - 1h 15m.
Your 3 man medic team consists of the following: SAR#1-Paramedic/firefighter
SAR#2-EMTII/firefighter specializes in vehicular extraction SAR#3-EMTII/sheriff's deputy. All are qualified to intubate, start IV's and administer emergency meds. Paramedic member is qualified for needle aspiration of pneumothorax, cricothyrotomy and a few other advanced techniques.
You have arrived on scene and begin your traverse to the site. The helo will remain on station for 45 min.
Game Time!
You have traversed down to the crash site with your team. The wreckage is mostly intact with the tail section separated from the fuselage by about 50 yards. The fuselage is in pretty bad shape. The nose was impacted and crushed back into the passenger compartment. After approach to the plane, you find 1 victim entrapped in the passenger compartment, another victim of smaller stature is in the rear of the passenger compartment. No other victims in the fuselage. You begin assessment on victim 1 while your EMT crawls into the rear of the fuselage to assess victim 2.
Victim 1 - adult male, age approx 40. He has obvious head trauma and is unconcious. He is tightly wedged into the cabin and is entrapped by fuselage and engine structure. You are unable to visualize his lower body. You palpate a carotid pulse. It is very weak and thready. Respirations are very shallow and rapid, occasionally the victim pauses in his respirations. You listen to breath sounds, victim has coarse rales and breath sounds are diminished. You exam pupils, both are dilated and unresponsive to light. The victim is unresponsive to any stimulus. Intravenous access is going to be extremely difficult as the patients arms appear to be entrapped as well.
Radio call: Med Chopper needs to return to base for fuel.
EMT in back reports adolescent female who is somewhat responsive but incoherent. On initial exam she appears to have a open fracture of the femur, multiple lacerations of the left arm and a scalp laceration. Respirations are regular and unlabored. Breath sounds are equal. B/P is 130/90 and heart rate is 110.
The other EMT is out looking through the wreckage.
Any thing you want to do at the moment?
vic 1 - look for a perferation to the chest wall, palpate for crepitus, listen and percus - collapsed lung? get fluid in him fast (subclavian? venus cut down?), so the intercranial bleed doesn't kill him. immobilize c-spine, why can't u see lower body??? maybe a bleeder! - this pt is in trouble! he also needs O2 STAT!, but probably not an airway. Those chest sounds sound text book (flail chest?) - but I took that class too long ago - something w/ the chest... the "occasionally pauses in his resperations" sounds like it *should* be textbook - but I have absolutly no recollection of this in my training...."
vic 2 - w/ an open femer fracture, my first instinct is shock, maybe a tourniquite needed, but the vitals are not that bad! - control any bleeding and ignore her. umm, ck puples, she should be screaming her head off... c-spine... vic 2 is a trick! somethings wrong here! endorphins kicking in, ok... but she shouldn't be that quiet w/ those vitals... (for that matter, she shouldn't have an open femer fracture w/ those vitals! - heart beat is abit high BP is just a tad over normal... hmmm.... something not right here! "be affraid of the quiet ones" is echoing through my head...)
bottom line - vic 2 will deffinantly be alive in 10 minutes, vic 1 may not be - ignore vic 2, for now... (post ABC)
ummm... is the floor soggy? (wet?, are you wading?) how soggy? - who's?
call the chopper to set it's sorry ass down - you've got a pasenger for it that won't wait! (vic 1 - how to extract is the question...)
look at the aircraft structually - any signs of a body being thrown or pulled from it? - which way? any footprints? blood trails? - apply those tracking skills. vic 1 may be the least of your worries... ( bad shape, but possibly expectant, via triage rules, depending on the condition of vic 3 & 4...) dispatch your EMT to help find vic 3&4 while you work vic 1
umm - a small prayer for vic 1 might be appropriate at this time... the odds are not good for him. More a matter of extraction time, weather and location than anything else...
Radio comm from Helo:
Negative on the dust off. Fuel level dictates otherwise. Coast Guard Helo will be on seen in 20 minutes. I'm outta here.
The sun has set. Light level is dropping rapidly. Victim #1 is now in full respiratory arrest. Victim #2 is still stable but incoherent. EMT2 has found 3rd victim. Adult female expired from massive blunt trauma. No sign of anyone else. First report had 4 souls on board, what do you want him to do? Keep looking or boogey back to crash site?
-----------------
My plan***
Victim #1 is non viable. I can't get him extracted and the injuries he has sustained appear to be non-survivable at this point.
Help EMT/1 with adolescent victim #2. Lets get a line in. Airway seems ok at the moment so just supplemental Oxygen. I want to immobilize that leg with a compression splint. Do a blood loss analysis. Immobilize the c-spine and see if we can raise that Coast Guard Helo for a possible extraction of victim #2.
Need to get some light on the subject. What have I got -- uh oh! Just my streamlight.
Victim #2 seems very clammy and cold. I vaguely remember something about hypothermia and delerium. Do I have anything to check her temp -- Doesn't matter. I need to warm her up now.
What else is in those go bags?
Radio doesn't have coast guard freq. Rant for a few minutes about why we can't have some frequency coordination. Back to the job at hand.
Jag
not sure I want to write off vic 1 just yet - aircraft are made from very light material - you could take one apart w/ trama shears if you were determined....
keep looking for vic 4 and TRY not to contaminate the trails - yeah, tracking in the dark is a drag, but it's your best bet! should be pretty easy to determine if there is a vic 4 if you don't walk all over the place.
set up a base camp, start a fire, warm some stones... (unless u have heat packs, but you'll want to warm up yourselves and get some dinner...) use the stones to heat the planes cabin - maybe extract vic 2 to near the fire. what coats, space blankets, etc do you have? preserve heat and add some... worst case, body heat works... so does friction... rubbing arms, etc.
sounds like she's in shock - but those vitals are weird! - adolecent should be slightly higher, but in shock, MUCH higher! (or lower, in the case of BP, w/ massive blood loss) - what's going on here...
need secondary assessment on both vics...
need to TRY to stabalize vic 1 STAT!, but have a deffinant cut off point depending on the condition of vic 2 and if there is a vic 3..., supplies, etc. right now it looks like a major and a minor, but the minor could turn major and is a better bet for salvage.
so, I havn't done this in years - how badly am I doing? ;-)
Hey Tang, you're doing fine. I work in a nice warm cozy hospital with all the gear I need. Things get a little dicey in the outback. How am I doing?
Here is a quick run down on my thinking so far: Vic 1 appears to be nonviable, but has survived to this point -- some 6 hours post crash. I just don't see how to do anything for this guy. I got one confirmed fatality, one checking out, one that appears to be stable but is just not quite what she appears to be and one lost.
Vic 2: The incoherence may be part of a closed head injury which would correlate with slightly elevated b/p, pupils are ok at this point but that is not all that definitive in early head injuries. Open fracture of the femur is not bleeding to much and we got a inflatable splint on that to stablilize that. We have a cervical collar on her and are ready to extract her from the wreckage where we can do a better assessment. Her airway seems ok at this point.
Vic 4: I am going to have the other 2 EMT's to start a radial search pattern for this victim.
How do I communicate with the incoming Coast Guard chopper? Do they know are precise location? I have a light -- maybe I can signal with it.
A second thought, maybe I can have EMT2, who has extraction experience try and get Vic 1 free then maybe we can try to get him back. The main reason I can't work on him is because he is so jammed in there and I can't get any access.
Coast Guard should be here any minute. What to do next?
Jag
Reasonable Rascal
03-11-02, 14:16
Just a quick toss in here. Vic. #1 being in resp. arrest. Maybe reversible, maybe not. Won't know unless we try. Could be airway compromise due to position, or several other factors. I'm a hardheaded, never-say-die sort of guy so he's going to get some ventilations to see if he's viable with assistance.
As far as cutting him out with a trauma shears - I doubt it. Sheet metal yes, I've done that with car roofs. Very time consuming; aircraft aluminum would be easier, but there will be structural frame members and they *will* require some serious effort to move. If this plane was a Moonie for instance (that's a brand of aircraft, not a flying rug associated with some eastern religion) you may be in for a real hard time without power tools or at least a decent hacksaw.
I need to find some time later to address this properly. last crash I had there was no accessibility problem. He was in an ultralight and stopped when he reached the limit of the control cables attached to his harness. Just so happens his legs met the ground at the same time. Ouch! Dual femur/tib/fibs.
RR
EMT2 is back and working on extraction on VIC-1. He has inserted a combitube and EMT1is ventilating the patient with a BVM resuscitator; No carotid pulse that they can find. They are unable to start chest compressions until victim is extracted. IV acess has been attempted via external jugular but unsuccessful. One dose of epi 1:10,000 has been given via combitube but no response.
EMT2 says extraction is going to be at least 15 - 30 minutes. He asks if you want him to continue. EMT1 asks about VIC-4.
VIC-2 (adolescent female) has been extracted from the wreckage. She appears to be in distress but no specific complaints (still incoherent). Her respirations are becoming somewhat labored and her lips are dusky. Spot check with SaO2 shows sat of 86%. Further exam shows obvious deformity of right collarbone. Respirations are diminished on the right side.
You hear Coast Guard helo in background but no visual yet.
What are you going to do now?
Jag
Reasonable Rascal
03-13-02, 08:49
Vic #1 is a coroner's case now. Entrapment + no pulse = field pronouncement and move on. This is reality. We don't have the resources or means in this case to fight for what is at best a 1% chance of succesful resuscitation. And I am not given to surrendering up easily.
Vic #2 sounds like a hemo or pneumo, possibly because of the Fx. clavicle puncturing the lung, or it could have resulted from several other directions. Might have finally popped with extrication movement or just now be readily discernable to ascultation.
Clavicle can be immobed using a triangular bandage (2 if you don't have large ones) in a figure 8 pattern behind the back. I might take this route were the victim ambulatory but in this case fixed sling and swath seems best since we still face a scene extraction from rugged terrain.
Vic #2 sounds like she needs a needle decompression of that lung. It's not going to wait for extraction either. Find a handy tree to prop her against so she can breath meantime and get ready for the Paramedic to make the stab.
RR
Jag - you're doing fine!
on vic 1 - yes, doesn't look good, but manpower is in place and I bet that coast guard chopper has a rescue axe and maybe even a hacksaw on board - that compleatly changes the extraction equasion. keep ventalating on a maintenance level and hope.
vic 2 - RR called that right.
vic 4 - keep looking. does the chopper have anything that would help? IR/thermal?
communications - do a radio patch or relay through base.
if anything, pull in EMT3 from the search to start a fire for signaling and warmth, for now. can continue the search eithor with the aid of the chopper or after man power has been freed up by a patient or two being taken off our hands.
RR/Tang -- excellent call on the pneumothorax. Do a needle aspiration and hopefully everything starts to get better.
Item found in pack -- Strobe light. Ahaaa! Strobe light is functioning and we have been spotted by Coast Guard Chopper. They are getting ready to rope insert parajumper and medic plus assorted gear.
Bad news -- it is now dark.
Vic 2 -- B/P now 90/50 Heart rate - 140 respirations 28. Less labored but shallow and rapid. Needle aspiration of Right chest got back 120cc of bright red blood and no air. Patient has changed from incoherent to lethargic and sluggish. You have a 16 gauge antecubital IV and have infused 1 liter of LR. Any other thoughts on how to proceed here. Looks like possible hemothorax. My quess would be possible laceration of subclavian vein or artery by fractured clavicle or rib. I say it's time to get this girl to a hospital.
Vic 1 is pronounced as deceased.
Tally thus far -- 2 dead, 1 in serious condition and 1 missing.
Jag
suspected hemothorax? - what else could it be?
bright red - that's arterial.
get her on board that bird and start looking for vic #4
Parajumper and medic have roped in from Coast Guard bird and are helping with VIC 2. She now has a second line 16 gauge Antecubial line in and is getting #3 Lactate Ringers. Respirations are still labored and B/P is holding @ 90/50, HR is 140. She is marked for immeadiate extract by basket and transport. This should be happening within 15 minutes. Still no sign of VIC 4, but report from Coast Guard is that VIC 4 is an infant according to filed flight plan. EMT#3 is looking for VIC 4. Coast Guard is going to leave a survival pak for you. Base has called in an reports Rescue Helo is refueled and ready to return. Do you want him enroute?
Jag
sounds good on vic 2
lets reorient the search for vic 3 in the direction that vic 4 was found. Locate her tracks and search everything to the side of them for maybe 10-15 feet in both directions. Maybe double check the plane - under seats, in the tail... infants are pretty small... I'm not holding out high hopes for vic 3, especially if we don't find him/her by morning...
nuther chopper? - sure, but before he leaves there are a few things I'd like him to pick up...:
1 tracking dog and handler (if possible)
1 thermal or IR scope
1 ICN transport crib w/ heater & extra blankets
1 ICN nurse – maybe a brunet? ;-)
1 complete set of airway supplies in pediatric sizes
2 bottles formula and 2 diapers
extraction equipment, for later...
3 body bags
1 8" meatball sub w/ chips ;-)
anything u guys want?
hmm... do we need re-supply on anything used so far or how are supplies holding out? Do we have IV needles for an infant? anything else?
before that coast guard bird leaves - do they have a radio on their frequency they can leave and any airway equipment in pediatric sizes - I don't recall our bringing any....
Affirmative on the request Tang,
Except for the ICU nurse, she says she has been there, done that and has the tee shirt (wet of course). Ahhh, as to food, you get a case of MRE's and extra water rations.
ETA on #2 bird is 1.5 Hour.
Hey wait--EMT says he thought he heard crying from under the tail section. Get on over here.
Jag
heads over to the tail section - whats there?
notes to self:
1) can we get that chopper to drop off the tracker and dog - if we found vic 3, would rather have the extra gas than a dog handler and pooch hanging around...
2) compose a letter to personnel about reforming their hiring practices of ICN nurses to favor traits like "adventurous"... ;-)
3) compose a looooonngg string of my finest Irish invectives to launch, at a high decibel level, in the direction of the logistics person that handles our "food service"... ;-)
Reasonable Rascal
03-24-02, 20:14
Time to check out the tail section as well as every other piece/part of the AC, providing nothing that explains the source of the reported crying is found in/under the tail.
The baby would have acted like a bag of flour so far as where he/she might have been tossed.
Tangent needs to thank his lucky stars this isn't a Sierra Club sponsored operation, else his rations might be granola and tofu-based. ;-) I get dibs on the BBQ whatever meal. Oh, and pass the hot sauce, just in case.
RR
HAY! - I'll take granola and yogert over a MRE ANY DAY OF THE WEEK!
Yes, there is some faint crying from under the tail section.
Got to get this section moved. How much does a tail section on a Cessna 172 weigh? Can we lift this thing or do we need to employ some leverage and ropes. Don't want the thing shifting and crushing the victum.
No dog or handler available. They are with ground SRT at staging point. Helo can stop and pick up if you request.
Full darkness now and temperature is in the 50's. EMT2 has built a fire and rummaged through the survival pack left by the Coast Guard -- Lots of good stuff in there!
Jag
Reasonable Rascal
03-25-02, 07:33
Tail section Cessna 172 = perhaps 150 lbs. 2 people could lift it straight up from a dead start.
http://www.flymfs.com/images/172b.jpg
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